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

Diagnosis: Fecal Impaction

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with a medical history of hemorrhoidectomy and an abdominoplasty. The patient presented to the Emergency Department (ED) with complaints that she had not had a bowel movement since the hemorrhoidectomy. The patient had been diligently taking her opioids and eating regularly.  The patient denied abdominal pain, but did complain of nausea. She reported that sometimes she passed gas but had not passed gas on the date of presentation. Her presenting vital signs were: blood pressure 106/71 and temperature 36.7 C.  A physical examination was performed that revealed her abdomen was soft and non-tender. An abdominal x-ray was done that revealed no evidence of free air or obstruction. The patient's surgeon recommended she come to the ED for an enema under sedation. The patient underwent an examination under anesthesia, minimal fecal disimpaction, and irrigation of the rectum with saline and Betadine. The patient was discharged in stable condition.

Based on the review of the medical record and literature, the inpatient admission was not medically necessary. The patient had post-operative constipation compounded by opiate use. The patient was hemodynamically stable and her labs were unremarkable. The patient's abdominal imaging did not reveal ileus or obstruction. While fecal disimpaction was appropriate, inpatient admission was not medically necessary. The patient could have received her care in the Emergency Room (ER) or at Observation level of care. 

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

Diagnosis: Right sided facial pain and swelling
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

Yes, the Inpatient admission was medically necessary.

The patient is a female whose inpatient admission is under review. The patient has a history of DM (diabetes mellitus). She presented with three days of Right-sided facial pain and swelling. Her presentation was also notable for fever and chills. She had previously received PO (oral) clindamycin, but she had not been compliant.

That same say, the patient had gone to her dentist. who told her to go to the ER (i.e., the dentist did not think that outpatient treatment was appropriate). 

In the ER, the patient's vitals were as follows: T (temperature) - 98.3, P (pulse) - 86, RR (respiration rate) - 20, BP (blood pressure) - 146/79. On general examination, the patient was noted to be NAD (no acute distress). Examination of her HEENT (head, eyes, ears, nose, throat) revealed erythema and swelling to right face, with swelling extending to below the orbit. She was noted to have multiple dental caries. Examination of her chest, CVS (cardiovascular system) and abdomen were normal.

The patient's labs were as follows:
WBC (white blood count) - 6.8
Hg (hemoglobin) - 13.5
Hct (hematocrit) - 41.5
Plt (platelets) - 254.

In the ER, the physician decided to treat the patient with IV antibiotics and admit the patient, meaning that the ER physician did not think outpatient treatment was appropriate. The patient was admitted, and the admission physician continued IV treatment for preseptal cellulitis, meaning that the admitting physician did not think outpatient treatment was appropriate. 

The patient was treated with IV clindamycin for several days. She improved, and she was then discharged home on PO antibiotics.

This patient should have had inpatient admission and treatment for many reasons, including the following:

1) The patient was evaluated by three different specialists (dentist, ER physician, and internist), all of whom thought she needed inpatient treatment.  The opinions of these three specialists, all of whom individually evaluated the patient, when taken with the following facts, lend weight to the decision to admit the patient.

2) The patient was treated for preseptal cellulitis in the setting of multiple dental caries. Untreated or poorly treated, this can lead to orbital cellulitis, blindness, brain abscess or death. Standard of care would be admission and IV treatment. 

3) The patient had a proven track record of not being complaint with PO clindamycin. Inability to be treated as an outpatient (for any reason) is by itself is an indication for IV treatment and admission (1).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchitis 
Treatment: Inpatient admission
The insurer is denied coverage for the inpatient admission.
The denial is upheld. 

This is a young male patient with a history of a past hospitalization at birth due to maternal fever during the delivery.  He presented to the Emergency Room (ER) with complaints of fever, coughing, rhinorrhea, decrease in oral fluid intake, and difficulty breathing; it was reported that he was in contact with a sick person at home. He had a recent history of an ear infection; amoxicillin prescribed.  A physical examination was performed that noted the patient was having fast and labored breathing; his respiratory rate was 31 with suprasternal and subcostal retractions and he had significant clear nasal secretions requiring frequent suctioning. The patient was treated with a bolus of intravenous (IV) normal saline and albuterol. A chest x-ray was done that did not show any evidence of pneumonia. Respiratory syncytial virus (RSV) influenza was done with negative results. Laboratory work up was performed that revealed white blood cell (WBC) count of 20,000. The patient was admitted to the hospital for continued medical treatment and management for bronchitis. The patient was medically stabilized and discharged.

