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

Diagnosis: Chest pain, Supraventricular tachycardia 
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a history of chest pain for several hours. He was playing lacrosse and then experienced fatigue, chest pain and palpitations. He had two previous episodes in the past year which had not been worked up; those episodes were relieved after emesis.
In the emergency department (ED), he was found to be in supraventricular tachycardia (SVT) with a heart rate in the 220 range. The SVT was broken with adenosine 12 milligrams (mg). He had no evidence of pre-excitation on electrocardiogram (ECG). His troponin was mildly elevated at 0.296 nanograms/milliliter (ng/ml). He was admitted to the pediatric floor for observation on telemetry. An echocardiogram was normal. No medications were started and follow-up with pediatric cardiology was arranged. He was discharged. At issue is the medical necessity of an inpatient stay.

An inpatient stay was not medically necessary. This patient could have been admitted at a lower level of care as it was very likely that his troponin leak was from the SVT (supraventricular tachycardia). A cardiology consultation with attendant studies could be (and were) done in an observation period. The patient was not high risk and did not have further comorbidities. He was stable once in normal sinus rhythm. Therefore, an inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cleft Palate and Lip
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned. 

This is a male patient with a history of complete cleft lip and cleft palate, Van Der Woude syndrome. The patient presented for an elective complex reconstruction, LeFort 1 advancement with bone graft, bilateral sagittal split osteotomy, septoplasty. The patient progressed well postoperatively and was discharged. At issue is the medical necessity of an inpatient stay.

The inpatient admission was medically necessary. Admission after orthognathic surgery for a syndromic patient is the standard of care and was medically necessary to monitor the patient's airway. Orthognathic surgery is traditionally performed at an inpatient level of care. There are no studies that show that outpatient surgery for cleft orthognathic patients is safe. This is a complicated syndromic patient with a history of cleft palate and clearly is not a low risk patient. Inpatient admission was necessary to monitor the patient's airway and was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Broken tooth

Treatment: Crown (D2740) on tooth number 30

The insurer denied coverage for crown (D2740) on tooth number 30

The denial is upheld 


Upon review of the documentation provided which includes copies of periapical and panoramic radiographs, and insurer correspondence and dental plan guidebook, it appears that this patient presented to the dentist for comprehensive care. The treating dentist recommended a crown for tooth number 30. The insurer has denied these services stating the clinical findings do not support the recommended treatment and therefore the services do not meet medical necessity criteria. 

The objective documentation provided for review is undated periapical and panoramic radiographs. It appears that there is no evidence of fracture or other pathology specifically affecting tooth number 30 based on the images provided for review. There does not appear to be any radiographic evidence of caries. There does not appear to be any structural or pathologic issue associated with the existing crown on tooth number 30. The radiographs do not substantiate the requested dental service as enumerated above. 

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 a crown (D2740) on tooth number 30 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dichorionic diamniotic twin gestation

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient is a female at 30 weeks of gestation with a dichorionic diamniotic twin gestation who presented to the hospital with complaints of gastro-esophageal reflux disease (GERD), and abdominal pain. Her GERD resolved and she was ruled out for preterm labor but was noticed to have elevated blood pressures. She was diagnosed with preeclampsia without severe features and completed a 24-hour urine collection. Since her blood pressures remained within normal limits, and 24-hour urine collection was negative, she was discharged with the diagnosis of gestational hypertension.

Preterm labor is an indication for admission and tocolysis. Preterm labor is defined as uterine contractions with cervical changes. During this admission, there was no documentation of any cervical changes. Repeat cervical examination did not show any changes. So, the patient was not in preterm labor. 

Ideally, this patient would have been observed in labor and delivery, received intravenous (IV) fluid and then reevaluated a few hours later.  If upon reevaluation, no cervical changes occurred then she would be sent home.  If cervical changes did occur, then she would be admitted for tocolysis and further management.

The main reason given for admission was for elevated blood pressure. According to American College of Obstetrics and Gynecologists (ACOG), ambulatory management at home is an option only for women with gestational hypertension or preeclampsia without severe features and requires frequent fetal and maternal evaluation. Hospitalization is appropriate for women with severe features. This patient did not have preeclampsia. She had a mild elevation in blood pressure that stabilized without any medication. In addition, there was no protein in the urine and her laboratory evaluation was normal.

