Persius/hicric huggingface dataset:
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Vomiting and epigastric pain.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.
 
The patient presented with vomiting and epigastric pain. In the emergency room (ER) the patient was found to be hypertensive. There was no abdominal rebound or guarding. There was no leukocytosis. A computed tomography (CT) scan showed mild diverticulitis, but it was felt that clinically the patient did not have diverticulitis. Hypokalemia was present and potassium was replaced. The patient's renal function was normal. The patient was given Zofran, and their symptoms resolved. The patient left the hospital against medical advice (AMA).

Milliman Care Guidelines (MCG) guideline M-05 lists clinical indications for admission for Undiagnosed Abdominal Pain. These indications include hemodynamic instability, peritoneal signs, intestinal obstruction or perforation, bacteremia, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

MCG guideline M-370 lists clinical indications for admission for Vomiting. These include having a severe metabolic derangement, hemodynamic instability, severe vomiting that is not responsive to antiemetics, bacteremia, severe electrolyte abnormalities, acute renal failure, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had epigastric pain and vomiting, which had resolved by the time of admission. Intravenous (IV) hydration with potassium replacement and antiemetics could have been given in the ER as an outpatient. The patient responded to the treatment given in the ER and was then stable for outpatient care. The patient did not meet MCG criteria for admission for either Undiagnosed Abdominal Pain or Vomiting. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Inpatient Hospital Admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Testicular cancer
Treatment: Inpatient Hospital Admission:
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

This patient is an adult male with a past medical history significant for childhood asthma, and testicular cancer. The patient presented for surgical intervention. The patient 
underwent a robotic retroperitoneal lymph node dissection. He reportedly tolerated the procedure and received postoperative care and monitoring via an inpatient hospital admission. The patient reportedly had an uneventful hospital course and was discharged the next day. The request for coverage of the inpatient hospital admission is under review.

The requested health service of an Inpatient Hospital Admission is not considered medically necessary. 

It is noted that the majority of patients who undergo robotic lymph node dissection can be discharged within 24 hours of the procedure. The procedure was an elective scheduled procedure. 
This patient did not have any significant risk factors that would have increased the risk of postoperative complications. His post-operative course was essentially normal, without any significant complications or issues with pain control. Observation status for this patient's clinical presentation and post-operative course was the safest, most effective, and most appropriate treatment option, in keeping with generally accepted standards. Admission status may be changed anytime during observation if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment. However, this was not the case for this patient, therefore, the requested health service is not considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prediabetes
Treatment: Trulicity
The insurer denied Trulicity.
The determination is upheld.

This is a male patient diagnosed with prediabetes. This request is for Trulicity. As per a visit note, he has obesity. He is on Trulicity.
His A1C (hemoglobin) was around 5.7 percent (%). At issue is the medical necessity of Trulicity.
The requested Trulicity is not medically necessary.
Trulicity is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus (1,2).
It is a glucagon-like peptide 1 (GLP-1) receptor agonist. The Limitations of Use are:
.	Not recommended as first-line therapy for patients inadequately controlled on diet and exercise 
.	Has not been studied in patients with a history of pancreatitis. Consider another antidiabetic therapy .
.	Not for treatment of type 1 diabetes mellitus or diabetic ketoacidosis.
.	Not for patients with pre-existing severe gastrointestinal disease.
The requested medication is approved for type 2 diabetes. There is no clear documentation of type 2 diabetes in the form of an elevated A1C level or blood glucose level. The request is therefore not medically necessary (3-5).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Narcolepsy
Treatment: Xywav 0.5 gram / milliliter (GM/ML) oral (PO) solution, procedure code J8499
The insurer denied coverage for: Xywav 0.5 gram / milliliter (GM/ML) oral (PO) solution, procedure code J8499
The denial is : Upheld
The patient is an adult with a reported diagnosis of narcolepsy, diagnosed 23 years ago. The patient presented for care taking Xywav 4.5 grams (gm) twice nightly, long-acting Ritalin 20 milligrams (mg), and regular Ritalin 10 mg. The patient is HLA DqB1**0602 negative. The last sleep study/multiple sleep latency test (MSLT) was in 2004 and showed 3 sleep onset rapid eye movement (REM) periods with a normal overnight study. There is no reported cataplexy, but the patient has had sleep paralysis and hypnagogic hallucinations. The patient was thus assigned a diagnosis of type II narcolepsy. The patient also has hypothyroidism and hypertension. The 2004 sleep study is included for review and showed an overnight REM latency of 55 minutes with a sleep latency of 6 minutes. The sleep efficiency was 94.9%. The patient had a normal apnea-hypopnea index of 1.2 events/hour and did not have periodic limb movements. The total sleep time was 399.5 minutes. The request is for Xywav 0.5 gram / milliliter, which is under medical review.