Based on the review of the medical record, the patient was treated appropriately in the
Emergency Room (ER) for bronchiolitis. The patient was not dehydrated and was able to tolerate oral feeding. There was no evidence of hypoxemia that required this patient's treatment with oxygen. While the patient required frequent nasal suctioning, this could have been done at home. The patient could have safely been discharged with instructions to the mother to administer saline to the nose and suction with a bulb syringe to help his breathing. A follow-up, outpatient visit could have been recommended with the pediatrician in 24-48 hours to monitor this patient's ongoing illness. The medical record does not support the need for admission to the hospital for bronchiolitis.

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

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

Diagnosis: Infectious Colitis, Gastroenteritis
Treatment: Inpatient admission 
The insurer is denied coverage for inpatient admission. 
The denial is upheld. 
This is a male patient who presented to the Emergency Department (ED) with complaint of a severe temporal parietal headache since that morning. He also reported complaints of nausea, vomiting, diarrhea, dyspnea and non-radiating mid-sternal chest pain. The patient reported using medical marijuana. His presenting vital signs were: temperature of 96.6 with oxygen saturation of 98% and blood pressure of 115/93. On physical examination tit was noted that he patient was alert and oriented but appeared to be ill and distressed. Laboratory work up was performed that revealed white blood cell (WBC) count 17.52 with no other significant abnormalities. Infectious Disease was consulted. The patient's urine toxicology was positive for tetrahydrocannabinol (THC). A computed tomography (CT) scan of the head was done that revealed no evidence of acute intracranial hemorrhage or territorial infarction. The patient's chest x-ray revealed no focal airspace opacity. An electrocardiogram (EKG) revealing a normal sinus rhythm. The patient was admitted to the hospital for further management of his elevated white blood cell (WBC) count. There were no further abnormalities during this patient's stay. The patient was discharged the following day after being treated with IV medication. The patient be discharged with outpatient follow-up.  

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient was admitted with nonspecific symptoms with no other laboratory abnormalities other than an elevated white blood cell count. The documentation detailed within the emergency department indicated that the patient received supportive measures, and the patient then reported feeling better. According to literature at this point, the patient could either be discharged or continue as Observation given the lack of documented hemodynamic instability or indication that the patient had any type of neurological compromise. Therefore, inpatient admission is not considered medically necessary for this patient. 

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 should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain with nausea and vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

No, the Inpatient admission was not medically necessary. The treatment as rendered was medically appropriate, but not medically necessary at the acute level of care.

The patient is a female. She presented to the hospital's ED with the complaints of abdominal pain. The pain was reported to be 10 out of 10 with associated nausea and emesis. The pain abated with immobility. The patient noted inability to tolerate oral intake the day prior to presentation. The patient noted a decreased appetite. The patient used marijuana four weeks prior to presentation. The patient had a history of GERD (gastroesophageal reflux disease), depression and thyroid disease.

A CT scan of the patient's abdomen and pelvis was unremarkable. The patient was admitted for hydration, supportive care and treatment for pain.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had abdominal pain without a clear cause; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the patient's care could have been rendered at a lesser level in its entirety.
Appeal type: Step Therapy
Decision: Upheld

Diagnosis: Osteoarthritis of the knee
Treatment: Hyaluronic acid
The Hyaluronic acid is not medically necessary.

The patient is a male who reported right knee pain.... His physician opined post traumatic arthritis. His physician provided Gel One injection to right knee.

Viscosupplementation can be provided for people who have osteoarthritis and have failed a course of conservative management. There should be consistency of subjective complaint, objective finding, imaging studies and diagnosis. 

There was no prior complaint made. There was no course of conservative treatment documented. There was no documented trial of formulary medication before use of other products. 

These findings do not support necessity of the Gel One.

