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

Cardiac
inpatient hospital

Diagnosis: chest pain
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned

The patient is a male who presented to the emergency department (ED) complaining of acute onset chest pain and diaphoresis. In the emergency department (ED), his blood pressure was 163/95 with a heart rate of 76 beats/minute. His respiratory rate was 18/minute with a room air oxygen saturation of 99%. An electrocardiogram showed inferior ST segment elevation consistent with an acute inferior ST segment elevation myocardial infarction. 

Based on the documentation provided, the inpatient hospital stay was medically necessary.
This man presented with an acute ST segment elevation myocardial infarction (STEMI) that was treated with a stent. The procedure was complicated by transient no-reflow phenomenon. Patients with STEMI are at significant risk for major adverse events including cardiogenic shock, malignant arrhythmias and death. They require careful and continuous monitoring with the ability to intervene emergently, if needed. Inpatient admission is the standard of care for patients with STEMI and is endorsed by the current guidelines. Moreover, the 2017 expert consensus document update from the Society for Cardiovascular Angiography and Interventions recommends inpatient admission following percutaneous intervention for patients with acute STEMI.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hernia
Treatment: Inpatient Hospital Stay.
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a male patient who presented to the hospital to undergo a scheduled repair of a recurrent ventral hernia. The past medical history included hypertension, hyperlipidemia, coronary artery disease, bipolar disorder and hypothyroidism. His vital signs were normal at the time of presentation to the hospital.

The records indicate that the patient underwent repair of a recurrent incisional hernia with explantation of prior mesh, component separation, musculofascial advancement flaps and implantation of mesh. The hernia defect size was 15-centimeters (cm) x 9-cm. Surgical drains were placed. The records state that the operation required between 2-3 hours to complete.

He was monitored in the hospital following surgery. The patient remained hemodynamically stable with normal vital signs following surgery. The diet was advanced. The patient was deemed to be stable for discharge from the hospital. At issue is the medical necessity of an inpatient stay.

Based on the submitted medical record and the referenced InterQual Guidelines, inpatient level of care was not required or medically necessary for this patient.
This patient had a large recurrent incisional ventral hernia. He patient presented to the hospital to undergo the elective repair of this hernia. He was hemodynamically stable at the time of presentation. The operation to repair the ventral hernia was performed without complication. The submitted records document clinical stability in the perioperative period and that the patient met criteria for discharge from the hospital on the first post-surgical day. While the operation included explantation of prior mesh, component separation, musculofascial advancement flaps and implantation of mesh, it was completed without complication and the patient was able to be advanced on a diet and oral pain management following surgery.
Per generally accepted guidelines for patient care, inpatient stay is needed for hemodynamic instability, peritoneal signs, suspected acute mesenteric ischemia, foreign body ingestion with signs of obstruction, surgical complications or other clinical issue that requires inpatient confinement. In this case, there is no documentation to support that these criteria existed to warrant an inpatient level of care. 

The health plan's determination is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left hip osteoarthritis
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay.
The determination is upheld. 

The patient is a female patient with a known history of left hip osteoarthritis. She failed conservative treatment for this condition and opted to undergo elective left total hip replacement surgery. The surgery was successful with no documented complications. The patient was subsequently admitted to the hospital for post-operative care and supervised physical therapy. The patient was eventually deemed stable for discharge home with home nursing care and home therapy.

The requested health service/treatment of an inpatient hospital admission was not medically necessary for this patient. The provided medical records document that this patient underwent a routine, elective left total hip replacement surgery. The operation was successful with no documented complications. The patient had an uneventful postoperative course after total hip replacement surgery. Her laboratory values and vital signs were within normal limits. In addition, there was no documentation of post-operative bleeding complications, no clinical signs of infection, and no evidence of deep vein thrombosis that would mandate a three night inpatient hospital admission.
The patient progressed well with supervised physical therapy following this elective total hip surgery and was recommended for home discharge with home health and home physical therapy. Based on the documentation in the provided records and progress notes, the patient was stable post-operatively and could have been discharged home under an alternate level of care hospital admission. This type of hospital stay is supported by the peer-reviewed research published by Leroux and colleagues in the Journal of Bone and Joint Surgery. The authors concluded that "When comparing matched cohorts of patients who underwent short-stay and longer-stay total hip arthroplasty (THA) or total knee arthroplasty (TKA), we observed no difference in outcomes, suggesting that a short stay with a discharge home in the appropriately selected patient is safe following THA or TKA." Thus, the short stay is supported in this case in which the patient underwent a routine elective total hip replacement operation with no documented complications.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hand Infection
Treatment: Inpatient admission
The insurer denied inpatient admission.
The health plan's determination is upheld. 

