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

Diagnosis: Cyanosis 
Treatment: Inpatient admission 

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

This is a female child admitted for an episode of loss of consciousness associated with cyanosis. The episode was self-resolving. The insurer has denied the admission stating that the services could have been provided in an observation setting. 

The history obtained by the Pediatric Cardiologist was that of a cyanotic breath-holding spell. She fell while running and cried "more vigorously than normal" followed by a period when she could not breathe and was cyanotic. She then lost consciousness (there was also a history of choking on rice at the start of the episode). She was stable and was noted to be "alert, awake and oriented in the Emergency Department [ED]" and there were no postictal signs. An electrocardiogram (ECG) showed sinus tachycardia. 

This history with the rapid recovery with return to normalcy, in addition to her age are typical of breath-holding, not an unexplained syncopal episode. She was stable and noted to be "alert, awake and oriented in the ED" and there were no postictal signs. An ECG showed only sinus tachycardia. 

In the denial appeal, the MCG criteria Syncope, Pediatric is referenced. However, none of the criteria for hospital admission given including hemodynamic instability, altered mental status, central nervous system [CNS] event, cardiac disease (i.e. ventricular tachycardia, supraventricular tachycardia [SVT], etc.) were present in this child. However, Alternative to Admission criteria, specifically "Outpatient evaluation in emergency department, urgent care center or medical office" is considered an appropriate care setting in this patient. 

Most importantly, the appropriate workup including cardiac, laboratory and specialty consultation were all performed within 24 hours. The initial triage was performed and workup was completed. Clearly this child's evaluation could have been performed in an observational setting and the inpatient admission was not medically necessary. Therefore, the denial should be upheld. 

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

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

Diagnosis: COPD exacerbation
Treatment: Inpatient hospital admission
The insurer is denied coverage for inpatient hospital admission.
The denial is upheld. 

The patient is a female with a history of COPD who was non-compliant with her COPD meds. She presented to the emergency department (ED) with complaints of worsening shortness of breath with wheezing for about a few weeks. The patient also reported some dry cough along with sore throat. The patient denied fever, chills, and chest pain. Vital signs at presentation to the ED were: Temperature 97.4F, Respirations 18, blood pressure 121/77 mm Hg, heart rate 76, and oxygen saturation was 99%. 

The patient was speaking in full sentences, was in no acute distress, and there was no use of accessory muscles noted. The lung exam revealed some decreased air entry bilaterally in all lung fields along with expiratory wheeze. The abdomen was soft and non-tender.  The patient was awake and alert. WBC was 8.1 K, BNP was normal, troponin was negative, influenza panel was negative, chest x-ray did not reveal any acute infiltrate. EKG revealed normal sinus rhythm and no acute ST-T changes.

The patient was treated in the ED with steroids, bronchodilators via nebulizers, and Magnesium. She received one dose of antibiotics. The patient was subsequently admitted for COPD exacerbation. As per the history and physical (H & P).  The patient was in no acute distress with minimal wheeze on exam. The patient was speaking in full sentences. There was no accessory muscle use or Tripoding. The patent remained stable after admission, was ambulating without any dyspnea, and was on oral medications and inhalers. Antibiotics were discontinued. As per a note, the patient remained afebrile and hemodynamically stable and on oral medication. This patient was discharged home with recommendations for outpatient follow up.

This patient did not need acute hospitalization. She could have been placed in observation status. She was afebrile, not hypoxic, and in no acute distress. She was tolerating oral intake and ambulating without distress. Labs were normal. No pneumonia, pleural effusion, CHF or pneumothorax on chest x-ray. The patient could have been placed in observation status while diagnostic testing and treatment were initiated.

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 hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male whose inpatient admission is under review. The patient has no PMH (prior medical history), and presented to the ER after recent travel to Texas with fever and malaise. The patient complained of chest pain, myalgia, dyspnea, URI (upper respiratory infection) symptoms, and headache. The patient had been seen once in the ER the day prior, with initial work-up negative and sent home. The patient returned with worsening symptoms.

