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

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

The patient is a male. He was hospitalized for chest pain. He presented to the hospital ED (emergency department) for evaluation of chest pain, SOB (shortness of breath) and fatigue with minimal effort. His past medical history is remarkable for diabetes, HTN (hypertension), morbid obesity, OSA (obstructive sleep apnea) treated with CPAP (continuous positive airway pressure) and former smoking.

The patient's vital signs were stable. EKG (electrocardiogram) showed SR (sinus rhythm) and NSIVCD (Non-Specific Interventricular Conduction Delay) and LVH (left ventricular hypertrophy). There were no arrhythmias or elevated troponin documented. Chest x-ray was negative. TTE (Transthoracic Echocardiogram) showed LVEF (left ventricle ejection fraction) 45-50%. Cardiac catheterization showed no CAD (coronary artery disease). There were no procedural complications and he was discharged to home the next day.

This is an appeal of the denied claim the requested Acute Inpatient Hospital Stay was medically necessary for this patient.

No, the Inpatient admission was not medically necessary.
Based on the peer-reviewed medical literature and this reviewer's expert medical opinion, there was not a medical need for the acute inpatient hospital stay. The severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. In this particular case, criteria for inpatient admission is not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome (ACS), acute myocardial infarction (AMI), chest pain that is indicative of a serious cardiac condition like pulmonary embolism (PE) or aortic dissection, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. The care he received, including cardiac catheterization with coronary angiography like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published evidence-based medical literature, the requested health service is not medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Dizziness, palpitations
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female who presented with dizziness, palpitations and left arm pain. She had a troponin of 0.18.  She was admitted to telemetry. 

The patient's chest x-ray (CXR) showed a possible nodule.  The patient had a history breast cancer and recent death of her husband. Her electrocardiogram (EKG) was normal. Recent catheterization did not show obstructive disease, but a presence of a myocardial bridge. The patient received intravenous fluids, a low dose beta blocker, and aspirin (ASA). Her hospitalization was uneventful and the patient was discharged.

No, the proposed inpatient admission was not medically necessary.
Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome. Exam and cardiac findings were normal. Biomarkers were minimally elevated and electrocardiogram (EKG) showed no evidence of acute ischemia. Chest x-ray was normal except for an incidental nodule. Echocardiogram showed no wall motion abnormality.  The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Recent catheterization did not show obstructive coronary artery disease (CAD). Orders did not include medical therapy for acute coronary syndrome such as intravenous (IV) heparin, dual anti-platelet inhibitors, high dose beta blockers or intravenous nitroglycerin (NTG).  

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care.  The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care.

There was no "complex" care that required inpatient level of care in this patient's care. This patient had no evidence of coronary artery disease (CAD) or malignant arrhythmias. All tests showed absence of ischemia and normal rhythm.  While there is always a potential for an adverse event, one did not happen and no actual treatment was added.

Milliman criteria requirements were not fulfilled as there was never any evidence of acute coronary syndrome present.

All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.

Yes, the health plan act reasonably, with sound medical judgment and in the best interest of the patient.
Appropriate level of care determination based on sound medical judgement is in best of interests of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient, previously healthy, with a history of undergoing a dental procedure for caries a few days prior, presented to the emergency room with complaints of left facial swelling. He had tachycardia (up to 136/minute), and fever (101.3 Fahrenheit).  He was administered analgesics (oral Tylenol, intravenous Ketorolac) and normal saline bolus, as well as intravenous (IV) Unasyn. He was admitted and made nothing by mouth (NPO) after midnight. On examination by Oral Maxillofacial Surgery (OMFS) in the emergency department (ED), and on the Pediatric history and physical (H&P), there was left facial swelling, erythema and tenderness, there was no trismus or fluctuance. He had tachycardia and fever but was not otherwise sick appearing. There was carious tooth #J (primary secondary molars) with no purulent discharge which was nontender to palpation or percussion and no effect on the airway. The computed tomography (CT) scan showed left sided facial subcutaneous swelling only. Although it is stated that he had Leukocytosis, his white blood cell count (WBC) count of 14,000 was within the range of 5000 to 15,000 for a child his age. 

