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

Diagnosis: Abdominal pain.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is upheld.

This is a female patient with a history of Helicobacter pylori (H. pylori) gastritis. She had a cholecystectomy. She presented to the emergency room (ER) with complaints of abdominal pain. Vital signs were stable. An abdominal ultrasound (US) revealed no significant findings. A computed tomography (CT) scan of the abdomen and pelvis revealed no evidence of small bowel obstruction or diverticulitis. There was biliary duct dilatation. Liver enzymes were elevated. The epigastrium was tender to palpation. The patient was admitted to the hospital with transaminitis.  

The patient presented with abdominal pain. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The patient's liver enzymes were elevated. Her bilirubin was 4.7. Her internationalized ratio (INR) was 1.1. Bile duct dilatation was found on a magnetic resonance cholangiopancreatography (MRCP). An endoscopic ultrasound was negative. A fine needle biopsy of the liver was done. The liver enzymes improved.

Clinical indications for admission for undiagnosed abdominal pain based on Milliman Care Guidelines (MCG) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

MCG clinical indications for admission for Bile Duct Inflammation or Stone includes having acute cholangitis, acute cholecystitis, or a calculous causing hemodynamic instability, obstruction, dehydration or severe vomiting. The patient did not have these conditions.  

This patient required a work-up for elevated liver enzymes and dilated bile duct. However, the endoscopic ultrasound (EUS) and liver biopsy could have been done on an outpatient basis. She did not meet MCG criteria for admission for either undiagnosed abdominal pain or bile duct inflammation or stone. She could have been managed with observation status. 

The healthcare plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.  

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

Diagnosis: Digestive System/Gastrointestinal-Gallbladder Problem.
Treatment: Inpatient Hospital stay.
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan determination. 

The patient has a medical history of Hashimoto's disease and current pregnancy at 11 weeks. She presented to the emergency department on  with epigastric abdominal pain and vomiting after eating a gyro, and the inability to keep food and medications down; she had a similar episode of pain the prior week. Physical examination was notable for soft, nondistended abdomen with right upper quadrant tenderness. Labs showed elevated white blood cell count of 11.6 thousands per cubic milliliter(K/uL) with 85.0% neutrophils. Ultrasound of the abdomen showed cholelithiasis, lack of gallbladder wall thickening or pericholecystic fluid, mild hepatomegaly, and otherwise unremarkable exam. She was treated with intravenous fluids, Zosyn, acetaminophen, and morphine. General Surgery consultation noted a positive Murphy's sign, intravenous fluids, nil per os (NPO), intravenous ceftriaxone and metronidazole, pain management, and oral challenge with clear liquids after improvement in pain. Obstetrics consultation noted unremarkable labs, and recommended management per Surgery. The following day she still had minimal right upper quadrant abdominal pain, and denied fever and chills; she tolerated a liquid diet. Physical examination was notable for right upper quadrant tenderness on palpation. Labs showed normalized white blood cell count. She was discharged on a low-fat diet and Tylenol as needed, with a plan for Obstetrics and Gynecology follow-up.

the inpatient level of care is not supported by the provided information. The patient presented with cholelithiasis, and concern for biliary colic and cholecystitis [1]. However, there was no persistent hemodynamic instability or other complications such as complicated choledocholithiasis, ascending cholangitis, hepatic abscess, active gastrointestinal bleeding, peritonitis, fistula, or sepsis, which would require a higher level of care [2-6]. The timing of laparoscopic cholecystectomy was contemplated, but ultimately not performed during the admission [7-9]. Given the lack of complications, and given improvement in one day, the care provided, including monitoring, labs, imaging, analgesia, and specialist consultations, could have been performed in sequence after presentation, without the need for the inpatient level of care [2-8]. For these reasons, the inpatient level of care is not supported, and the care provided could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Facet Arthropathy. 
Treatment: Facet Joint Injections (outpatient procedures 64493 x2, 64494 x2, 64495 x2). 

The insurer denied coverage for facet joint injections (outpatient procedures 64493 x2, 64494 x2, 64495 x2). 

The denial is overturned. 

That patient is a male with a past medical history of arthritis, hypertension, atrial fibrillation, neck pain and chronic lower back pain.  The patient's pain is worse with standing, walking and bending.  He attended physical therapy for 1 month.  He also takes medications including Tylenol, Voltaren gel and lidocaine patches.  X-rays of the lumbosacral spine indicated moderate to severe spondylitic changes with levoscoliotic curvature, and no acute disease.  A magnetic resonance imaging of the lumbosacral spine without contrast indicated the patient has severe facet arthropathy resulting in severe canal stenosis at multiple levels. 