This patient is a female house cleaner with a past medical history (PMH) of vertigo who presented to the emergency room complaining of severe left thumb pain with decreased ability to move her finger. She reported worsening left thumb pain, redness and swelling for 2 days at an intensity of 10/10 associated with decreased ability to move her finger. She reported no history of trauma or laceration to her finger while working as a house cleaner. On assessment, she was tachycardic with a heart rate of 101, she had "erythema from base of thumb distally, circumferentially...tenderness of flexor surface from distal to proximal interphalangeal joints (PIP) to pulp, tenderness of proximal and distal segments dorsally, minimal flexion of distal interphalangeal (DIP) and PIP secondary to pain, decreased passive range of motion (ROM), unable to fully-oppose, pain in volar and dorsal sides with passive extension."
Her laboratory workup was significant for a white blood cell count (WBC) at 14.44, neutrophil absolute (Abs) at 9.98, and lymphocyte at 18.6. Given her 2 days of worsening left thumb pain associated with redness and swelling, there were concerns for possible flexor tenosynovitis versus (vs) cellulitis. She was admitted as an inpatient for dual intravenous (IV) antibiotics, strict hand elevation, pain control and management as well as serial laboratory workup.
The patient's pain and swelling did not improve. She underwent an incision and drainage (I&D) of dorsal fluctuance of her left thumb. Post procedure, her left hand was placed in a betadine/soap soak wherein a dressing was applied. She continued to receive dual IV antibiotics, she was maintained on strict hand elevation in stockinette as well as pain control management. Her symptoms improved following incision and drainage and she was discharged.
At issue is the medical necessity of inpatient admission.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of inpatient admission is not medically necessary for this patient.
This patient was medically stable and needed only antibiotics and incision and drainage. She was ready for home within 24 hours of incision and drainage. The patient had a hand infection that responded to appropriate treatment with antibiotics and surgical drainage. She was otherwise clinically stable and not in need of intensive care unit treatment or constant nurse monitoring per the documentation. In this case, the patient responded rapidly to the interventions and was able to be safely transitioned to home. Inpatient admission was not required because the patient responded rapidly and appropriately to treatment interventions.
Therefore, the requested health service/treatment of inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 

Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld.  

Asked to review the case of a patient that presented to the hospital with chest pain, and cough. Pain was exacerbated when coughing. Past medical history was significant for ischemic heart disease and coronary artery bypass graft (CABG). On arrival to the hospital vital signs were stable (blood pressure 135/72, pulse 48, temperature 98.6 degrees).  Physical examination was positive for crackles in the left intrascapular region. 12 lead electrocardiogram (ECG) revealed sinus bradycardia without nonspecific T wave inversions in the anterior and inferior leads. Serum blood testing demonstrated a normal white blood cell count (5.2) and troponin was not elevated (<4). The patient was admitted to the hospital for observation and additional testing.  Echocardiogram demonstrated a preserved left ventricular ejection fraction (50 %) and moderate to severe pulmonary valve regurgitation. Computed tomography (CT) of the chest demonstrated no evidence of pulmonary consolidation or pneumonia. The patient remained afebrile off of antibiotic therapy and waited for several days to undergo exercise perfusion testing and was ultimately discharged on medical therapy with cardiology follow up. 

This patient presented with atypical chest pain that was pleuritic in nature. Her pretest probability of coronary artery disease was high (1).  Utilizing the HEART (History, ECG, Age, Risk Factors, Troponin) score the patient was considered low risk (2).  Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days (3). Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the Thrombolysis in Myocardial Infarction (TIMI) risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, 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 admission to is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain. 

Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This patient had an acute episode of low back pain without antecedent trauma. The patient does have a history of epilepsy. The patient's spine x-rays were negative.  The patient was given Toradol, Diazepam and Tylenol during admission. Inflammatory markers were elevated. The health plan denied the admission. 	

The patient did not have Red Flag symptoms and was not administered intravenous opiates. Clinical practice guidelines1 do not support admission absent Red Flag symptoms. 

Casazza2 reviewed symptoms (Red Flags) that should prompt aggressive treatment.  The patient did not have any of these: 

"Certain red flags should prompt aggressive treatment or referral to a spine specialist, whereas others are less concerning. Serious red flags include significant trauma related to age (i.e., injury related to a fall from a height or motor vehicle crash in a young patient, or from a minor fall or heavy lifting in a patient with osteoporosis or possible osteoporosis), major or progressive motor or sensory deficit, new-onset bowel or bladder incontinence or urinary retention, loss of anal sphincter tone, saddle anesthesia, history of cancer metastatic to bone, and suspected spinal infection. Without clinical signs of serious pathology, diagnostic imaging and laboratory testing often are not required." 

The in-patient hospital admission was not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan acted 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: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Dupixent
The insurer denied the request for Dupixent.
The health plan's determination is upheld.

The patient is a female with moderate to severe atopic dermatitis associated with eczematous patches and plaques of the hands and fingers. The patient frequently works with her hands. The patient has tried and failed topical Triamcinolone ointment and cream, Hydrocortisone, Clobettasol, Ketoconazole, and Opzelura.

The requested health service/treatment of Dupixent is not medically necessary for this patient. The patient has no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors, and/or standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Methotrexate, Azathioprine, or Mycophenolate Mofetil) that would obviate the need for further topical therapies (despite these oral medications not being required step therapy for Dupixent). Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, as per the patient's health plan policy language [1], and consistent with current medical literature [2-5], the requested Dupixent is not medically necessary and does not meet the health plan coverage requirements.
 The patient has not tried and failed nonsteroidal therapies, including Tacrolimus (Food and Drug Administration (FDA)-approved for moderate to severe atopic dermatitis), which has the ability to reduce reliance of topical steroids to control this patient's condition. Alternative oral and/or light therapies have not been tried and failed to conclude that further topical therapies would be unlikely to benefit this patient.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intrauterine Fetal Demise. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The health plan's determination is upheld. 

The patient is a pregnant female at 20 weeks gestation who presented with no fetal heart tones at the obstetric triage. She was admitted as an inpatient for an intrauterine fetal demise (IUFD) for delivery. She delivered and was discharged the next day. 

The requested health service/treatment of Inpatient Hospital Stay is not medically necessary for this patient. The patient was without significant comorbidities. She had an IUFD however no hemorrhage, anemia nor need for blood transfusion. Her vital signs were normal and she had no hemodynamic instability. This can be managed at an alternate level of care with a dilation and evacuation in a surgical center or in an outpatient facility. There was no reason for acute, inpatient monitoring. She had no pulmonary, renal or hepatic concerns. She had no hemorrhage, infection nor poor healing. 

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: pyelonephritis
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a female without significant past medical history who presented complaining of right sided abdominal and flank pain which began the day prior. The pain was intermittent and sharp in nature. She also reported nausea and vomiting. She denied fevers, chills, chest pain ,urinary symptoms, change in bowel habits, weakness or visual defects. She was bradycardic with a pulse in the 50s with blood pressures in the 100/50s. She was afebrile and not hypoxic. On exam, she had mild costoverterbral tenderness on the right side. Her laboratory tests were unremarkable. A urinalysis showed large blood but was otherwise unremarkable. A computed tomography (CT) of the abdomen and pelvis showed multiple patchy segmental defects in her right kidney suggesting possible ischemia versus pyelonephritis. 