There were no extenuating circumstances documented to substantiate use of the viscosupplementation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperglycemia with dehydration and hyperketosis

Treatment: inpatient hospital admission

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

This patient is a male with a history of epilepsy and diabetes, who presented to the Emergency Department (ED) with complaints of polydipsia, polyuria, and vomiting for several days prior to ED arrival.  As per a relative the patient has not been taking his insulin or was able to follow-up with his primary care provider because of issues with his health insurance. At the ED, the patient appeared dehydrated with dry buccal mucosa.  The patient's blood glucose level was 652 milligrams per deciliter and his osmolarity was 305. The patient's venous blood gas showed that the venous pH was low at 7.34 and the bicarbonate level was low at 17.6. The patient's beta hyroxybutyrate was elevated at 8.21mmol/L, and the patient's urinalysis was positive for glucose (>=1000mg/dL) and ketones (>=80 mg/dL). The patient's venous pH was low at 7.34. Endocrinology was consulted for this case.  Endocrinology noted that the patient was not acidotic, and did not need insulin drip.

Though this patient had ketosis present in urine and dehydration that required intravenous (IV) fluids, this patient's hyperglycemia did not meet the clinical criteria for diabetic ketoacidosis and the need of inpatient insulin administration. However, this patient was noted to be admitted for not only for hyperglycemia with dehydration and hyperketosis, but also for social issues. On the ED note, the patient was noted to not have been taking his insulin or following up with his primary care provider because his primary care provider no longer accepted his health insurance. While, the care that the patient received as inpatient could have been provided at a less intensive setting, such as observation, there was social concern that this patient would require longer than 12-24 hours care to treat, manage, and ensure that the patient would have the social means to follow-up for his diabetes management as outpatient.

As per MCG health guidelines on Diabetes, Pediatric RRG, this patient met the inpatient level of care because of the time that was needed to arrange a glucose management regimen that was suitable for this patient's outpatient setting. Thus, this patient's inpatient admission was medically necessary to treat this patient's hyperglycemia and to prevent this high-risk patient from developing diabetic ketoacidosis as outpatient due to this patient's noncompliance to medication and outpatient follow-up.

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

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

Diagnosis: Autoimmune encephalitis with refractory seizures 
 Treatment: Octagam 

The insurer denied coverage for Octagam. The denial is reversed. 

This patient is a male who has been previously diagnosed with Crohn's disease.  A letter of medical necessity indicates the patient was also being seen by Neurology for a complex neurological condition.  The patient was noted to have autoimmune encephalitis with secondary intractable epilepsy.  The patient had an explosive onset 6 months prior with multiple and refractory focal seizures with secondary generalization captured during a prolonged hospital stay.  The patient has undergone extensive evaluation to include CSF examination which returned a positive result for high levels of myelin basic protein.  The patient did respond well to an initial course of Solu-Medrol and an attempt to taper then led to worsening seizure frequency.  The patient was utilizing 2 AEDs at very high doses in combination with oral prednisone.  The patient was recommended to continue chronic immunosuppression.  

Additional submitted documentation does include a chart note when the patient was seen for a follow-up.  The documentation did detail the patient was recently admitted for an episode worsening seizures.  The patient responded well to Solu-Medrol in addition to valproic acid (VPA).  The patient did attempt to taper off steroids as noted above however this worsened the seizures.  The documentation detailed the patient was feeling okay since the hospital visit.  The physician indicated the patient presented with a new onset seizure-like event following a fall.  By description and video review, events are atypical for seizures; however recent evaluation confirmed the epileptic nature.  The documentation indicated the recent emergent admission in response to Solu-Medrol, as well as worsening seizures with steroid discontinuation, supports the autoimmune etiology of epilepsy.  It was recommended the patient continue multiple medications and begin IVIG.  

IVIG is commonly used for cases of autoimmune encephalitis with refractory seizures and is in the standard of care. A variety of clinical studies, some randomized, blinded studies have shown efficacy with IVIG.  Therefore, the use of Octagam is medically necessary in this case for this patient with treatment failure with steroids and multiple anticonvulsant medications.  The decision is overturned and Octagam should be approved in this case.  

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

Based on the above, the medical necessity for Octagam is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral plantar fasciitis, peroneal tendinitis and pes planus
 
Treatment: Custom shoe inserts

The insurer denied coverage for custom shoe inserts. The denial is reversed. 

This patient is a female who presented to the podiatrist's office with a chief complaint of pain with ambulation, extending from the lateral ankle to the medial and lateral arch of the feet.  The provider's assessment revealed that the patient had bilateral plantar fasciitis, peroneal tendinitis and pes planus.  Per the provider's note, custom orthotics were prescribed for the peroneal tendinitis with a varus post and deep heel cup.  The plan for the plantar fasciitis included physical therapy, stretching and change in shoe gear with possibility of an injection if no improvement after several weeks.   

