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

Diagnosis: Blood Disorder 
Treatment: Inpatient Hospital 

The insurer denied the inpatient stay. The denial is upheld in whole. 

The patient is a female with past medical history of sickle cell disease and unprovoked deep vein thrombosis who presented to the emergency department with acute onset of right shoulder and upper arm pain. On presentation, she was afebrile with heart rates in the 80s, systolic blood pressures in the 140s-160s, with oxygen saturation 94-96% on room air. Exam otherwise noted no clear acute abnormalities. Labs resulted with hemoglobin (HGB) 8.5, platelets 424, elevated lactate dehydrogenase (LDH) at 784, increased reticulocyte count, and with basic metabolic panel otherwise normal. Computed tomography (CT) venogram of the right upper extremity did not show any evidence of deep vein thrombosis. She received intravenous (IV) fluids and Dilaudid IV x2 in the emergency department with resultant vomiting and only mild pain relief. The patient was subsequently brought into the hospital with concerns for sickle cell disease and acute vaso-occlusive pain crisis with plans for IV hydration, supplemental oxygen, oxycodone and IV morphine as needed, hematology consultation, and consideration of starting hydroxyurea. 

She remained hemodynamically stable without fever, hypotension, tachycardia, tachypnea, or hypoxia. She received IV morphine x 1 overnight for pain. The plan was to continue IV fluids in addition to pain control and the patient was transitioned to a full oral regimen of oral narcotics and Tylenol. The patient was discharged. 

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

Inpatient care was not medically necessary for this patient. This is a patient who presented with a sickle cell crisis as manifest by arm pain requiring pain control with oral and IV opioids. She was hemodynamically stable without evidence of fever, hypotension, tachypnea, or hypoxia, did not have evidence of other serious sickle cell complication such as acute chest syndrome, or cerebrovascular accident (CVA), and her pain was adequately managed without a patient controlled analgesia (PCA) pump and with only oral medications within 48 hours. Pain management could have been provided safely at a lower level of care status in the absence of any other complications of sickle cell disease. Inpatient care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/circulatory.
Treatment: Home health care.
The insurer denied the Medical Necessity of PCA services.
The health plan's determination is overturned in whole.

The patient has a past medical history of diabetes mellitus (DM) type 2, hypertension, gastroesophageal reflux disease (GERD), coronary artery disease, cerebrovascular accident (CVA) with left sided hemiplegia, dysphagia, dementia, incontinence of bowel and bladder, falls, and anxiety who had been assigned 12 hour/day, 7 days/week to total 84 hour/week of Personal Care Assistant (PCA) services. The patient had a stroke with resultant left hemiparesis and dysphagia. The patient was hospitalized with diabetic ketoacidosis and severe sepsis. There was a request for increase in PCA services to 24 hours/day, split-shift, 7 days/week to total 168 hours/week. The patient had assessment tool performed showing the patient required total assistance with tasks of meal preparation, ordinary housework, stairs, shopping, transportation, bathing, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use and clean up, maximum assistance with tasks of personal hygiene and bed mobility, and extensive assistance with tasks of managing finances, managing medication and phone use. The assessment noted the patient had complete incontinence of bowel and bladder and requires a Hoyer lift for any type of transfer and is wheelchair bound. In addition, the assessment reported the patient needs assistance with positioning in bed. The patient's primary care physician wrote a letter stating the patient is unable to turn self in bed and needs diaper change and position change to prevent bed sores. The patient was then assigned 24 hour/day, live-in, 7 days/week to total 168 hours/week of PCA services.
The requested service of personal care services to 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week is medically necessary for this patient.
The patient had CVA with left hemiparesis and dysphagia with the need to be transferred to and from bed in a Hoyer lift. The patient is wheelchair bound. The patient has no informal helper. The patient has complete bowel and bladder incontinence and requires toileting and clean up in the overnight hours at unpredictable times. The patient also is unable to reposition in bed and would require repositioning in the overnight hours to prevent sores. A live-in PCA, as previously approved, would not be able to get 5 hours of uninterrupted sleep due to the patient's care needs with activities of daily living (ADL's) in the overnight hours. The patient's PCP provided letter of medical necessity for the overnight care needs stating the patient is unable to turn self in bed and needs diaper change and position change to prevent bed sores.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System
Inpatient hospital

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

The patient is a boy who presented with generalized seizures.
He was well until the day of admission, when he was witnessed at school running around, and then becoming wobbly and disoriented. He vomited 2 times and then was noted to have approximately 3 seizures. He was described as becoming tonic on the right side with shaking and right eye deviation. He was given 5 milligrams (mg) of intravenous Valium at that time which seemed to abort the seizure. His past history is significant for a febrile seizure at age 2, with no further episodes after that.
Upon arrival in the emergency department, he was described as being in mild distress, and there was initially concern for possible need for intubation because of a concerning venous blood gas (VBG) with a pH of 7.18 and a CO2 of 81. He was noted to be hypothermic with rigors, his eyes were deviated to the right and his pupils were described as pinpoint and nonreactive.