According to Milliman care Guidelines (MCG), admission is indicated for one or more of the following: Condition requiring premature delivery, Fetal distress or demise, Preterm pre-labor rupture of membranes, Significant maternal disease, Vaginal bleeding, Complications of tocolytic treatment, Continued fetal monitoring that require inpatient care, Tocolytic therapy needed that requires inpatient care, and Inability to stop preterm labor.

Observation care is appropriate for patients with one or more of the following:
Condition requiring premature delivery suspected, Preterm premature rupture of membranes suspected, Suspected maternal infection, Ongoing uterine contractions (tocolytic therapy needed, monitoring of cervical changes needed), Fetal distress suspected, Suspected placenta previa, and vasa previa or placenta accreta.

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: Dyspnea, cough, wheezing
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient who presented to the emergency department (ED) complaining of dyspnea, a cough and wheezing. Her medical history was remarkable for asthma, hypertension, obstructive sleep apnea and nonischemic cardiomyopathy. Her physical exam was remarkable for wheezing. An electrocardiogram showed sinus tachycardia with nonspecific ST segment and T wave abnormalities. A viral screen was positive for enterovirus/rhinovirus.  Chest computed tomography (CT) angiography showed no evidence of a pulmonary embolism. She had mild hypokalemia and hypomagnesemia. The patient was treated with intravenous steroids, albuterol, Atrovent, aspirin, magnesium and potassium. She had persistent wheezing and was admitted to the hospital. Steroids, albuterol and Atrovent were continued. She had a persistent cough and wheezing. The Solu-Medrol dose was increased. Intermittent wheezing persisted. Her heart failure medication regimen was adjusted. Farxiga and Entresto were prescribed. She was discharged. The medical necessity of an inpatient admission is under review.

Based on the documentation provided, an inpatient level of care was medically necessary.
This patient presented to the emergency department with an acute exacerbation of asthma due to a respiratory virus infection. She had an incomplete response to therapy in the emergency department with persistent wheezing despite treatment with steroids, albuterol and Atrovent and was admitted to the hospital. The wheezing continued for more than 48 hours post-presentation with oxygen saturations as low as 91 percent (%); levels less than 94% are considered an indication for hospitalization. This patient had a history of nonischemic cardiomyopathy. Her N terminal proBNP level was 32 picograms per milliliter (pg/ml) upon presentation and increased more than 50-fold by the next day suggesting some degree of heart failure decompensation. Heart failure in patients with asthma is a serious comorbidity associated with an increased risk for adverse events, including mortality. Given this patient's persistent symptoms despite treatment, her arterial oxygen desaturation and her risk for adverse events, careful and continuous monitoring with the ability to intervene emergently, if needed, was medically necessary. This warranted an inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headaches (Migraines)
Treatment: Botox Injection
The insurer denied: Botox Injection
The denial is overturned.

The patient is an adult female with chronic migraines. She is currently on Emgality. She is also on Eletriptan for migraine abortive. The Provider wishes to start Botox, the request was previously denied as patient had not tried at least 2 different medications from 2 different classes for migraine prevention.

Botox is medically necessary. 

The patient has chronic migraines and the American Academy Neurology Botox guidelines recommends the use of Botox for chronic migraines noted that Botox is establishing a safe and effective for reducing the number of headache days and chronic migraines. There is no recommendation of trying at least 2 preventative medications before trying Botox.
Appeal type: Step Therapy
Decision: Overturned

Diagnosis: Diabetes
Treatment: Mounjaro
The insurer denied: Mounjaro
The denial is overturned.

This is an adult male with type II diabetes. Request for continuation of Mounjaro is under review. The prior request was denied because "your doctor must provide documentation showing that you have had serious side effects or drug failure to two of the following: Ozempic, Trulicity, and Victoza." The provider is appealing this determination. The patient was started on Mounjaro last year with improvement in glycated hemoglobin (A1C) from 6.9 percent to 5.4 percent. He was able to stop Humalog and taper U-500 insulin from 90 units daily to 10 units daily.

The proposed Mounjaro is medically necessary.

