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

Diagnosis: Pregnancy 
Treatment: Inpatient stay 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

In this case, the patient is a female who presented at 27 1/7 weeks gestation with a chief complaint of preterm labor. The patient reported positive fetal movements and cramping. She denied vaginal bleeding, leakage of fluid, headache, chest pain, shortness of breath or chest pain. She had a reactive NST and vaginal exam noted her to be 3-4 centimeter (cm) dilated. She was sent over and repeat exam was 4/90%/-3 and intact. Fetal fibronectin was not collected. She was noted to have a blood pressure of 143/81. 

The inpatient admission was not medically necessary for this patient with a dilated cervix without cervical change documented, regular contractions or bleeding. There was noted to be reassuring fetal assessment with uterine irritability on monitoring. There were normal lab values noted on CBC and CMP. There was no need for tocolytic therapy given the absence of cervical change or preterm labor as noted by contractions being absent. Magnesium in this case was used for a short course for neuroprotection and achieving steroids for transfer which was reasonable. There was no positive fetal fibronectin in this case. The patient had no change in the cervix based on exam during her hospitalization. There was no evidence of rupture of membranes or labor.
The Milliman Care Guidelines (MCG) for "Preterm Labor, Threatened" were not met. 

There was maternal monitoring for the fetus and contractions, performance of an ultrasound for presentation, and administration of steroids and neuroprotective magnesium for 12 hours, but this is noted to be a treatment that is defined as a care plan that does not require admission under the MCG. This care can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bipolar disorder and generalized anxiety disorder
Issue under review: One registered nurse (RN) assessment, including PRI (Patient Review Instrument) to evaluate whether the patient would qualify for potential home care services, including home health aide ADL assistance. 
The insurer denied the registered nurse (RN) assessment, including PRI (Patient Review Instrument). 
The denial is overturned. 

The patient is a female with a history of bipolar disorder and generalized anxiety disorder. Documentation from the patient's case manager indicates that the patient has been experiencing mental status changes and increased falls, rendering her dependent for assistance for completion of certain activities of daily living (ADL), such as bathing. An appeal review requested for potential approval of one registered nurse (RN) assessment, including PRI (Patient Review Instrument) to evaluate whether the patient would qualify for potential home care services, including home health aide ADL assistance. 

Yes, the proposed one RN assessment, including PRI, to evaluate whether the patient would qualify for potential home care services including home health aide ADL assistance is deemed medically necessary. 

This is a female with a history of bipolar disorder and generalized anxiety disorder. Documentation from the patient's case manager indicates that the patient has been experiencing mental status changes and increased falls, rendering her dependent for assistance for completion of certain activities of daily living, such as bathing. The denial letter state that the physician's order and examination must be within 30 days of this request. However, due to the current COVID19 (Coronavirus disease 2019) outbreak, all outpatient non-urgent/non-critical medical appointments have been canceled, making it impossible for the patient to meet this specific timing criterion. Given the extenuating circumstances, and given that the patient is at high risk for fall injury and inability to perform critical ADL, such as bathing, the proposed treatment of one RN assessment, including PRI, to evaluate whether patient would qualify for potential home care services including home health aide ADL assistance is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Esophageal foreign body.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male child. He presented with an esophageal foreign body.  There was a witnessed coin ingestion, and the coin was noted on x-ray to be at the esophageal inlet.  The patient was started on an IV and kept NPO (nothing by mouth).  The coin was removed in the OR (operating room), and the patient was discharged.  

No, the Inpatient admission was not medically necessary.

The patient's vital signs were stable, and the patient was afebrile.  There was no respiratory distress.  There were no complications during or after the procedure.  The patient was taking POs (by mouth) after the procedure and the pain was in control.  Esophageal FBs (foreign bodies) are typically addressed with same day removal followed by observation.  Therefore, based on the information provided, the medical necessity of the inpatient admission from cannot be confirmed, as the patient could have been managed with a lower level of care, observation.
Appeal type: Medical necessity
Decision: Upheld

Skin Disorder.
Inpatient hospital.