He had a first set of diagnostic medial branch blocks which produced 80% pain relief. The request is for a second set of diagnostic medial branch blocks. 

Clinical practice guidelines (Cohen et al) support a second set of diagnostic medial branch blocks when the first set produces 80% pain relief as in this case.  A second set is medically reasonable and necessary. 

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

The insurer's denial of coverage for facet joint injections facet joint injections (outpatient procedures 64493 x2, 64494 x2, 64495 x2) is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Wheezing; Shortness of breath
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She presented to the emergency room with wheezing and shortness of breath. The patient had tried and failed outpatient treatment. Patient was found to be in mild asthma exacerbation.

In the emergency room, the patient was hemodynamically stable and was in mild respiratory distress. With oral steroids, IV (intravenous) magnesium and nebulization treatments, the patient's wheezing and SOB (shortness of breath) improved partially. The patient was admitted to acute in hospital level of care. The patient was continued on oral steroids and nebulizations. The patient's condition improved significantly within 24 hours of treatment.

The patient's mild asthma exacerbation improved with emergency room care. The patient was tolerating oral diet and was ambulating. The patient was tolerating oral medications. The patient's SOB (shortness of breath) and wheezing had improved significantly. The blood work was within normal range.

No, the Inpatient admission was not medically necessary.

The patient's mild asthma exacerbation improved with emergency room care. The patient was tolerating oral diet and was ambulating. The patient was tolerating oral medications. The patient's SOB (shortness of breath) and wheezing had improved significantly. The blood work was within normal range. The acute inpatient admission was not medically necessary. The patient could have been safely and effectively treated at an observation level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Back Pain

Treatment: Diclofenac Epolamine 1.3% patch

The insurer denied coverage for Diclofenac Epolamine 1.3% patch

The denial is overturned

The patient is a female with chronic lower back pain that developed an acute exacerbation of axial back pain. The progress note states that she did not receive relief from the topical diclofenac gel.

Diclofenac Epolamine 1.3% topical patch(1) is Food and Drug Administration approved for musculoskeletal sprains. Stanos(2) reviewed the efficacy of the Diclofenac patch and found it comparable to oral formulations without the gastrointestinal side-effects. In a Cochrane review, they found the data for non-steroidal anti-inflammatory drugs (NSAIDs) best supported use of diclofenac and they stated "Direct comparison of topical NSAID with an oral NSAID did not show any difference in efficacy. There was an increase in local adverse events (mostly mild skin reactions) with topical NSAIDs compared with placebo or oral NSAIDs, but no increase in serious adverse events. Gastrointestinal adverse events with topical NSAID did not differ from placebo, but were less frequent than with oral NSAIDs."

The requested medication is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the medication Diclofenac Epolamine 1.3% Patch is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Hypertension.
Treatment: Inpatient Hospital Admission.
The insurer denied coverage for Inpatient Hospital Admission.
The denial is modified. 

The patient is a female with a history of hypertension (HTN) and atrial fibrillation (AF) who presented to the Emergency Room (ER) with complaints of worsening lower extremity (LE) edema, a 1 day history of elevated blood pressure, and "feeling foggy". She recently had a baby via normal spontaneous vaginal delivery (NSVD).  The recent workup for preeclampsia was negative. The patient was admitted to labor and delivery with a diagnosis of preeclampsia.  The plan was to start a 24 hour Magnesium IV(intravenous) drip and administer IV Hydralazine as needed (PRN) for blood pressure greater than 160/110.
 
Cardiology evaluated the patient and interrogated her loop recorder.  There were no signs of arrhythmia.  A chest x-ray (CXR) came back within normal limits (WNL). Medicine consulted over the case.  A transthoracic echocardiogram (TTE) came back WNL.  Nifedipine was added to the medication regimen for blood pressure control.  Two days later, the patient reported that symptoms significantly improved. 

This patient presented 3 days weeks after delivery with elevated blood pressure. Delayed postpartum preeclampsia can be defined as signs and symptoms of the disease leading to readmission more than two days but less than six weeks after delivery.

The diagnosis of preeclampsia is based on the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman:

Systolic blood pressure >=140 mmHg(millimeters of mercury) or diastolic blood pressure >=90 mmHg, and
Proteinuria >=0.3 grams in a 24-hour urine specimen or protein: creatinine ratio >=0.3, or
Signs of end-organ dysfunction (platelet count <100,000/microliter, serum creatinine >1/1 mg/dL(Milligrams per decilitre) or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration).