This request is for the continuation of Mounjaro for the treatment of type two diabetes. The prior request was denied as the patient has not tried two of the formulary glucagon-like peptide 1 (GLP-1) receptor agonists, Ozempic, Trulicity, and Victoza. Mounjaro has been shown to be superior to Ozempic, the most potent glucagon-like peptide 1 receptor agonist [1]. The mean change from baseline in the glycated hemoglobin level was 2.01 percentage points, 2.24 percentage points, and 2.30 percentage points with 5 milligrams (mg), 10 milligrams, and 15 milligrams of Mounjaro, respectively, and 1.86 percentage points with Ozempic; the estimated differences between the 5 milligrams, 10 milligrams, and 15 milligrams Mounjaro groups and the Ozempic group were 0.15 percentage points (95 percent confidence interval [CI], 0.28 to 0.03; P=0.02), 0.39 percentage points (95 percent CI, 0.51 to 0.26; P less than 0.001), and 0.45 percentage points (95 percent CI, 0.57 to 0.32; P less than 0.001), respectively. This is of clinical importance to this patient who has required multiple daily insulin injections. Without Mounjaro, this patient will be at high risk of uncontrolled hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, yes, the proposed Mounjaro is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol and Drug Withdrawal
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult female with a history of alcohol abuse and alcohol withdrawal seizure. She presented for detoxification from alcohol and Xanax. Her vital signs were stable. Her heart rate was 85. Her exam was unremarkable. Her Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score was three. Complete blood count (CBC) and basic metabolic panel (BMP) were unremarkable. Urine toxicology was positive for alcohol. 
Electrocardiogram (EKG) showed normal sinus rhythm. The patient was admitted with alcohol withdrawal. Plan of care included Ativan taper. The patient remained clinically stable and asymptomatic during the hospital stay. Ativan was tapered and the patient was discharged on day #(number) 4.

The proposed treatment was not medically necessary. 

This patient with a history of alcohol abuse and withdrawal was admitted after presenting for alcohol detoxification. She was not acutely intoxicated. The patient was hemodynamically stable and afebrile. She did not have tachycardia or arrhythmia. The exam was unremarkable for findings of alcohol withdrawal. She did not have comorbid conditions. The patient was admitted with a plan for Ativan taper. During her hospital stay, she did not have findings of alcohol withdrawal. She was being managed with oral medication assisted treatment. The patient was clinically stable and did not have symptoms that required an acute inpatient level of care. She had not failed a lesser level of care. The acute inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Stone. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult female with history of stones who presented to emergency department with flank pain. She had a urinalysis with no signs of obstruction. Ultrasound showed mild hydronephrosis with no stones reported. The patient refused computed tomography scan and was discharged to home with Toradol and hydrocodone. The patient represented with complaint of pain refractory to the Toradol and hydrocodone, some nausea without vomiting, and no fevers or chills. A computed tomography scan demonstrated a four millimeter partially obstructing stone at the right ureterovesical junction (UVJ) with mild right hydroureteronephrosis. The left kidney had left pelviectasis without significant hydronephrosis. Lab values were normal on initial presentation, however on presentation the next day, the patient's white blood cell count was 12, her creatinine was 1.25 (normal up to 1.20), urinalysis had 13 red blood cells, no bacteria, negative nitrites, and negative leukocyte esterase. The patient received a bolus of saline, fentanyl, Zofran, ketorolac, Compazine and Rocephin in the emergency room. Urology consulted and recommended admission. 
On the day after admission, the patient's creatinine increased to 1.3. She received three doses of intravenous morphine and one dose of intravenous Dilaudid. On day #3, the patient's white blood cells decreased to 9.1, her creatinine remained at 1.3, she received two doses of intravenous Dilaudid and she was taken to the operating room. She underwent cystoscopy, ureteroscopy and stent placement and was discharged to home later that day. 

The acute inpatient admission was denied as not medically necessary - severe problems did not exist. 

The proposed inpatient hospital admission was not medically necessary. 

This patient represented to the emergency department with recurrent severe pain and nausea - on presentation she was dehydrated requiring intravenous fluids and received medication for nausea and pain. Despite this, the patient had no hemodynamic instability noted, she was not described as septic, she was afebrile, her urinalysis did not show signs of infection, and she had a normal contralateral kidney and thus could have been treated at a lower level of care. Furthermore, the procedure anticipated if her pain did not resolve, or the stone did not pass is a procedure which does not require inpatient admission and the patient is routinely discharged to home after.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Excess skin and tissue of arms. 
Treatment: Lipectomy of arms (removal of excess skin and tissue). 
The insurer denied the lipectomy of arms (removal of excess skin and tissue). 
The denial is upheld. 

