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

Diagnosis: Chronic Kidney Disease.

Treatment: Inpatient Admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient has a history of chronic kidney disease secondary to hypertension  and diabetes and was admitted for tachycardia and elevated blood pressure. She was asymptomatic, denied chest pain, shortness of breath, headaches, blurry vision, dizziness. Renal ultrasound was unremarkable. Doppler of lower extremities was negative for deep venous thrombosis.

She was noted to have anemia but without active source of bleeding and etiology was likely secondary to chronic kidney disease and iron deficiency. She was evaluated by nephrology during this admission and etiology of worsening kidney function was likely progression of chronic kidney disease with possible acute kidney injury. She did not require renal replacement therapy during this admission and was discharged in stable condition.

Her condition could have been treated under lower level of care.  Database analysis of a cohort of 552,569 patients (mean age 58 years) discharged from an emergency department with a primary diagnosis of hypertension found that in the weeks after discharge the rate of intracerebral hemorrhage was exceedingly low (less than 0.02 [percent] %), and not elevated to a statistically significant degree compared to the rate the same patients experienced over the same time period a year later.

In the same analysis, amongst the 10,288 patients discharged with a diagnosis of malignant hypertension, the rate was similarly low (0.03%), and also not different from the same time period a year later.

A multiyear database analysis of patients seen in a Canadian emergency department with a primary diagnosis of hypertension, found in the last year of the study (25,950 patients, median age 64 years) that over 92% of patients were treated without admission to inpatient care.

Her condition responded to observational period of 48 hours and inpatient admission was not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Intraperitoneal bleeding following egg retrieval. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission.  The denial is modified. 

This is a female patient with no significant past medical history who presented to the Emergency Department (ED) for 3 near syncopal episodes. The patient was status post egg retrieval procedure. The patient reported that after the procedure, she went home and started to feel dizzy with lower abdominal pain. She also complained of shortness of breath and lightheadedness. Bedside ultrasound demonstrated free fluid in the abdomen. Gynecology (GYN) was consulted and recommended continuation of intravenous (IV) fluids and monitoring for intra-abdominal bleeding. The patient's hemoglobin was 9.8 grams per deciliter (g/dL). She was admitted as an inpatient to GYN Services for further evaluation of syncope, pain control and repeat lab work. During the hospital course, the patient's hemoglobin dropped to 6 g/dL, and she was treated with 1 unit of packed red blood cells. She was monitored and her pain was controlled. The patient was discharged home in a stable condition. 

During transvaginal oocyte aspiration, the aspiration needle may injure the adjacent pelvic organs and structures leading to serious complications. The most common complications are hemorrhage, trauma and injury of pelvic structures, and pelvic infection. The provider who performed the procedure stated that the egg retrieval was difficult, and he was concerned about injury to pelvic organs. 
 
This patient presented with intraperitoneal bleeding following egg retrieval. There was evidence of active bleeding, as the patient's hematocrit had dropped significantly and the patient was symptomatic. Admission to monitor for additional bleeding was necessary. 
 
Repeat complete blood count (CBC) showed a significant decrease in hematocrit necessitating a blood transfusion. However, following the transfusion the patient was feeling better with minimal pain. Her hematocrit was stable, and she could have been discharged that day. 

Milliman care guidelines list the clinical indication for inpatient care for patients with anemia. These include: active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope. 

This patient had 3 syncopal episodes. Her egg retrieval was difficult. There was fluid in her abdomen and her hematocrit dropped significantly. 

Admission on day 1 of admission is considered medically necessary for this patient. Continued admission was not. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient in denying coverage for day 1 of admission but did act reasonably in denying the continued admission the days after. 

The insurer's denial of coverage for the inpatient hospital admission is modified. Medical necessity is partially substantiated. 

The insurer's denial of coverage for the inpatient hospital admission is modified. Medical necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tracheitis.

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient has a past medical history (PMH) of hydrocephalus secondary to aqueductal stenosis, septum pellucidum and splenium agenesis, intra ventricular hemorrhage, chronic midline shift, subdural hematoma (SDH) status post (S/P) bilateral(B/L) craniotomies, right facial palsy and epilepsy. The patient is status post tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement. The patient was sent from nursing home for evaluation of tracheostomy.