The inpatient admission was medically necessary in this case. The patient presented with acute onset of right flank pain associated with nausea and vomiting. An initial evaluation in the emergency room led to a diagnosis of pyelonephritis versus renal infarcts. Given the uncertainty of the diagnosis, the patient's presenting symptoms, and the risk of decompensation with untreated systemic embolic disease she required admission for further management, testing and treatment to ensure that she had the best possible outcome. Untreated systemic embolic diseases could lead to end organ damage and death.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic
Pharmacy/prescription drug

Diagnosis: osteoporosis
Treatment: Romosozumab (Evenity)
The insurer denied Romosozumab (Evenity)
The health plan's determination is overturned.

The patient is a female diagnosed with severe Osteoporosis. As reported, she is on Methimazole for hyperthyroidism due to Grave's disease. She has high parathyroid hormone (PTH) levels. She has no history of fractures.

Romosozumab (Evenity) is medically necessary.
Romosozumab (Evenity) is Food and Drug Administration (FDA) approved for osteoporosis [1]. It has been shown to be effective in the treatment of osteoporosis [2, 3].
The American Association of Clinical Endocrinologists recommend the use of Romosozumab (Evenity) over other treatments in patients with very high risk of fracture defined as:
Recent fracture (e.g., within preceding 12months), fracture while on anti-osteoporosis medication, multiple fractures, fractures while taking drugs that affect bone adversely (eg, long-term glucocorticoid therapy), a bone mass density (BMD) T-score <=3, high risk of falls or previous history of injurious falls, and a very high fracture probability (the example given is a FRAX score >30% for major osteoporotic fracture and >4.6% for hip fracture).
The patient has a T-score at spine was -3.8; LFN (left femoral neck) was -2.4; left total hip was -1.6; left total forearm was -3.0.
The patient has a very high risk of fracture at the spine. Romosozumab (Evenity) is preferred for patients such as this patient. Therefore, it is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse.
Treatment: Inpatient Admission.

The insurer denied the Inpatient Admission.  The determination is upheld.

The patient is a male, who presented to the emergency department with a request for detoxification treatment and was medically screened and admitted to inpatient level services for detoxification of heroin and cocaine use, as well as intermittent use of cannabis.

The patient had no history of severe withdrawal symptoms or complicated withdrawal. He also used unspecified amounts of street buprenorphine/Suboxone on occasion. His referral was prompted by his desire to receive substance abuse treatment in the context of continued use of substances despite participating in multiple past substance use disorder treatments with relapses.  He presented with mild symptoms of withdrawal with a Clinical Opiate Withdrawal Scale (COWS) scale score of 10 with joint pain, sweats and chills, irritability, and insomnia together with normal vital signs. 

There were no acute or chronic general medical issues in this case. 

His mental status examination was free of severe symptoms such as thought disorder, mood disturbance, psychosis, cognitive impairment, or perceptual disturbance. 
The patient was admitted and placed on a detoxification regimen with methadone, comfort medications, as well as vitamin replacement therapy. The detoxification was uncomplicated regarding withdrawal management with no complaints other than persistent aches and anxiety that resolved on day 3 of the detoxification treatment episode.

At issue is the medical necessity of inpatient admission.

The requested health service/treatment of inpatient substance abuse admission was not medically necessary for this patient. The requested treatment and withdrawal management and other medical services could have been safely and effectively provided with lower-level services. The patient was using heroin together with crack cocaine on a continuous daily basis, as well as intermittent use of cannabis. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have warranted admission for inpatient level services. The withdrawal symptoms were not reported to be severe, and the patient's clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment or monitoring. There were no safety concerns in this case and no history of complicated withdrawal from drugs or alcohol. The patient was motivated for detoxification treatment and had access to substance use disorder services in the community.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied Braces.
The determination is overturned.

This is a female patient with a Class II(two) Division 1 malocclusion with maxillary and mandibular crowding. She has an 8-millimeter (mm) overjet and 3 mm overbite. She is treatment planned for 24-30 months of orthodontics with extraction of teeth 5 and 12 to correct her malocclusion. At issue is the medical necessity of braces.

This patient, like fifteen percent of the population, exhibits an Angle's Class II bite. (1) Patients with a Class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. (2) Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6 plus (+) mm overjet, which this patient has. (3) For these reasons orthodontic treatment is deemed medically necessary.