In the ER, the patient was thought to have sepsis of unclear source. The sources considered were pulmonary, urinary, CSF (cerebral spinal fluid), as well as systemic. He was started on IV (intravenous) antibiotics. A lumbar puncture performed and the patient was admitted. During the admission, the patient's fevers continued. Further workup with CT (computed tomography) scan revealed pneumonia, at which point therapy was directed at this. The workup for a specific etiology remained negative. The patient improved and he was discharged on PO (oral) antibiotics.

Yes, Inpatient admission was medically necessary.

The insurance company denied this admission because it did not meet the requirements for pneumonia. In that they are correct, as the patient does not meet the criteria for inpatient admission for pneumonia set out by the Infectious Diseases Society of America (1).  

However, this patient was not admitted for a pneumonia (that was only found after an exhaustive workup). The patient presented with sepsis without a clear source. In this case, standard of care would require inpatient admission, observation, and work-up to rule out lethal entities such as endocarditis and meningitis. Failure to admit such a patient could lead to organ failure, septic shock, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath.  
Treatment: Inpatient admission.  

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

The patient is a female with history of COPD (chronic obstructive pulmonary disease).  She presented to the emergency room for shortness of breath.  The patient was found to have elevated troponin in the setting of COPD exacerbation.  The patient was admitted to acute in hospital level of care for IV (intravenous) steroids, nebulization treatment, and work up of elevated troponin.  

The patient's emergency room work up included, EKG (electrocardiogram), troponin and CT (computed tomography) scan of chest for her shortness of breath.  At the time of admission and throughout hospitalization the patient was hemodynamically stable.  The patient was not in any distress.  Her blood work was with in normal range.  The troponin was mildly elevated, but she had similar elevation in the past with negative cardiac work up.  Patient was treated with IV steroids and nebulization for the COPD exacerbation.  

No, the proposed inpatient admission is not "medically necessary".  

The patient was treated for COPD exacerbation, as well as for elevated troponin.  The acute coronary syndrome could have been ruled out as an observation level of care.  The patient's COPD exacerbation appeared mild and could have been treated with oral steroids as an outpatient.  The entire admission is not medically necessary.  The patient could have been safely and effectively been treated initially at an observation level of care followed by outpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse. 
Treatment: Continued Inpatient Substance Abuse treatment. 

The insurer denied the continued inpatient substance abuse treatment. The denial is overturned. 

The patient is a male. The patient presented requesting detoxification treatment. He was admitted to acute inpatient level care beginning to address substance use disorder with alcohol and stimulant (cocaine) class substances, as well as past use of sedative-hypnotic-anxiolytic class drugs of abuse. The patient had been using large quantities of alcohol daily together with cocaine intermittently with use of approximately $500 worth of crack cocaine per week. He has no history of withdrawal seizures or delirium tremens. He has a history of prior detoxification and substance use disorder treatments with up to four prior treatment episodes. His self-referral for treatment was prompted by multiple stressors including housing, primary support, social environment and other psychosocial domains, as well as general medical issues and health concerns. 

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with tapering dosages of Librium and PRN (as needed) medications for comfort, as well as vitamin replacement therapy and use of quetiapine and melatonin. The program provided for case management with referral to sober housing and access to rehabilitation treatment that included comprehensive evidence-based treatments. 

During the continued stay for detoxification treatment the patient engaged in counseling sessions, focusing on education about the disease model of addiction, and, involvement with counseling and milieu activities including peer support and education sessions to motivate the patient to proceed to rehabilitation treatment. Vital signs remained abnormal intermittently as noted during his brief stay. The patient remained engaged with detoxification treatment; he was cooperative with the tapering dosages of Librium. Withdrawal symptoms remained mild, but persisted with tremor, anxiety and insomnia requiring PRN medications and monitoring. 

The patient completed his detoxification treatment and was discharged with referral for clinically appropriate aftercare with an outpatient mental health and substance use disorder treatment program.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Urinary Tract Infection.
Treatment:  Inpatient hospital admission.