At presentation to the emergency department (ED), the patient had complaints of some increased tracheal secretions. The patient also had some lower extremity pain.  Vital signs (V/S) at presentation Temperature 98.2 Fahrenheit, Heart Rate 76, Respiratory Rate 18, Blood Pressure 122/83. The patient's oxygen (O2) saturation on trach collar was 100 percent (%). Initially, the patient had a transient desaturation to 90% which improved with suctioning and placing him on O2.  The patient was in no acute distress the trach site was clean with no erythema. Lungs were clear. Cardiovascular system was normal. Abdomen was soft, and non-tender. Neurological exam was at baseline.

The patient was admitted for trach evaluation, questionable tracheitis. Rule out (R/O) deep vein thrombosis (DVT).  The patient was seen by Otolaryngology who determined that trachesotomy was in order. They just recommended a dressing change but no other intervention. The patient had a DVT study done which was negative.

As per the history and physical (H&P) the patient was in no acute distress, was afebrile, and hemodynamically stable. Lungs were clear with oxygen saturation at 100%.  Lab work was normal. DVT study was negative. No ortolarygologic intervention was recommended for his trach. The patient remained stable after admission and was discharged back to the nursing home after a few days.

This patient did not need acute hospitalization. He could have been placed in observation while his tracheostomy was attended. DVT evaluation did not need inpatient stay. Ultrasound could have been done in emergency department (ED) to rule out DVT. All labs were normal. The patient's Arterial Blood Gas was normal. The patient was at baseline after evaluation and treatment in ED and could have been discharged back to the nursing home after a period of observation.

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Other/Left Sided Numbness and Difficulty Walking
Treatment: Inpatient Hospital
The health plan denied the requested hospital stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a female who was admitted to the hospital for numbness and difficulty walking. She has a history of a pituitary adenoma status post resection, a carotid occlusion, and a stroke. On presentation, the patient had left sided facial and abdominal numbness. Vitals were significant for a blood pressure of 193/102 millimeters of mercury (mmHg) and an unremarkable electrocardiogram (EKG). A computed tomography (CT) of the head noted encephalomalacia. A computed tomography angiography (CTA) of the head and neck showed right internal carotid artery (ICA) occlusion. A magnetic resonance imaging (MRI) of the brain noted chronic ischemic changes. An echocardiogram showed a preserved ejection fraction. A urinalysis was consistent with a urinary tract infection (UTI) and she was started on intravenous (IV) antibiotics. The patient's numbness improved, and she was discharged in stable condition. She was continued on aspirin and a statin.
The question at hand is whether she met medical necessity for the acute inpatient level of care.

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

The patient in question does not meet medical necessity for the acute inpatient level of care per MCG criteria, current literature, or standard of care. In order to meet medical necessity for inpatient criteria, the patient must have a severe central nervous system (CNS) infection, vasculitis, aneurysm, severe neurologic finding requiring inpatient care, myasthenia gravis, or severe myopathy. Additionally, the patient does not meet medical necessity for the acute inpatient level of care per current literature or standard of care. According to Easton et al., (2009), Kernan et al., (2014), and Gupta et al., (2011), the patient did not have any severe or persistent neurologic findings consistent with a stroke. There was no transient ischemic attack (TIA) documented. The patient also had an uncomplicated UTI that did not require inpatient care. Observation level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: mild maxillary and mandibular crowding
Treatment: Braces
The insurer denied braces. The health plan's determination is upheld. 

The patient is a male with mild maxillary and mandibular crowding. Tooth # (number) 27 is erupting lingually within the arch. The patient has a Class II occlusion with 3 millimeter (mm) overjet and deep overbite. The patient is treatment planned for 24-30 months of orthodontics (braces) with exposure and ligation of tooth #27 to align the teeth and correct the bite. This is the subject of this review.