This patient has lost 70 pounds following bariatric surgery. She complains of bothersome excess skin on her arms. The skin causes anxiety. Brachioplasties are planned. 

The proposed treatment is not medically necessary. 

The records do not establish medical necessity for the proposed brachioplasties. The patient's condition does not meet the American Society of Plastic Surgery criteria for third party coverage of skin resection following massive weight loss. According to the American Society of Plastic Surgery Position Paper "Treatment of Skin Redundancy For Obese and Massive Weight Loss Patients" (1), "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic. Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically, these procedures are performed to improve appearance and are therefore cosmetic in nature." The records do not document any rare circumstances that mandate treatment with brachioplasties. According to a 2010 outcome analysis of brachioplasty surgery, "Patients report improvement in contour and self-esteem, and a high level of satisfaction with this procedure, despite the potential for an unfavorable scar." This study found improvements in self-esteem and contour but did not describe functional benefits from brachioplasty surgery. According to Sergesketter et al.: "Brachioplasty has become one of the fastest-growing aesthetic surgery procedures, paralleling rising rates of weight loss surgery nationally." The records do not document any health or functional problems due to the excess arm skin. The procedure will primarily improve appearance and is cosmetic.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic
inpatient hospital

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

This case describes a female patient with a history of right elbow contracture. She had undergone prior surgery for a displaced right radial head fracture a few years earlier and had persistent stiffness in the affected right elbow. She opted to undergo elective right elbow contracture release and concomitant right elbow ulnar nerve transposition. The surgery was completed successfully with no documented complications. The patient was deemed stable for discharge home.

The inpatient hospital admission was not medically necessary for this patient.
First, the provided medical records document that this patient opted to undergo elective right elbow contracture release along with ulnar nerve transposition. She had previously undergone surgery for a displaced radial head fracture and had a persistent and painful right elbow contracture. The care rendered was consistent with the current standard of acre as documented by Aldridge and colleagues in their article published in the Journal of Shoulder and Elbow Surgery in 2020. According to the records, this surgery was successful with no documented complications. The patient was then admitted to the hospital for further monitoring and care. The patient had a surgical drain removed and her pain was controlled. Her lab values and vital signs were within normal limits, yet she remained in the hospital for another night until her discharge. Based upon the provided records and the recommendations of the peer-reviewed literature, the inpatient hospital admission was not medically necessary in this case. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 
 
Asked to review the case of an adult that presented to the first hospital with complaints of dyspnea, cough, orthopnea and pedal edema. Work up revealed influenza B infection and bilateral pulmonary infiltrates on computed tomography (CT) scan.  Her hospital course was complicated by persistent dyspnea and echocardiography revealed significant mitral and aortic valvular disease as well as congestive heart failure.  She was transferred to another hospital for work up and treatment of congestive heart failure.  Upon arrival vital signs were stable. Physical examination was significant for a 3/6 systolic murmur. Serum blood testing revealed hypokalemia with a potassium of 3.2 and an elevated B type natriuretic peptide 1692.  Transesophageal echocardiogram revealed a left ventricular ejection fraction of 45-50%, a bicuspid aortic valve with severe aortic stenosis and severe aortic regurgitation. Cardiac catheterization was ordered in preparation for aortic valve replacement surgery.  Results confirmed severe aortic stenosis and revealed normal coronary arteries.  The patient was treated medically with beta blocker therapy and diuretics and discharged with plans for eventual aortic valve surgery. 

This patient presented with symptoms of heart failure complicating a recent viral infection and required extensive work up for bicuspid aortic valve with severe stenosis and regurgitation. Recent American Heart Association/American College of Cardiology guidelines recommend a multidisciplinary approach when treating patients with valvular heart disease and congestive heart failure in order to prevent worsening of heart failure and adverse outcomes. (Reference 1) Given this patient's presentation with acute and difficult to manage congestive heart failure, it was appropriate that such a multidisciplinary approach occur in an inpatient setting.  Masri et al. compared patient outcomes following treatment of acute congestive heart failure in observation and inpatient settings and demonstrated a significant readmission rate in patients managed in observation. (Reference 2) Patients in this study that required cardiac catheterization and detailed diagnostic work up tended to be managed utilizing an inpatient hospital strategy.  This patient presented with severe aortic stenosis and regurgitation and congestive heart failure that required inpatient treatment and work up.  

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 the inpatient admission is substantiated.