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

This patient is a female child who was first seen in a hospital emergency room (ER) for fever.  A UTI was diagnosed based upon positive urinalysis, and she was sent home on cefdinir.  Based upon urine culture showing E. coli resistant to cefazolin, which implies cefdinir resistance, she was called back to the ER for bloodwork and possible intravenous (IV) antibiotic therapy.  At home in the interval she had new onset URI symptoms with fever 104 recorded 1 day prior, although her initial vital signs were within normal limits, except for tachycardia:  temperature 98.2F, pulse 148, respirations 36, and blood oxygen saturation 100% on room air.  Lab tests on this second ER visit revealed white blood cell (WBC) count 16,600.  Blood and urine cultures were sent.  On sonogram there was mild fullness was noted in the right renal pelvis and left renal collecting system and mild debris within the bladder dependently, which findings are consistent with pyelonephritis.

The patient was appropriately admitted for IV ceftriaxone with a diagnosis of urinary tract infection (UTI).  In young infants with pyelonephritis, initial treatment is often administered intravenously.  At the initiation of treatment an antibiotic by oral or parenteral route is equally efficacious, but the choice of antibiotic needs to be modified based upon culture results with sensitivity if available.  In the patient's case, the E. coli was a multi-resistant strain for which no oral agent was available, so the only choice was to admit her and administer a parenteral antibiotic (ceftriaxone in her case).

There are several additional reasons on her clinical profile that make her admission justified:  1) Even though a respiratory virus panel was positive for enterovirus/rhinovirus and she had a recent URI, the high fever at home on cefdinir was an indication of possible pyelonephritis; 2) Renal sonogram findings were consistent with pyelonephritis; 3) The fact that on a specified date urine culture ultimately came back negative does not impact the decision to admit for IV antibiotics, because although the infection can spontaneously clear, there is no way to know this at the time the decision needs to be made.

The health plan did not act reasonably with sound medical judgment 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 is overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Pan-ulcerative colitis.
Treatment: Formulary exception for Budesonide ER ER 9mg tab. 
The insurer denied the Formulary exception for Budesonide ER ER 9mg tab. 
The denial is upheld. 

The patient is a male with pan-ulcerative colitis. He has failed treatment with sulfasalazine and Lialda. His provider is requesting an eight-week course of budesonide ER.

No, the health plan should not cover the Formulary exception for Budesonide ER ER 9mg tab.

The patient has pan-ulcerative colitis and has failed treatment with 5-ASA (mesalamine). Medical literature supports the use of both a course of prednisone or budesonide in such patients to achieve remission. While prednisone is not a safe long-term treatment option, it is safe for short-term use. Budesonide, on the other hand, is safer to use if long-term steroid use is required. Dexamethasone, methylprednisolone, prednisolone and hydrocortisone are not as appropriate as prednisone for this patient. As the patient has not failed a course of the formulary preferred prednisone, the health plan should not cover the proposed budesonide at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Helicobacter Pylori Infection
Treatment: Talicia 10mg-250mg cap 
The insurer denied the Talicia 10mg-250mg cap.
The denial is upheld. 

The patient is a female with H. pylori. She has failed multiple regimens, including Augmentin/omeprazole, Prevpak and a Cipro/metronidazole. Her physician is requesting treatment with Talicia. 

No, the treatment with Talicia 10mg-250mg cap is not medically necessary.

The patient has H. pylori and has failed multiple treatment regimens. There is no documentation that the patient has tried and failed the plan-preferred treatment regimen for H. pylori, metronidazole, tetracycline and bismuth in combination with a proton pump inhibitor. Based on the current literature, the health plan's preferred treatment regimen is expected to be at least as efficacious as the requested Talicia. Therefore, the proposed Talicia is not medically necessary, and the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia and urinary tract infection
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a female whose inpatient admission is under review. The patient has a history of diabetes and HTN (hypertension), and presented with two days of myalgias, cough, right flank pain, fevers, nausea, and vomiting.

In the ER she was thought to have pneumonia and/or UTI, and was started on IV ceftriaxone and azithromycin, and admitted. She did have a fever to 100.6 the first day in the hospital and did improve while there. She was discharged on PO (by mouth) medications.

Yes, the Inpatient admission is medically necessary.