The inpatient hospitalization was medically necessary for this patient.
This is a young boy who presented after a significant seizure event at school. Upon presentation, he was unresponsive and had an abnormal VBG. He required prompt evaluation for a first-time non-febrile tonic-clonic seizure and close observation with further intervention as needed.
The decision-making at the time of admission was consistent with his young age, the presence of a new onset seizure with unresponsiveness and acidosis the time of presentation, and the need for prompt evaluation and monitoring and initiation of further therapies as needed for potential deterioration in clinical status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression, Suicidal Ideation.
Treatment: Inpatient admission.
The insurer denied the inpatient hospitalization.
The denial was overturned. 

This is a female patient who was admitted for inpatient mental health treatment due to worsened depression, suicidal thoughts and self-harm behaviors including scratching self, and feelings of hopelessness. The patient also exhibited behaviors of eating disorder such as restricting and purging. The patient had multiple past suicide attempts including overdose and hanging. The patient reportedly had multiple past inpatient psychiatric hospital and residential treatments. It was reported that she tried to elope several times from the residential treatment and also made suicide attempts, such as strangulation while in the residential treatment. The patient was diagnosed with Major Depressive Disorder and Generalized Anxiety Disorder. The patient continued to report suicidal ideation and was discharged to residential treatment. 
  
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk for suicide. In this case, this patient had a history of multiple suicide attempts including suicide attempt while in a 24-hour residential treatment in which she tried to hang and strangulate herself. During the denial period, the patient continued to report severe depressive symptoms including depressed mood and suicidal thoughts. The patient reported suicidal plans to hang self or slit her wrist; thus, she was considered a high risk for suicide while still reporting suicidal ideation.  The patient could not safely be discharged to an outpatient setting and needed to remain in this 24-hour hospital setting until her discharge to the 24-hour mental health residential treatment. The patient's history of multiple suicide attempts with this current, active suicidal thoughts and depressed mood put this patient at high risk for suicide. The APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors also reports that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital and that observation in the hospital is appropriate to better ensure their safety. This was the case scenario for this patient. In order to ensure this patient's safety, continued inpatient mental health service was medically necessary. The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for inpatient mental health services is substantiated.  The insurer's denial should be overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Respiratory System
Treatment: Pharmacy/Prescription Drug
The insurer denied: Alvesco
The denial is: Upheld in whole

The patient is a female who suffers from asthma. The treating provider is requesting coverage for treatment with Alvesco. According to a letter from the treating provider the patient tried and failed or has been intolerant to Arnuity, QVAR, Pulmicort and Flovent. The patient has been stable on Alvesco for four years.

The health plan's determination is upheld, in whole. 

The formulary drug (Arnuity Ellipta, Asmanex, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler, QVAR Redihaler) would not be/has not been ineffective and would not be less effective than the non-formulary drug Alvesco. The formulary medication will be as effective and safe as the non-formulary drug Alvesco.
There is no convincing and objective evidence (in terms of office progress notes) that the patient failed or has been intolerant to Arnuity, Flovent, Pulmicort Flexhaler, and QVAR. There is no evidence that Alvesco is superior to Arnuity, Flovent, Pulmicort Flexhaler, or QVAR in the management of asthma.
There are no adequate or well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature that established the long term efficacy and safety of Alvesco over Arnuity, Flovent, Pulmicort Flexhaler, or QVAR in the treatment of asthma.
There is no high-quality literature showing an improvement in health outcomes with the use of Alvesco over other inhaled steroids for this patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis 

Treatment: Inpatient admission 

The insurer is denied coverage for inpatient admission.

The denial is upheld. 