This patient had elevated blood pressure, no protein in the urine and no elevated liver function tests (LFTs) and no end organ dysfunction. 

This patient did not have a diagnosis of preeclampsia.  She had significant elevation in her blood pressure. There was, however, a concern about a cardiac issue, arrhythmia and cardiomyopathy.

While blood pressure control could have been managed at an observational level, there was concern about significant heart pathology so admission was medically necessary for a complete evaluation.  However, once the patient has been worked up and cleared from any cardiac pathology, she could have been discharged and followed as an outpatient for control of her blood pressure.

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

The Inpatient Hospital Admission was medically necessary.  However, ongoing admission is denied. The insurer's denial of coverage for the Inpatient Hospital Admission is modified.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skeletal Class I relationship, mild Maxillary and
mandibular crowding, anterior crossbite with
gingival attachment loss
Treatment: D8080 Braces, D8670 Monthly Visits, Pre-service
The insurer denied the D8080 Braces, D8670 Monthly Visits, Pre-service.
The denial is upheld. 

The patient is a female. The request is for benefits for orthodontic treatment (Braces, monthly visits).

The patient presents with a skeletal Class I relationship, mild Maxillary and mandibular crowding, anterior crossbite with gingival attachment loss (lower left lateral incisor).

No, the proposed  treatment of orthodontic therapy is not medically necessary.

The patient's lower left lateral incisor does sit just slightly anterior to the upper lateral incisor. However, this discrepancy is evidenced to be very small. The severity as described in the dental clinical summary is not supported by the documentation submitted.

Based on the documentation presented, the severity of the crossbite is not substantiated. Thus, the treatment of orthodontic therapy is not warranted in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Buccal crossbite. 
Treatment: Braces and Periodic Visits. 

The insurer denied the Braces and Periodic Visits. 
The denial is overturned. 

Yes, the proposed Braces and Periodic Visits are medically necessary. 

Tooth #12, the upper left first premolar, is in complete buccal crossbite, meaning it is totally outside of (towards the cheek) the lower premolar. This will ultimately cause trauma to this tooth and the one below it as they will grind together improperly during the chewing cycle. Fracturing will become a distinct possibility. This case has medical necessity as the only way to correct this problem is with orthodontic treatment.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a morbidly obese male admitted with exacerbation of his congestive heart failure (CHF). The patient was estimated to be grossly fluid overloaded with at least 30 pounds of excess despite high dose oral diuretics at home. The recommendation was for intravenous (IV) diuresis of two liters per day. Co-morbidities included obesity, hypertension, atrial fibrillation, chronic renal failure (CRF), diabetes mellitus (DM), hyperlipidemia (HLP), obstructive sleep apnea (OSA), and recent knee surgery. Chest x-ray (CXR) showed pulmonary vascular congestion and examination revealed bi-ventricular failure. Ejection fraction (EF) was reduced at 40%. Diabetes was poorly controlled. The patient was started on intravenous diuresis with Lasix 80 milligrams (mg) daily. Advanced heart failure therapy was initiated.

Yes, the proposed inpatient admission was medically necessary.

This is an extremely complex patient with congestive heart failure (CHF) who failed outpatient medical therapy. High dose intravenous diuresis and addition of advanced congestive heart failure therapy were initiated. With the presence of multiple co-morbidities, including renal failure, uncontrolled diabetes and morbid obesity, the patient was extremely difficult to manage. He did require daily labs to monitor his renal failure (risk of worsening was high). He had failed outpatient therapy with high doses of oral diuretics. His care and treatment did require inpatient level of care.

The patient's actual treatment met standard of care and required inpatient admission to achieve.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Inpatient Hospital Admission
The insurer denied coverage for inpatient hospital admission
The denial is overturned

The patient has a past medical history significant for hypothyroidism. She presented to the Emergency Department with complaints of right thumb pain, erythema, and swelling after cutting hand on bottle cap.  The patient was evaluated at urgent care, underwent an incision and drainage (I&D), and treated with antibiotics.  Vitals on presentation included: Temperature. 98.5 Fahrenheit , Blood Pressure-158/81, Pulse-76, Respiratory Rate-19, and Oxygen (O2) saturation-98% on Room Air.  Laboratory results included the following: White blood cell (WBC) count-12.2, hemoglobin (HGB)-12.7, hematocrit (HCT)-39.8, creatinine-0.9, and glucose-116. The patient was started empirically on intravenous (IV) antibiotics (vancomycin and Zosyn) for right thumb cellulitis/cellulitis.  X-ray of the right hand showed no acute findings.  The patient underwent another I&D procedure by Hand Surgery.  Infectious Diseases consulted and adjusted antibiotic coverage.  Magnetic resonance imaging (MRI) was negative for osteomyelitis.  The patient remained afebrile, clinically, and hemodynamically stable.  She was discharged to continue antibiotics (Levaquin) as an outpatient. 