The documentation provided does not establish a diagnosis of narcolepsy type II. The actual multiple sleep latency results are not provided for this review but there is a summary in the office visit note that says there are 3 sleep onset REM periods obtained on a multiple sleep latency test (MLST) following an overnight sleep study. The overnight REM latency on the provided sleep study is longer than 20 minutes (55 minutes according to documentation) so there is not an overnight sleep onset REM period. In order to meet the health plan criteria (or any criteria established by guidelines), the patient's mean sleep latency needs to be less than 8 minutes and the testing needs to show at least 2 sleep onset REM periods either from the MSLT or from a combination of the MSLT and the overnight sleep study. The documentation provided does not show a mean sleep latency of less than 8 minutes because this information is not provided. It does show more than 2 sleep onset REM periods according to the clinic note summarizing the MSLT. Thus, according to national guidelines as well as health plan policy, treatment with Xywav is not indicated since the diagnosis of type II narcolepsy has not been established based on the documentation provided.      

Xywav 0.5 gram / milliliter (GM/ML) oral (PO) solution, procedure code J8499 is not considered medically necessary for this patient.

The documentation provided about this patient does not establish a diagnosis of narcolepsy type II.  As such, treatment with Xywav is not medically necessary.



Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Xywav 0.5 gram / milliliter (GM/ML) oral (PO) solution, procedure code J8499 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic prostate cancer, pain, hypercalcemia
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.


This is a male patient with metastatic prostate cancer who presented from the oncology clinic with hypercalcemia and increasing pain. In the emergency room, he was evaluated and found not to have cord compression. He received intravenous (IV) fluids and zoledronic acid in the emergency room with improvement. The patient was admitted. His pain was ultimately controlled on oxycodone-acetaminophen. The patient was discharged; the medical necessity of an inpatient level of care is under review.
The inpatient hospital admission was not medically necessary. The services provided to this patient do not require the inpatient level of care and are typically administered at a lower level of care. This patient is noted to have been improving at the time of admission based on interventions (fluids and zoledronic acid) taken in the emergency room (ER). The patient received supportive care including IV fluids and oral analgesics during his hospitalization. Imaging was also performed but this was unremarkable for changes requiring acute intervention - only chronic findings related to his known, progressive cancer. For these reasons, support in the peer-reviewed literature and national guidelines for this inpatient hospitalization is not available and medical necessity cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult male. He was hospitalized for chest pain. He presented to the emergency department for evaluation of left-sided chest pain on effort reminiscent of when he underwent prior percutaneous coronary intervention (PCI). His past medical history includes known coronary artery disease (CAD) treated with two stents, hypertension, and negative stress test 1 month prior. The patient's vital signs were stable. Troponin panel was non-diagnostic for acute myocardial infarction (AMI). Chest film was negative. There were no electrocardiogram (EKG) changes reported. Renal function improved with intravenous fluids for acute kidney injury (AKI). He was treated medically and discharged to home. The Inpatient Admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The Inpatient admission was not medically necessary.

Based on the peer-reviewed medical literature, including the MCG (Milliman care guidelines) guidelines for Chest Pain, #M-89, criteria for inpatient admission are not met, including 
hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom, or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient hospital stay. The care that the patient 
received for an uncomplicated chest pain syndrome, like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the 
current published medical literature, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever and Headache
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

The patient is an adult male. He was admitted in the setting of headache, fever, diarrhea, and abdominal pain. Despite treatment with anti-emetics and pain medication, he continued to have headaches. Given headache and fever, there was concern for meningitis. Spinal tap was not successful. Magnetic resonance imaging (MRI) was ordered. Meningitis/encephalitis was eventually ruled out. The inpatient admission was denied coverage by the health plan as not medically necessary. The 
denial is being appealed.