Diagnosis: leg abscess.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This case involves a man with history intravenous (IV) drug abuse, as well as previous methicillin-resistant staphylococcus aureus (MRSA) infections, who came into the hospital with left leg pain, found to have a left leg cutaneous abscess. It was drained at bedside via incision and drainage (I&D) with packing in the emergency department. He was slated for admission. He was given a dose of intravenous (IV) vancomycin, but after receiving it, he refused to remain in the hospital. The medical team, out of concern for the patient's belligerent behavior, prescribed Bactrim and Keflex for ten days at the time of discharge, despite the patient leaving Against Medical Advice.

The inpatient hospital admission was not medically necessary. There is no evidence of necrotizing fasciitis or gas gangrene. The patient had a superficial abscess, which was amenable to bedside I&D. The patient has a history of MRSA and likely has a recurrent MRSA infection. There is no documentation of hemodynamic instability. There is one documented low-grade fever, but clearly no signs of sepsis. The patient was able to ambulate as documented in the behavioral notes. There is no documentation of a rapidly progressing infection or a limb-threatening infection. The patient can tolerate oral hydration, and no documentation of severe pain requires acute inpatient management. As a result, this type of presentation can be accomplished at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Upper and lower crowding of teeth.
Treatment: Braces.
The insurer denied the braces.
The denial is overturned. 

The patient is a female.  The request is for orthodontic benefits.

Yes, the braces are medically necessary. 

Upon regrading the handicapping index scale, the new score becomes 26, which is the threshold for benefits. The part of the scale regarding grading of the upper and lower anterior teeth should not have been downgraded to just "1", as both the upper front teeth and the lower front teeth have crowding. With the new score being 26, the patient orthodontic benefits are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Non-Syndromic Hearing Loss.
Treatment:  Genetic testing. 

The insurer is denied coverage for genetic testing.  The denial is upheld.

This is a male patient who presented for a genetics consultation.  The patient's partner was a carrier for non-syndromic hearing loss for a global panel.  The patient had a 50% chance of having children who are carriers for non-syndromic hearing loss with this partner.  The patient's maternal grandmother had colon cancer.  The patient's maternal first cousin had congenital deafness, congenital rubella syndrome, and cerebral palsy.  The patient's immediate family history was negative for birth defects, genetic disorders, and mental retardation.  The deafness in the patient's maternal first cousin had an unknown etiology.  The patient was from an Italian/German ethnic background.  Consanguinity was denied.  The provider discussed the Progenity Pre-Parent Global Panel, which was noted to be a type of expanded carrier screening that testing was performed to evaluate for 200 or more hereditary disorders that could cause serious health issues.  The patient decided to proceed with the Progenity Pre-Parent Global Panel.

The genetic testing for the expanded panel of 200 genes is not medically necessary for this patient.  He only needed to be tested for variants in the GJB2 genes because the couple is only at risk for non-syndromic hearing loss if he is a carrier for a variant in this gene.  Expanded carrier screening is not needed because the partner is not a carrier for the other genes tested by this panel.  Expanded genetic screening is based on the application of new technology for the screening of rare genetic disorders (Lazarin & Haque, 2016).  Screening for carrier status of a limited number of single-gene conditions is the current standard of care, and the adoption of expanded screening requires more studies before it is implemented (Haque et al., 2016).  The benefits of carrier studies for specific genes and the limitations of expanded panels have been reviewed (Yao & Goetzinger, 2016).

In this case, since the patient's partner was found to be a carrier for a variant in the GJB2 gene for an autosomal recessive non syndromic hearing loss using an expanded screening panel for 200 genes, there is no need to test the patient for the expanded panel.  The patient only needed to be tested for variants in the GJB2 gene. 

The health plan acted reasonably with sound medical judgment.

Based on the above, the medical necessity for genetic testing is not substantiated.  The insurers denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the Inpatient admission was not medically necessary.

This patient is a man. He presented to the ED with complaint of nausea and vomiting of three-day duration.  His comorbid health conditions include a surgical history of laparoscopic sleeve gastrectomy for the diagnosis of morbid obesity. The patient had undergone cholecystectomy for the diagnosis of gallstone pancreatitis.  He has lost 110 lbs. since bariatric surgery.

The patient's vital signs at presentation were normal. The heart rate was 60/minute.  WBC (white blood cell) count and serum electrolytes were normal.  Abdominal examination in the ED was soft, non-distended and non-tender.  The patient was admitted to the hospital and treated with IV fluid, IV antiemetics, and antacids.  Surgery was consulted.  A contrast UGI (upper gastrointestinal series) identified findings that were consistent with prior sleeve gastrectomy.    