The patient had cellulitis overlying a clinically diagnosed dental space infection, but no dental abscess was revealed by the CT scan. Caries that was noted on tooth #J was the likely source of the cellulitis. Adequate justification (i.e., medical decision making) for admission level of care is not documented.  Although Oral Surgery extracted tooth #J, this could have been done as an outpatient. Oral Maxillofacial Surgery (OMFS) had recommended coming to clinic for panoramic radiographic X-ray in a week.

Odontogenic infections are usually confined to the alveolar ridge vicinity, usually as a periapical infection, and complications are uncommon. The most important treatment modality in such an odontogenic infection is surgical elimination of the primary source of the infection, with antibiotics given as adjunctive therapy, but this was not recommended to be done immediately by the OMFS service, presumably because they did not consider the infection severe enough for immediate intervention. Moreover, as the patient's vital signs were stable and oral intake was not diminished, admission to the hospital was unnecessary solely for administration of IV antibiotics, and the tooth extraction could have done as an outpatient. 

The patient's condition did not warrant inpatient hospital admission. He could have been discharged on oral antibiotics and followed up at the dental clinic as an outpatient. 

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 hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck Pain, and Left Shoulder Pain

Treatment continued Physical Therapy, two units of manual therapy (97140) and one unit of each therapeutic exercise (97110) and electric stimulation-constant attendance (97032) 

The insurer denied coverage for continued Physical Therapy, two units of manual therapy (97140) and one unit of each therapeutic exercise (97110) and electric stimulation-constant attendance (97032) 

The denial is upheld

The physical therapy treatment notes provide insufficient clinical information to support the medical necessity of continuing physical therapy.  This physician agrees that the physical therapy notes do not provide specific detail regarding the services provided.  The treatment notes are essentially hand-written entries noting non-specific range of motion, palpation, and pre/post pain levels.  However, particular detail regarding the billed therapeutic exercises, manual therapies and electric stimulation-constant attendance are insufficiently documented.  

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  From a physical medicine and rehabilitation/pain management perspective, continued Physical Therapy, two units of manual therapy (97140) and one unit of each therapeutic exercise (97110) and electric stimulation-constant attendance (97032) were not medically necessary. 

Based on the above, the medical necessity for the continued Physical Therapy, two units of manual therapy (97140) and one unit of each therapeutic exercise (97110) and electric stimulation-constant attendance (97032) are not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertriglyceridemia

Treatment: Vascepa

The insurer denied coverage for Vascepa.

The denial is overturned.

The patient is a female with a past medical history notable for hypertriglyceridemia, hypertension, carotid artery atherosclerosis, and type 2 diabetes mellitus. She had a triglyceride level of 1505 mg/dL (milligrams per deciliter) and LDL (low density lipoprotein) of 23 mg/dL. She previously tried statin therapy, but was unable to tolerate these due to myalgias. She was also treated with fenofibrate and gemfibrozil at maximum doses, which did not result in control of her triglycerides. She previously tried generic Lovaza, which was also ineffective. 

Vascepa is medically necessary. This medication has been shown in a large randomized clinical trial to improve cardiovascular mortality in patients on maximally tolerated statin who either have established clinical atherosclerotic cardiovascular disease or diabetes mellitus type 2 with risk factors. The patient has the latter condition. She was not able to tolerate statins due to myalgias, however her LDL level was 23 mg/dL; per policy, it must be <100 mg/dL to be approved for Vascepa. Moreover, she has tried other conventional therapies for elevated triglycerides, without an appropriate clinical response. The use of Vascepa has been demonstrated to reduce major adverse cardiovascular outcomes in clinical trials of similar patients. The member has diabetes mellitus and other atherosclerotic cardiovascular risk factors, therefore, Vascepa is medically necessary and is approved as requested. 