The Inpatient admission was medically necessary.

Inpatient admission was indicated, as the patient did not respond to treatment for headaches, and there was concern for meningitis. Cerebrospinal fluid (CSF) testing was not able to be done in an orderly fashion. Given the suspicion for meningitis, inpatient admission was indicated for frequent neurologic checks, as meningitis can result is significant morbidity and mortality. 
Therefore, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

This case involves a man admitted to the hospital with right lower quadrant pain for two days. The pain was associated with fevers and chills. No other constitutional symptoms were reported. Vital signs showed a blood pressure of 90/60, a heart rate of 90, with excellent oxygen saturation.
Laboratory studies showed leukocytosis of 15,000 and creatinine of 1.4. A computed tomography (CT) abdomen showed enterocolitis involving the small intestine and right colon.
The patient was admitted to the hospital and given intravenous (IV) Toradol for pain and IV Zosyn for intra-abdominal coverage. Interestingly, the abdominal exam showed no tenderness or hepatomegaly and normal bowel sounds.
The medical team changed the antibiotics to metronidazole and Levaquin, started IV fluids, and ordered procalcitonin, calprotectin, C. difficile (clostridium difficile) studies, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR), as well as cultures.

The inpatient hospital admission was not medically necessary. The patient was admitted to the hospital with leukocytosis and findings of enterocolitis on a CT scan. However, the abdominal exam was benign, both in the ED (emergency department), and as well as subsequently, on examinations by the medical and the surgical team. Acute appendicitis was clinically ruled out. The patient tolerated a clear liquid diet and received broad-spectrum antibiotics empirically for suspected infectious causes. There is no documentation of uncontrolled severe pain, peritoneal signs, or rigidity. The patient did not require surgical intervention. There is no evidence of bowel ischemia. The laboratory studies improved within 48 hours back to normal. Although the documentation reports the presence of septic shock, the vital signs do not support this conclusion. There is no evidence of lactic acidosis. Blood cultures and urine cultures remain negative. As a result, there was no clear indication of why the patient's condition could not be managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Increase Personal Care Aide (PCA) Services for a Total of 168 Hours per Week (Split Shift) 
The insurer denied: Increase Personal Care Aide (PCA) Services for a Total of 168 Hours per Week (Split Shift.) 
The denial is upheld.

The patient is an elderly female with dementia (described as "worsening"). The patient reportedly has experienced recurrent falls in 2002, and e additional falls this year, (there is a note of chronic left 9th (ninth) and 10th (tenth) rib fractures). The patient's other medical history listed include repeated falls, urinary tract infection, vascular dementia (unspecified severity, without behavioral disturbance), psychotic disturbance, mood disturbance, anxiety, age-related osteoporosis with current pathological fracture, (unspecified site), initial encounter for fracture, hyperlipidemia, iron deficiency anemia, type 2 (two) diabetes mellitus without complications, other lack of coordination, age-related physical debility, unspecified pain, difficulty in walking, unspecified disorder of muscle, generalized muscle weakness, other specified personal risk factors, unspecified disorder of bone density and structure, other 
cerebrovascular disease, dysphagia following other cerebrovascular disease and history of falling. A Uniform Assessment System [UAS]) performed 9 months ago, indicated that the patient has total dependence with meal preparation, ordinary housework, and shopping. She required maximal assistance with medications, stairs, transportation, bathing, and lower body dressing. She required extensive assistance with hygiene, upper body dressing, walking, locomotion (with 
wheelchair and walker), toilet use, and bed mobility. Two months ago. the final denial notice was rendered denying the request for increased personal assistance time and re-affirmed the 45.5 hours per week assistance. The denial letter cited the Uniform Assessment System (UAS) assessments. The request for an increase in Personal Care Aide (PCA) Services for a total of 168 hours per week (Split Shift) is under review. 

The requested health service of an Increase of Personal Care Aide (PCA) Services for a Total of 168 Hours per Week (Split Shift) is not considered medically necessary. 

As noted above, the request for increased hours of personal assistance is deemed not medically necessary, as this patient requires a higher level of care that a personal assistant is not properly trained to provide, even with (split) 24-hour care. Taking her overall recent medical history, the patient is likely to benefit from a skilled nursing facility stay where she can receive physical therapy (PT) and occupational therapy (OT), as well as frequent skills to help prevent urinary tract infection (UTI), pressure sores, and falls.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough.