Braces are not medically necessary for this patient. While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. If his teeth were aligned it would provide an aesthetic improvement but it would not create a medically significant improvement to the patient's health. The patient also has an extremely high plaque index as shown by the photographs. Given this poor hygiene, orthodontic treatment has the potential to reduce the health of his teeth. For these reasons, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite with gingival attachment loss. 
Treatment: Braces and Monthly Visit, Pre-service. 

The insurer denied the Braces and Monthly Visit, Pre-service. 
The denial is overturned. 

The patient is a male with severe Class I malocclusion. 

Yes, the proposed braces and monthly visit are medically necessary. 

The patient has an anterior tooth (#27) that is in crossbite with gingival attachment loss. This alone is enough for medical necessity per the handicapping index scale. 

In addition to this, the patient has two other lower teeth in crossbite as well as upper canines (#'s 6 and 11) that are blocked out from fully erupting into position. They are being held high up in the jawbones because there is not enough arch space to have them erupt properly into their correct positions. Without the upper canines in their proper position, there can be no "canine guidance", which means that many of the other teeth will bang and grind into each other during the chewing cycle and the results will be fractured and/or worn down teeth. All these conditions require orthodontic treatment to correct and there is definite medical necessity to do so.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post cardiac catheterization. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male whose symptoms began approximately one month prior. He was scheduled for an elective radial cardiac catheterization. He has a history of previous percutaneous coronary intervention (PCI) and has risk factors of hypertension, hyperlipidemia, and diabetes mellitus (DM). Uncomplicated catheterizations revealed two vessel disease in the left anterior descending (LAD) and circumflex arteries. They were stented sequentially without difficulty. The patient's diabetic medications were adjusted and he was discharged on optimal medical therapy. 

No, the proposed acute inpatient hospital admission was not medically necessary. 
This admission was for an elective, uncomplicated catheterization and percutaneous coronary intervention (PCI) that was scheduled one month after onset of symptoms. The patient was always hemodynamically stable with normal vital signs, a normal electrocardiogram (EKG), normal left ventricular (LV) function, and no ectopy. The only care given after the uncomplicated radial catheterization was monitoring, intravenous fluids (IVF), and routine medications. The care rendered is consistent with a lower level of care without any indication for a higher level. Many institution protocols and standard of care include a same day discharge. 

Radial catheterization was developed with one of its advantages being the safety in early ambulation and discharge. The overnight stays for observation and telemetry do not change that determination. While possible, bleeding post radial artery intervention is not seen, nor does it require extended monitoring. Of note, many institutions perform interventions on both arteries in one sitting, as it has a safe outcome. 

The letter of appeal was carefully considered, but offered no evidence to support a higher level of care. The only care provided was telemetry, which is frequently performed at a lower level of care. The patient was admitted for monitoring and routine post catheterization care; neither required an inpatient level of care. There was no complex care required in this patient's post catheterization course. While always a potential for an adverse event, one did not happen and no treatment was needed. 

The denial was consistent with guidelines and usual community care. Post cardiac care as described is routinely performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Painful crises

Treatment: Inpatient Hospital

The insurer denied coverage for inpatient hospital.

The denial is upheld.

The patient has a history of asthma and sickle cell anemia and presented to the emergency room with uncomplicated pain crisis. He was clinically stable in the emergency room with normal blood pressure and no fever. A chest x-ray showed bilateral air space disease. He was not hypoxic. He had hemoglobin of 7.4. He was admitted to the hospital. He left against medical advice 1 day later.

"SCD [sickle cell disease] patients experience significant morbidity and mortality secondary to cerebrovascular accident, acute chest syndrome, acute vaso-occlusive pain crises, SCD-related multi-organ failure, cholecystitis, acute intrahepatic cholestasis, acute sickle hepatic crisis, acute hepatic sequestration, priapism, and renal disease. Emergency physicians must recognize acute manifestations of SCD in order to deliver timely management and determine patient disposition." (Simon E., et al, 2016)

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

Uncomplicated sickle cell pain crisis can be managed at an alternative level of care such as observational status. As there were no signs or symptoms of acute chest, aplastic crisis, priapism, stroke or other serious medical issues, this individual could have been managed in a lower level setting. This patient had a condition that could reasonably be expected to be stabilized within 24 hours; observational status would be appropriate.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Septic shock

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned. 