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

The insurer's denial of coverage for Vascepa is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcoholic Gastritis

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient had a history of cardiac disease and ulcer disease and presented after vomiting blood. He was having chest discomfort and abdominal pain. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The hemoglobin was 10.9. An endoscopy revealed mild gastritis with no signs of active bleeding. The troponin was negative. The electrocardiogram (EKG) did not have acute changes. A computed tomography scan was negative for acute disease. He was diagnosed with alcoholic gastritis. Intravenous (IV) hydration, proton pump inhibitor therapy (PPI) therapy and antiemetics were given. The abdominal pain improved, and the hemoglobin remained stable.

Clinical indications for admission for Upper Gastrointestinal Bleeding Milliman Care Guidelines (MCG M-180) include hemodynamic instability, ongoing active bleeding, high risk endoscopic features, severe anemia, and peritoneal signs. The patient did not have these conditions.

Clinical indications for admission for Gastritis (MCG M-560) include gastric outlet obstruction, peritoneal signs, severe vomiting, severe dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient vomited blood and was diagnosed with alcoholic gastritis. The endoscopy was negative for active bleeding or high-risk endoscopic features. He could have been treated with a PPI and antiemetics and then have the endoscopy performed with observation status. He did not meet Milliman Care Guidelines (MCG) criteria for admission for either Upper Gastrointestinal Bleeding or Gastritis. The health care plan acted reasonably and with sound medical judgement. An 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 hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: CHF(congestive heart failure), Diabetes.
Treatment: skilled nursing and rehabilitation facility (SNF).
The health plan denied skilled nursing and rehabilitation facility (SNF).
The determination is upheld.


The patient has a medical history significant for diabetes, hypertension, pain in the left hip and congestive heart failure who was admitted to a skilled nursing facility following hospital stay. At issue is whether continued stay at the skilled nursing and rehabilitation facility (SNF). 
Continued stay was not medically necessary for this patient.
Documentation was reviewed and the patient required minimal assistance (MINA) for upper body dressing (UBD), contact guard assist (CGA) for bedside commode transfer with a front wheeled (FWW) and was dependent for bathing and lower body dressing. Supine to sit with bedrail and trapeze remained MINA and UBD remained MINA. Also, on both dates the patient remained dependent for clothing management after bathroom. While bedside commode transfer with FWW did improve from a CGA to a stand by assist (SBA) but she regressed to CGA. CGA is an appropriate functional level to discharge to a lower level of care. Similarly, while the distance of ambulation had improved from 15 feet [']  with FWW to 30' the level of assistance had only changed from CGA to SBA/CGA and the patient was back to walking 25' with FWW CGA and  the patient was still only able to ambulate 20' with the walker and SBA. The patient had only improved to MINA for UBD and bathing, maximal assistance (MAXA) for lower body dressing and bathing and bedside commode transfer had only improved back to SBA. Therefore, the continued SNF stay was not medically necessary or appropriate as functional progress was limited.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory. 
Treatment: DME. 
The insurer denied implantable loop recorder. 
The denial is upheld.

The patient is a male with a history of hypertension, hyperlipidemia, and frequent premature ventricular complexes. He underwent implantation of an implantable loop recorder (ILR); the indication for implantation was not documented in the medical records provided for review. During the 42-month recording period, one 14 beat run of nonsustained ventricular tachycardia was documented. No other significant arrhythmias were detected. The patient had an episode of syncope; this was not associated with an arrhythmia. The patient was seen by a cardiologist. At that time, he complained of fatigue and dyspnea. The record does not document complaints of palpitations, syncope or near syncope. Given the lack of detected significant arrhythmias during the monitoring period, the patient was offered explantation of the ILR without re-implantation of a new device. However, the patient elected to have a new device implanted. He was seen in the emergency department complaining of chest pain, dyspnea, rhinorrhea, and palpitations. His electrocardiogram showed sinus rhythm and evaluation was unrevealing. His symptoms were attributed to an upper respiratory infection. The patient underwent explantation of the previously implanted ILR and implantation of a new device. Medical necessity for implantation of the new ILR is at issue. Of note, the procedure note stated that the indication for the ILR was paroxysmal atrial fibrillation (PAF). However, the cardiologist's note does not indicate a history of PAF.