Treatment: inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is a child, at the time of admission, with a history of a previous admission to the Pediatric Intensive Care Unit (PICU) for bronchiolitis. She had been coughing for 8 days and was seen on several occasions in the pediatric pulmonary clinic. She was treated with albuterol, budesonide, and prednisone. Two days before admission she was started on Augmentin and the day before admission she was started on azithromycin. The pediatric pulmonologist then referred her to the emergency room (ER) for additional treatment.

In the emergency room (ER) she was noted to have increased work of breathing. The pulse oximeter was 100% on room air and her vital signs were stable. On physical examination, she was not in distress and did not appear sick. There was no wheezing but there were decreased breath sounds noted over the left lung. A chest x-ray was read as negative. The white blood cell (WBC) count was elevated at 18,000. A venous blood gas was normal at 7.42 with a pCO2 of 38. She was treated with a few treatments inhaled DuoNeb, magnesium sulfate, and an intravenous (IV) bolus of normal saline. Steroids were not administered in the emergency room (ER) since she had been receiving prednisone for 8 days and there was no wheezing. Following treatment her pulse oximeter reading remained normal and there were mild crepitations heard over the left lung. The decision was made to admit her with a diagnosis of status asthmaticus for ongoing treatment with Augmentin, azithromycin, and albuterol, every 4 hours. 

The child was treated appropriately in the emergency room (ER) for a cough and decreased breath sounds were noted upon auscultation of her lung. The medical record indicates that the child was not in distress and did not look sick upon arrival at the ER. The decision to admit to the hospital for ongoing treatment with albuterol every 4 hours and continuation of Augmentin and azithromycin was not consistent with the standard of care for a persistent cough. The pulse oximeter was normal on arrival in the ER, and it remained normal during the treatment in the ER. The child was not heard to have wheezing and did not appear to be in respiratory distress. The child was stable enough to be discharged safely to home with ongoing treatment with antibiotics and albuterol with a follow-up visit with her pediatrician in 24 - 48 hours.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Overturned
The patient is an adult with a history of osteoarthritis, asthma, hypertension, and vertigo who presented to the Emergency Room (ER) with lightheadedness, palpitations and dizziness. This request is for coverage of admission. On initial presentation, the patient had unremarkable vital signs (temperature of 97.7 degrees Fahrenheit, pulse 96 beats per minute (bpm), respiratory rate 16 breaths per minute (bpm), blood pressure 168/106 millimeters of mercury (mmHg), and oxygen saturation 96% on room air. The patient was found to have hypoglycemia (glucose 65 milligrams/deciliter [mg/dL]). 

The patient was admitted to rule-out arrhythmia, a neurological event, and to determine if the patient had ongoing hypoglycemia as the cause of syncope. Laboratory results were: White blood cell count (WBC) 8.7k, Hematocrit 39.2, prothrombin time (PT) 12.3 sec, international normalized ratio (INR) 1.03, partial thromboplastin time (PTT) 31.9 sec, glucose 83, blood urea nitrogen (BUN) 12, Creatinine 1.0, Sodium 141, Potassium 3.7, Chloride 103, carbon dioxide (CO2) 23, Anion gap 15, Anion gap with K 18.7, Albumin 4.8, Bilirubin 0.7, aspartate aminotransferase (AST) 22, Alkaline phosphatase 102, estimated glomerular filtration rate (eGFR) 63.3, Sepsis Risk Score: 0.57.

The patient was admitted because the cause of the syncope was unclear. During the admission, cardiac causes were ruled out.  Neurological causes were ruled out. The patient had hypoglycemia on admission. The patient required monitoring to determine if the hypoglycemia was ongoing or caused her syncope. The diagnosis of the cause of hypoglycemia in patients who are not on hypoglycemic agents requires frequent monitoring or a 72 hour fasting study to induce hypoglycemia and draw a critical sample to determine the cause of hypoglycemia (1-4). The patient had documented hypoglycemia without being on any hypoglycemic agents. The patient was being monitored for recurrent hypoglycemic episodes after cardiac and neurological causes were ruled out.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an inpatient admission to is substantiated.