Following evaluation, the patient was started on a liquid diet.  His nausea and vomiting resolved, and he was considered to be stable for discharge home with instructions to follow up with the bariatric surgery department.

The health plan rationale for denial of inpatient admission is that the patient was hemodynamically stable without a severe intra-abdominal process, obstruction, perforation, infection, ischemia, ischemic colitis, or toxic megacolon.  There were no electrolyte abnormalities or intractable vomiting or diarrhea.  Per the denial letter from the Plan, criteria for full hospital admission were not met.

The records do not support that inpatient admission was medically necessary.  The care and treatment provided to this patient could have reasonably been administered in the emergency department (rather than acute inpatient admission).

The patient was clinically stable at the time of presentation and remained stable throughout the period of hospitalization from.  Vital signs were normal in the ED.  The initial WBC count was normal.  Electrolytes and renal function were normal.  The patient was evaluated with imaging studies that included contrast UGI that identified expected post gastric sleeve anatomy.  Following the ED evaluation, the patient's diet was advanced, and he was considered to be stable for discharge from the hospital.

Based on the available medical record, the medical necessity of inpatient admission is not established.  The records support the health plan contention that this care and treatment provided could have been completed in the emergency department. This level of care would have allowed for provision of the medical treatment that was rendered in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Plaque psoriasis.
Treatment:  Stelara.

The insurer denied the Stelara.  The denial is upheld. 

No, the proposed treatment, Stelara, is not medically necessary. 

This is a man with psoriasis, affecting 20% BSA (body surface area), for whom Stelara is requested.  He has tried and failed topical steroids and phototherapy previously.

The current treatment guidelines that are in accordance with nationally accepted standards of medical practice for moderate to severe plaque psoriasis, recommend typical first line treatments, such as topical corticosteroids and calcipotriene followed by typical second line treatments, such as ultraviolet phototherapy, oral systemic treatments (methotrexate, cyclosporine, acitretin) and biologics.  There is no documentation that the patient has failed or has an intolerance to traditional systemic therapy (such as: acitretin, methotrexate, or cyclosporine).

Per the policy, there must be documentation of drug failure or serious side effects with at least three months of a first-line oral medicine (such as: acitretin, methotrexate, or cyclosporine).  If there is a medical reason why the first-line treatments should not be used, then a three month trial of ONE of the following is required:  1) ultraviolet B-light treatment in combination with coal tar, topical steroids, or tazarotene, 2) psoralen therapy used with ultraviolet A light in combination with coal tar, topical steroids, or tazarotene, or 3) topical steroids in combination with anthralin, calcipotriene, or tazarotene.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Influenza A.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

No, the Inpatient admission is not deemed medically necessary. 

The patient is a female with a history of pulmonary embolus, DVT (deep vein thrombosis) and anemia who presented to the ER for further evaluation/management of headaches, dizziness and left shoulder pain. Intake vitals were notable for mildly febrile temperature of 100.3 F but otherwise hemodynamically stable and non-hypoxic on room air. Examination was non focal. EKG revealed evidence of T wave inversions in all leads. Laboratory testing was notable for positive influenza A, but no other critical findings were noted.

Medical records indicate that the patient was admitted to the inpatient hospital service in stable condition where she continued to receive treatment including serial cardiac enzymes, continuous cardiac monitoring, analgesics, IV fluid hydration and Oseltamevir. She improved with the prescribed therapies and was subsequently discharged in stable condition. Appeal review requested for potential approval of Inpatient admission.

This is a female with a history of pulmonary embolus, DVT and anemia who presented to the ER for further evaluation/management of headaches, dizziness and left shoulder pain. Intake vitals were notable for mildly febrile temperature of 100.3 F but otherwise hemodynamically stable with no evidence of profound hypotension, tachycardia and non-hypoxic on room air. Examination was non focal. EKG revealed evidence of T wave inversions in all leads but no other evidence of ST segment deviations or arrhythmia. Laboratory testing was notable for positive influenza A but no other critical findings were noted including any evidence of end organ damage. Medical records indicate that the patient was admitted to the inpatient hospital service in stable condition where she continued to receive treatment including serial cardiac enzymes, continuous cardiac monitoring, analgesics, IV fluid hydration and Oseltamevir. She improved with the prescribed therapies and was subsequently discharged in stable condition. There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed treatment of Inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia, Asthma
Treatment: Acute inpatient stay
The insurer is denied coverage for acute inpatient stay.  
The denial is overturned. 