For UTI alone, the patient meets criteria for hospital admission and IV treatment as she had evidence of systemic infection (elevated pulse, leucocytosis, and bandemia). In addition, she had pneumonia, and standard of care would also require hospitalization when there are multiple infections in an elderly, immune compromised (diabetes) host. Thus, this admission was warranted, supported by standard of care and IDSA guidelines. Failure to admit such as a patient can lead to organ failure, septic shock, or death.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male child with medical history significant for asthma. He presented to the ED with three-day history of cold symptoms followed by difficulty breathing. He began using his Flovent (prescribed twice daily but used as needed) and albuterol (used as needed) one day prior to presentation, taking albuterol treatments as often as every four hours. He was seen by his pediatrician several hours before presenting to the ED, with recommendations to continue the breathing treatments. He came to the ED because of increased work of breathing despite consistent bronchodilator treatments at home.

The patient's vital signs included temperature 37.5, heart rate 133, respiratory rate 55, and blood pressure 113/70. Examination was significant for no apparent distress, diffuse wheezing with suprasternal/subcostal/intercostal retractions, benign abdomen, and non-focal neurologic exam. He was given three back-to-back albuterol/Atrovent treatments as well as a dose of steroids. Because he remained sufficiently symptomatic, he was given a dose of magnesium and a fluid bolus and maintained on albuterol treatments every two hours.

The patient was subsequently admitted for further management of acute asthma exacerbation. Admission orders included albuterol every two hours weaning as tolerated, serial respiratory scores, regular diet, enteral corticosteroids, and development of an asthma action plan. He tolerated weaning of albuterol to every three hours and then every four hours by night time. An electrocardiogram was obtained because of persistent tachycardia revealing sinus tachycardia thought to be a result of the albuterol treatments. An asthma action plan was reviewed with the family. He was subsequently deemed stable for discharge home. 

No, the Inpatient admission was not medically necessary.

In the ED, primary management strategies include correction of hypoxia, rapid improvement of airflow obstruction, and prevention of progression. This is achieved with supplemental oxygen, bronchodilators, and steroids. Fluid hydration may also be necessary. For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED, admission is necessary.

This patient with history of asthma, three hospital admissions for exacerbations, and no consistent asthma care plan presented to the ED with signs and symptoms of acute asthma exacerbation secondary to viral respiratory illness. He responded to the treatments in the ED, but not sufficiently to be deemed stable for discharge home. He required bronchodilators every two hours initially. While it was medically necessary and reasonable to continue his treatments in the hospital, he was overall hemodynamically stable with no supplemental oxygen requirement, no signs of impending respiratory failure, and positive response to treatment. He did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Full hospital admission
The insurer denied the full hospital admission.
The denial was upheld.

This is a female patient with a past medical history significant for hypertension, multiple sclerosis, morbid obesity, deep vein thrombosis (DVT), and chronic venous stasis who presented to the Emergency Department with complaints of lower extremity swelling and sores. Her vital signs on presentation included a temperature of 98.3F, a blood pressure of 126/92, a pulse of 99, a respiratory rate of 18, and an oxygen saturation of 100%.  Laboratory values were notable for the following: white blood cell (WBC) count of 7.21, hemoglobin of 14.9, a hematocrit of 44.4, a creatinine of 0.6, and glucose of 118.
She was admitted for evaluation of lower leg swelling and lymphedema.  She was empirically started on intravenous antibiotics (Cefazolin).  A chest x-ray was negative.  A Doppler of the lower extremities was negative for a deep vein thrombosis (DVT).  Infectious Diseases consulted and antibiotics were changed to vancomycin.  Vascular Surgery recommended dressing changes and leg elevation; no surgical intervention was deemed necessary.  The patient remained afebrile and hemodynamically and clinically stable.  She was discharged to continue oral antibiotics as an outpatient.  

The patient presented with bilateral lower swelling and erythema with open sores.  Otherwise, she was afebrile, hemodynamically stable, and with unremarkable laboratory results including a normal WBC count.  Vascular Surgery consulted and deemed no surgical intervention was required.  Findings were believed to be secondary to chronic venous stasis.  Based on the above findings, the patient fulfilled criteria for observation level of care monitoring.      

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

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