The insertion and replacement of the loop recorder is not medically necessary for this patient. This patient underwent implantation of an implantable loop recorder (ILR); the indication for the initial implantation was not documented in the records provided. During 42 months of recording, no significant arrhythmias were documented. There was one brief run of nonsustained ventricular tachycardia. The patient had an episode of syncope during the recording period; no arrhythmias were documented at that time. The physician's note does not mention any symptoms suggestive of an arrhythmia. The patient did complain of palpitations; these were not further described. An electrocardiogram showed sinus rhythm and the patient's symptoms were ascribed to an upper respiratory infection. In summary, given the lack of any documentation of significant symptoms suggesting an arrhythmia, and the lack of any documentation of significant arrhythmias during a 42-month monitoring period, the indication for implantation of a second ILR is unclear. Thus, it cannot be considered to be medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The determination is upheld.

The patient has a past medical history (PMH) of hypertension (HTN) and morbid obesity and was admitted with complaints of (c/o) chest pressure radiating to the left arm and back associated with shortness of breath (SOB), nausea, and vomiting. Her vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD). Lab work was notable for negative cardiac enzymes. A chest x-ray (CXR) showed no acute pathology. An electrocardiogram (EKG) showed no acute ischemia. The patient was diagnosed with chest pain and was treated with nitroglycerin, statins, a proton pump inhibitor (PPI), and cardiovascular (CV) work-up. She was discharged with a diagnosis of gastroesophageal reflux disease (GERD). The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care.
This patient presented to the ED with c/o chest pain that radiated to the left arm associated with SOB. The EKG did not demonstrate any acute ischemic changes. For the chest pain, the patient's HEART [History, EKG, Age, Risk factors, and troponin] score was 4, indicating that the patient had a moderate score, and not a high score. Given that the patient had stable vital signs, no unstable co-morbidities, a non-ischemic EKG and negative cardiac biomarkers, no new left bundle branch block (LBBB) or newly inverted T-waves believed to be ischemic in origin, and no classic anginal symptoms or other serious or life-threatening cardiopulmonary etiologies, and an ultimate diagnosis GERD, for which a PPI regimen was prescribed, this patient could have been safely and appropriately treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient admission. 
The denial is upheld.

This is the case of a female who came to the emergency department (ED) with complaint of decreased oral intake after outside diagnosis of coxsackie disease. She had decreased number of wet diapers, fever to 101 Fahrenheit (F), and complained of sore throat. Symptoms began 2 days prior. Review of symptoms (ROS) was negative for diarrhea, cough, or vomiting.
Vitals were temperature (T) 36.6 Celsius (C), heart rate (HR) was 132, respiratory rate (RR) was 20, and oxygen (O2) saturation was 97% on room air. Weight was 19.4 kilograms (kg).
Exam was notable for no tears when crying. Throat examination showed diffuse golden papules of the posterior oropharynx with no tonsillar exudate or hypertrophy. Labs revealed bicarb=17.4 with increased anion gap (AG)=19, otherwise normal electrolytes, and complete blood count (CBC) with white blood cell (WBC)=15.3, hematocrit (Hct)=36.9, platelets (Plt)=412. Strep, Influenza, and respiratory syncytial virus (RSV) testing was negative. The patient was given intravenous fluids (IVF) bolus x 2 in the ED and was noted to have tear production but no urine. The decision was made to admit for further intravenous (IV) hydration. The next morning the patient had voided, urine specific gravity (SG)=1.031. She was able to be discharged home with outpatient follow-up. At issue is whether the inpatient admission was considered medically necessary.

The health plan's determination is upheld.

Based on review of the medical records provided, full inpatient admission was not considered medically necessary for this patient and treatment could have been managed at a lower level of care.
This is an otherwise healthy toddler who presented to the ED with decreased oral intake due to coxsackievirus. There was no additional fluid loss due to vomiting or diarrhea. She was found to have mild dehydration by clinical assessment. The patient received IVF bolus x 2 but was not prepared for discharge home. Given her clinical stability and lack of medical complexity, this patient could have been cared for at a lower level of care.