This is a male patient with a history of asthma who presented to the emergency Doom with a diagnosed with influenza.  The patient's family history was significant for asthma in both of his parents. The patient had been prescribed medication for the flu but was only able to take 2 days of the medication because he could not tolerate it. The patient then developed a fever and a cough at home the day prior to returning to the ER. The patient also had significant abdominal pain, nausea, vomiting and fever. It was reported that he was unable to tolerate oral liquids. In the ER, the patient was initially afebrile and was noted to have a low oxygen saturation of 93% on room air. On physical examination, the patient was noted to have shortness of breath with abdominal tenderness, and a decrease breath sounds with audible wheezing and rales upon auscultation of the chest. The patient subsequently was noted to have fever of 103 degrees. The patient's chest x-ray demonstrated evidence of right lower lobe pneumonia. The patient was given intravenous (IV) fluid bolus of normal saline and was started on oxygen, albuterol and ceftriaxone. When the patient's symptoms persisted despite treatment in the ER, the decision was made to admit the patient to the hospital to treat for his asthma and pneumonia. The patient was medically stable and discharged.

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. The patient was treated appropriately in the Emergency Room (ER) and was diagnosed with right lower lobe pneumonia. The patient had low oxygen saturation and was treated with oxygen. There was a history of abdominal pain with nausea and vomiting at home, and the patient was not tolerating oral fluids. The decision to admit to the hospital for continued oxygen therapy, antibiotics and nebulized albuterol was appropriate and consistent with the standard of care for treating a pediatric patient with pneumonia and an inability to tolerate oral antibiotics. The patient was recently diagnosed with influenza and he was not able to tolerate an antiviral medication at home. Since children with the influenza virus are known to be at risk to develop bacterial infections such as pneumonia, this patient would be considered in a high risk category. The clinical presentation of this patient, the evidence of pneumonia on chest x-ray and the recent illness from influenza placed this patient at risk for bacterial sepsis. Thus, the admission to the hospital was appropriate and consistent with the standard of care.

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 acute inpatient stay is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Otitis Media.
Treatment:  Inpatient hospital admission.

The insurer is denied coverage for inpatient hospital admission.  The denial is upheld. 

This is a male patient who presented to the Emergency Department with complaints of vomiting and non-bloody diarrhea for several days.  The patient's mother reported that the vomiting had resolved hours prior to presentation, and that the patient had been tolerating Pedialyte at home.  The patient's vital signs on arrival were: heart rate of 136, temperature of 100.2 F, respiratory rate of 36, blood pressure of 104/59, and a room air oxygen saturation of 100%.  Physical exam showed a well-developed, well-nourished, irritable male, who was awake and alert.  Abdomen exam was soft with normal bowels sounds.  Laboratory work was performed that revealed a sodium of 136, a potassium of 3, a bicarbonate of 13, a blood urea nitrogen (BUN) of 21, a creatinine of 0.24, a glucose of 67, a white blood cell count of 5.66 without a left shift (neutrophils 51%, no bands), a hematocrit of 35.5, a platelet count of 410, a lipase of 11, and a normal liver profile.  An EKG was performed with a heart rate of 104 and normal axis/intervals.  He received intravenous two normal saline boluses.  He was given Pedialyte in the Emergency Department with reported vomiting (no details); he was voiding urine well.  His diet was advanced to a regular diet and was tolerated.  The patient was discharged home for outpatient follow-up. 

The documentation of this child's appearance and vital signs would indicate minimal to mild dehydration that resolved by the time of the decision to admit to the hospital.  After bolus fluid resuscitation in the Emergency Department and observation, the child could have avoided an unnecessary acute care admission.  He actually received no acute care after admission to merit reimbursement at that level, except for continued intravenous fluids despite tolerating feeds without issue. 

The insurer acted reasonably, with sound medical judgement, and in the patient's best interest. 

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.