According to documentation, the patient presented with worsening right thumb infection despite outpatient intervention that included I&D procedure, as well as oral antibiotics. Although patient was afebrile, lack of fever may be related to antibiotic therapy.  The patient reported pain 10 out of 10.  Laboratory results showed an elevated WBC.  Based on these findings, including failure of outpatient management, hospital admission was medically necessary for administration of IV antibiotics and surgical intervention (I&D). 

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

The insurer's denial of coverage for the inpatient hospital admission from 8/21/20 to 8/24/20 is reversed.  Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Generalized weakness, constipation, and weight loss.
Treatment: Inpatient admission.

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

This patient is a female with type II diabetes and hyperthyroidism who presented with generalized weakness, constipation, and weight loss for months. 

In the emergency room, the patient's blood pressure (BP) was 104/75, pulse (P) was 79, temperature (T) was 98.6F, and respiratory rate (RR) was 18. The patient's body mass index was 19.97, glucose was 301 milligrams per deciliter (mg/dL) and bicarbonate (HCO3) was 32. Thyroid stimulating hormone (TSH) was less than (<) 0.05. Thyroid ultrasound revealed bilateral thyroid nodules. Endocrinology was consulted and the patient was started on methimazole. In addition, the patient was treated with ceftriaxone for a urinary tract infection and was transitioned to Keflex. Her urine culture was positive for Escherichia (E) coli. 

The patient was evaluated by speech therapy for dysphagia and continued on regular textures and thin liquids. She was evaluated by physical therapy and discharged to subacute rehabilitation. The request for inpatient stay is under review.

No, the proposed inpatient stay was not medically necessary.

This patient presented with weakness and weight loss. This was determined to be related to uncontrolled type II diabetes and hyperthyroidism. She did not have diabetic ketoacidosis or hyperglycemic hyperosmolar state. She did not have thyroid storm. She had a urinary tract infection. She did not have sepsis. She was hemodynamically stable. She was weak and had difficulty walking. She had no focal neurological findings, and her generalized weakness was determined to be due to chronic illnesses. She required physical therapy at a subacute rehabilitation, but this did not require an inpatient stay. Therefore, no, the proposed inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Hip Arthritis

Treatment: Hospital admission 

The insurer denied coverage for hospital admission

The denial is upheld

This patient is a female with a past medical history of hypertension, hyperlipidemia, coronary artery disease, type 2 diabetes mellitus, morbid obesity, obstructive sleep apnea and known bilateral primary hip osteoarthritis.  The patient was admitted to the Hospital where she underwent a left total hip replacement due to a diagnosis of left hip arthritis. The patient tolerated the procedure and was noted to be in stable condition.  Post-operatively, the treatment plan included pain management, intravenous antibiotics, deep vein thrombosis prophylaxis treatment, physical therapy, occupational therapy, weight-bearing activity as tolerated, intravenous fluids, monitoring urine output and encourage the use of an incentive spirometer.  The patient's lab work was significant for a hemoglobin of 9.7, hematocrit of 31.9, and sodium of 133 and creatinine of 1.01.  The patient was placed on oral fluid restriction.  The patient had mild hypotension and was also tachycardic.  The patient received bolus fluids of normal saline twice.  The patient was able to ambulate 50 feet with limited fatigue.  Her lab work was significant for a hemoglobin of 9.2, hematocrit of 30.6, and creatinine of 0.92 and sodium of 140.  Fluid restriction was then discontinued.  The patient was able to ambulate 150 feet and negotiate stairs with physical therapy.  The patient was discharged in stable condition with outpatient instructions to follow up with Orthopedic Surgery.

Based on the review of the medical record and literature, full hospital admission was not medically necessary for this patient. The medical record was significant for the occurrence of hypotension in the Post-Anesthesia Care Unit (PACU).  The condition was responsive to medical management.  The remainder of the post-surgical course was non-complicated.  There was no evidence of bleeding.  The patient's abnormal hemoglobin value was expected after hip arthroplasty.  There was no need for transfusion.  The person was able to ambulate stairs and use a walker.  The patient's vital signs were stable.  There were no reports of inability to tolerate oral pain medication.  There were no reported problems with wound.  There were no records of treatments required for other underlying medical conditions. These findings do not substantiate the necessity of the full inpatient admission level of service. 

The full hospital admission is not considered medically necessary for this patient.

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

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