This male patient has a history of high-risk relapsed stage IV neuroblastoma who was admitted for therapy per chemo protocol including Temozolomide, Irinotecan, Dinutuximab, and Sargramostim. The patient tolerated chemotherapy well. It was noted he had nausea and vomiting. With initiation of protocol, the patient was started on cefixime for diarrhea prophylactically. The patient was treated with Kytril with small dose of Ativan as needed. On day 3 the patient became febrile and sepsis work up was initiated. He was switched from cefixime to ceftriaxone. The patient was discharged.

The use of Dinutuximab for the treatment of high-risk neuroblastoma requires acute inpatient hospitalization. This drug is known to cause edema and fluid issues. Other common toxicities in a Children's Oncology Group (COG) clinical trial were fever/infection [18 (35.3%) of 51], neutropenia [17 (33.3%) of 51], pain [15 (29.4%) of 51], and diarrhea [10 (19.6%) of 51]. This would meet the criteria for inpatient hospitalization as the medication is known to have common, severe side effects.      

The patient had multiple complications of the use of Dinutuximab, which required inpatient hospitalization. He required admission for observation and then required intravenous morphine, and later was diagnosed with sepsis. These issues could not have been managed in a lower level of care or an outpatient setting. Therefore, the inpatient admission was medically necessary.

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

The carrier's denial of coverage for the inpatient hospital admission is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Growth hormone deficiency	

Treatment: Norditropin FlexPro 10 milligrams (mg)/1.5 milliliter (ml) pen injector

The insurer is denied coverage for Norditropin FlexPro 10 milligrams (mg)/1.5 milliliter (ml) pen injector.

The denial is overturned. 

This female patient has a history of growth hormone deficiency (GHD). She presented to the Pediatric Endocrinologist's office for a follow up visit. Height was 156.3 centimeters (cm), which was at the 25th percentile. Interval growth velocity was 5.7 cm/year. The physician recommended increasing Omnitrope and obtaining a new bone age x-ray. She recommended administering Norditropin FlexPro 10 milligrams (mg)/1.5 milliliter (ml) pen injector to treat GHD.

Referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 standard deviations (SD) below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 year more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 year in children over 2 years of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 year or more than 1.5 SD sustained over 2 years. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak growth hormone (GH) less than 10ng/ml (nanograms per milliliter).

The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than 10. Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4, 5, 6, 7, 8, 9]. 

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

The carrier's denial of coverage for the Norditropin FlexPro 10 milligrams (mg)/1.5 milliliter (ml) pen injector is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a  man with a history of asthma who presented with concern for rectal bleeding and abdominal pain that had been ongoing for the past four months. He also reported occasionally decreased caliber of the stool and weight loss. In addition, he reported rectal pain occasionally and an episode of vomiting on the prior day. He stated that he took non-steroidal anti-inflammatory drugs (NSAIDs) for abdominal pain on occasion. Review of systems was negative for chest pain and shortness of breath but positive for fevers. Vital signs showed temperature 98.1 Fahrenheit, blood pressure 132/90, heart rate 62, and respiratory rate 17. On exam, heart was regular, breath sounds were normal, and the abdomen was soft. There was mild tenderness in the upper quadrant and epigastric region. Labs showed white blood cell count (WBC) 5.8, hemoglobin 11.7, platelets 286, sodium 136, and glucose 77. Computed tomography (CT) imaging showed fluid collection along the wall of the sigmoid colon possibly related to remote history of perforated diverticulitis. The patient was admitted for suspected diverticulitis with concern for perforation.

The inpatient hospital admission was medically necessary. The patient's complexity would not have been appropriate for a lower level of care. He simultaneously was being managed for suspected acute gastrointestinal bleed and possible intra-abdominal infection and abscess, and he required consultation with both general surgery and gastroenterology. While both consulting services ultimately determined that he do not need an acute invasive intervention during the hospital stay, the inpatient level of care was still appropriate based on the patient's complexity.