The patient returned and saw a second provider.  The patient stated that the custom orthotics that she had were no longer helping her pain, and that she was experiencing plantar medial and lateral heel pain.  On this date of service, the provider's assessment was plantar fasciitis and bilateral pes planus, for which the patient was prescribed custom orthotics. The patient returned once more and saw a third provider.  The patient now complained of extreme pain of the left leg with no history of trauma.  On this visit, the provider worked the patient up for a deep vein thrombosis (DVT) of the leg with no mention of orthotics being a treatment for her pain.  Furthermore, it was noted that the patient was unable to take non-steroidal anti-inflammatory drugs (NSAIDs) due to drug-drug interactions with her other medications.

Based on this review of the medical record, this patient met the MCG guideline for "Foot Orthotics, Custom" clinical criteria: the patient's symptoms were for more than three months; the patient's symptoms did not improve with adjustment of activities or with prefabricated orthotics; the patient could not tolerate anti-inflammatory medications due to drug-drug interactions, and thus could not be used to improve symptoms; the patient's over-the-counter orthotics failed to improve symptoms; and the patient's symptoms did not improve with stretching of calf muscles and plantar surface.  The doctor's notes are clear in their description that the patient tried and failed all of the listed treatments, including over-the-counter orthotics. 

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

The carrier's denial of coverage for the requested custom shoe inserts (code L3000 x 2) should be reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a male. He presented with signs and symptoms of appendicitis. 

The patient's vitals were stable, with a heart rate of 68 and a temp of 99.7 degrees. There was a one day prodrome with abdominal pain and vomiting. There was RLQ (right lower quadrant) tenderness and a positive CT scan for appendicitis with no evidence of perforation or associated abscess.  WBC (white blood count) was elevated at 13.2K with normal electrolytes and liver function tests.  

The patient underwent laparoscopic appendectomy where an obvious inflamed appendix was identified. The diet was advanced and discharged in stable condition the following day tolerating a diet and ambulating. 

The patient presented with typical signs and symptoms of acute appendicitis. There was no evidence of hemodynamic instability or sepsis in the preoperative evaluation. The patient was taken appropriately to the operating room and found to have an uncomplicated acute appendicitis, which was removed without difficulty. There were no postoperative untoward events, and the patient remained stable throughout his entire course.

After either open or laparoscopic appendectomy for nonperforated appendicitis, patients may be started on a clear liquid diet and advanced as tolerated to a regular diet. Antibiotics are not required postoperatively. Most patients are discharged within 24 hours of surgery. Same-day discharge is feasible, most commonly following a laparoscopic appendectomy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission

Inpatient admission was not medically necessary.

The patient is a female. Her medical history included uterine fibroids. The patient presented to an emergency department with a three to six-month history of "occasional" right upper quadrant abdominal pain, anorexia, early satiety, nausea, and vomiting. 

The patient's vitals were temperature 98.2, pulse 83, blood pressure 133/68, respirations 18, oxygenation 99%. Physical examination demonstrated a large abdominal mass and abdominal tenderness to palpation. Urinalysis was positive for a urinary-tract infection. Computed tomography demonstrated a 27-centimetere (cm) intra-peritoneal mass, ("concerning for malignancy such as sarcoma").

The patient was admitted at an acute inpatient level of care. She was provided with fluids, antibiotics, antacids, and anti-emetics. She was scheduled to undergo further laboratories, imaging, and consults. However, the patient left against medical advice. 

The patient presented with a chronic problem, lasting three to six months. The patient was stable with normal vitals and without physiologic derangements.  All of the patient's symptoms were mild and "occasional". All of the patient's work-up and treatment -- fluids, antibiotics, antacids, and anti-emetics; and further laboratories, imaging, and consults -- could have been completed on a lower level of care. 

The patient presented with a chronic problem, lasting three to six months. The patient was stable with normal vitals and without physiologic derangements.  All of the patient's symptoms were mild and "occasional". All of the patient's work-up and treatment -- fluids, antibiotics, antacids, and anti-emetics; and further laboratories, imaging, and consults -- could have been completed on a lower level of care.