This patient a female with right sided chest, elbow, thumb swelling and redness prior to admission. Patient was seen in urgent care, treated with Benadryl and sent to emergency department (ED) for further evaluation. In ED patients was diagnosed with cellulitis and treated with IV clindamycin. Patient had unremarkable diagnostic evaluation (normal CBC, CRP ESR) and was discharged to home within 24 hours of admission to complete many days of clindamycin by mouth. Patient did not have fever and did not appear septic on presentation. It is not clear to the reviewer why the patient required inpatient admission status given the low risk for serious complications of cellulitis (i.e.bacteremia).  

As noted by Stevens et al: "Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability (mild nonpurulent; Figure 1) (strong, moderate). Hospitalization is recommended if there is concern for a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a severely immunocompromised patient, or if outpatient treatment is failing (moderate or severe nonpurulent;"

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Brain lesions
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a history of hepatitis B virus infection who presented to the Emergency Department with complaints of a cough and speech change for six months. His cough had started a year ago. Of note, some of the documentation indicates the presence of cough for one month. It had worsened and he developed a change in voice and pleuritic chest pain. On exam in the Emergency Room, he was oriented times one and Dysarthric. 

Chest x-ray had no mass or infiltrate. Head computed tomography (CT) showed likely multiple metastatic lesions. CT of the chest/abdomen/pelvis was without evidence of a primary tumor

Flexible fiberoptic laryngoscopy was negative for a tumor. Magnetic resonance imaging (MRI) of the brain was performed and was read as most consistent with neurocysticercosis.

An Infectious Disease (ID) consult was performed. Neurocysticercosis was raised for the cause of the brain lesions. The ID consult requested outpatient follow-up within a month when discharged.

ID consult recommended lumbar puncture to obtain cerebrospinal fluid for cysticercus antibody and cell counts to assess for eosinophilia. ID recommended the start of antihelmintics.

Lumbar puncture was performed, and the patient was discharged.

No, the proposed inpatient hospitalization was not medically necessary.

The patient was an older gentleman. He presented with subacute/chronic complaints. He had a cough for one year and dysarthria for six months. His exams were normal, his vital signs were stable, and he was afebrile. The dysarthria was difficult to evaluate as he spoke only a foreign language.

CT of the head showed multiple brain lesions concerning for metastases. There was no evidence of hemorrhage. There was no edema or mass effect. All findings were consistent with the brain lesions being a chronic condition. 

The evaluation of possible brain metastases does not require acute inpatient hospitalization. (References 1, 2, 3)

Indications for admission for workup of brain lesions would include mass effect and hemorrhage. These were not present. 

An MRI of the brain was obtained and was most consistent with neurocysticercosis, which is an endemic in Eastern China. (Reference 4) Neurocysticercosis is a chronic condition and does not require inpatient workup and management. (Reference 5)

During the hospitalization, the patient remained clinically stable and evaluation (including MRI and lumbar puncture), which are normally performed as an outpatient, were performed. None of the dates of service were medically necessary at the inpatient level of care. 

The workup performed did not require acute inpatient hospitalization. It was not in the best interest of the patient to keep the patient in the hospital when this was not required.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Streptococcal pharyngitis
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

This is a male patient with a medical history significant for immunocompromising illness, throat cancer, alcohol and marijuana abuse, and recent tracheostomy (trach). The patient presented to the emergency room (ER) with 10/10 throat pain, a history of fever, decreased appetite, and complaints of difficulty breathing. The patient's bloodwork was significant for an elevated white blood cell count, normocytic anemia, transaminases, and an elevated lactic acid level. The patient also had a very low magnesium level of 1.1 which was attributed to dehydration and poor oral intake with nausea and vomiting. In the ER, the patient was diagnosed with streptococcal (strep) pharyngitis and was given intravenous (IV) Ofirmev and 1000cc normal saline IV fluid, magnesium, and IV Rocephin. The patient was admitted to the Medical Surgical unit and was seen by infectious disease (ID) who recommended oral amoxicillin every 12 hours for the patient's strep infection. The patient's chest x-ray was unremarkable. The patient's pain medication treatment included oxycodone, gabapentin and trazodone. The patient was seen by hematology/oncology services and the pain management team. The patient's trach had to be changed, and the patient improved clinically. The patient was appropriately treated for infection, pain, dysphagia, and electrolyte abnormalities. The patient's diagnostic studies revealed a lesion in the pancreas for which it was recommended that the patient follow-up as outpatient. 
   
Based on the review of the medical record and literature, the inpatient hospital admission was medically necessary for this patient. This patient had multiple comorbidities on admission including immunosuppression, dehydration, possible sepsis and high lactate levels. The patient was at risk for progressive malnutrition, worsening dehydration, aspiration pneumonia from vomiting, arrhythmias from hypomagnesemia, and progressive dysphagia. The patient was found to have a laryngeal epiglottic neoplasm that would require urgent therapy. To undergo such potential life-saving treatments, this patient's health status needed to be optimized as much as possible. With all these comorbidities and unknown causes for most of his symptoms, this patient required an inpatient level of care, and timely care that would have been difficult to obtain in an outpatient setting. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Recurrent falls
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female with hypertension and marijuana use who presented with recurrent falls related to chronic right lower extremity weakness.  

The patient's blood pressure was 176/105 in triage, related to the patient not having taken antihypertensive medications for the prior week.  Intravenous hydralazine was provided.  The electrocardiogram showed sinus rhythm without acute ischemic changes, and cardiac enzymes were negative.  Computed tomography of the brain demonstrated no acute process.  Laboratory indices were unremarkable.  The neurologic examination demonstrated 4-/5 strength in the right lower extremity with no other abnormalities.  

On admission the patient was afebrile with a blood pressure 140/93.  Home antihypertensive medications were reinitiated.  Computed tomography of the lumbar spine demonstrated degenerative disc disease at L3-4 and L5-S1; magnetic resonance imaging of the spine demonstrated moderate disc herniation at L5-S1 and multilevel degenerative changes with severe spinal stenosis at L3-4.  Physical therapy consulted.  Magnetic resonance imaging of the brain demonstrated findings consistent with chronic hydrocephalus, with no acute cerebrovascular accident.

The patient did not have syncope, new focal neurologic deficit (the mild right lower extremity strength noted on examination was documented to be chronic), seizure activity, decreased level of consciousness, arrhythmia, acute coronary syndrome, or injury related to the fall.  There was no evidence of fracture.  No acute finding was noted on computed tomography and magnetic resonance imaging of the brain and lumbosacral spine.  The elevated blood pressure on presentation was followed up with only a slightly elevated blood pressure at the time of admission.  No intravenous antihypertensive agents were required after admission.  There was no evidence of hypertensive emergency.  In summary, acute inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with no past medical history (PMH) who was admitted  with complaints of (c/o) a sore throat, fever, weakness and muscle aches. Of note, the patient had previously been treated with oral antibiotics, without improvement. Her vital signs were notable for a temperature of 102.1 degrees Fahrenheit, a pulse of 120, a peripheral capillary oxygen saturation (SpO2) of 97% on room air (RA), and a blood pressure (BP) of 128/84. The physical exam was significant for a leftward uvula deviation and swollen tonsils, lethargy, and no acute respiratory distress. The patient's lab work was notable for a white blood cell count (WBC) of 15 with a left shift. A computed tomography (CT) scan of the neck was completed which showed bilateral cervical adenopathy and small tonsillar abscesses. The patient was diagnosed with peritonsillar abscess and treated with intravenous fluids (IVF), pain control, intravenous (IV) steroids, and IV antibiotics. The patient was discharged in stable condition.

The health plan's determination is overturned.
This patient presented to the emergency department (ED) with c/o a several day history of throat pain and odynophagia associated with fever, tachycardia, and leukocytosis and an inability to take oral intake. She met sepsis criteria, the expected length of stay was greater than 24 hours, and the patient failed outpatient treatment. Overall, this patient presented with clear signs of sepsis, which increased her risk of complications and the need for close monitoring for these complications, such as airway obstruction, aspiration pneumonia, septicemia, internal jugular vein (IJV) thrombosis and mediastinitis. The failure of outpatient therapy and the specialist's confirmation of the need for IV antibiotics further suggested the need for intravenous antibiotics and that an inpatient level of care was required for safe medical evaluation, monitoring and treatment.

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

Diagnosis: Rectal bleeding 
Issue Under Review: Inpatient admission 

Determination: The inpatient admission was not medically necessary. 

The patient is a male. He was admitted via the emergency department to the hospital.  The patient noted rectal bleeding and generalized weakness the morning of presentation. The impression was hemorrhoidal bleeding as the most likely cause. The patient evidenced anemia. 

On presentation, the patient had a hemoglobin of 6. He received two units of blood and evidenced no bleeding during the hospitalization. The patient was discharged with a plan for close follow-up. 

The patient presented with anemia and received two units of blood. The patient evidenced only generalized weakness from the anemia. There was no reported hypoxia, active bleeding, coagulopathy, or planned surgery. The care as rendered could have been delivered at a lower level of care in its entirety.