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

Diagnosis: coronary artery disease
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a female who presented for cardiac catheterization and possible percutaneous coronary intervention (PCI). Her MPI (myocardial perfusion imaging) was suggestive of minimal apical-septal ischemia and left ventricular ejection fraction (LVEF) of 54% (percent).
The patient had a past medical history of hypertension (HTN), HLD (hyperlipidemia), and end-stage renal disease (ESRD) on HD (hemodialysis).
The patient also had a history of spinal stenosis, diverticulitis, and anemia. Upon presentation, the patient's vitals were as follows: blood pressure (BP) 132/65, heart rate (HR) 55, Temperature 36.6 degrees Celsius, and peripheral capillary oxygen saturation (SpO2) 100% (percent). The patient was alert, awake, and oriented times three.
The electrocardiogram (ECG) revealed normal sinus rhythm, possible left atrial enlargement, left ventricular hypertrophy (LVH), inferior infarct, and age undetermined.

The requested Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented directly to the elective procedure, cardiac catheterization. She was scheduled after she had an abnormal stress test. The patient's condition was stable, and her symptoms were chronic. She underwent coronary angiography, and it revealed in-stent re-stenosis. The patient underwent coronary intervention with percutaneous transluminal coronary angioplasty (PTCA) and atherectomy. The procedure went as planned without complications.
After the procedure, the patient was stable, and she stayed overnight for observation. She was consulted by a cardiothoracic surgeon and gastroenterologist. The patient's condition and management did not meet inpatient admission criteria. She was stable and the procedure was elective. Her troponin was elevated, most likely due to her being on dialysis. A lower level of care would have been more appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholecystitis.
Treatment: Inpatient Hospital Stay.

The insurer denied Inpatient Hospital Stay. The determination is overturned.

This is a male patient who presented to the emergency department with mid-epigastric abdominal pain. His past medical history included hypertension, hyperlipidemia, and papillary thyroid cancer. His vital signs were acceptable, with mild hypertension. A right upper quadrant (RUQ) ultrasound demonstrated a mildly distended gallbladder containing sludge without wall thickening or pericholecystic fluid but with positive sonographic Murphy's sign. General surgery was consulted to see the patient in the emergency department. General surgery admitted the patient overnight. The patient was reported to be feeling well without nausea and vomiting. His pain was controlled. He was still tender in the RUQ. The WBC had increased to 16. The patient was planned for a laparoscopic cholecystectomy. The patient had not undergone surgery due to operating room (OR) availability issues. The patient's WBC had improved to 11.6. The patient was placed on a clear liquid diet and, if doing well, was planned to be discharged home. The patient did well and was discharged home on Augmentin to follow up for outpatient interval cholecystectomy. At issue is the medical necessity of an inpatient stay.

Full hospital admission was medically necessary for this patient. The patient had acute cholecystitis. The patient had right upper quadrant tenderness and positive Murphy's sign. The patient's white blood cell count reached 16, indicating signs of systemic inflammation. The patient was treated with Ceftriaxone and Flagyl initially and then switched to intravenous (IV) Zosyn. The patient initially worsened but then improved. After discussion with the patient, an interval cholecystectomy after treatment with antibiotics was planned. The hospital course is consistent with Milliman Care Guidelines (MCG) criteria for inpatient admission for acute cholecystitis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fracture of the left anterior superior iliac spin
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male who was running and felt a pop in his left hip, associated with pain. He saw an orthopedic surgeon who identified an avulsion fracture of the left anterior superior iliac spine (ASIS). Several days later he was admitted to the hospital for surgical treatment of this injury. At issue is whether inpatient hospital admission was medically necessary.
Avulsion of the anterior superior iliac spine is a common injury in adolescent boys and usually occurs when the child is running. The vast majority of these injuries are treated non-surgically with analgesics and limitation of activity until the discomfort resolves and normal activities can be resumed. Some surgeons feel that superior results can be achieved by reducing and fixing the fracture. If this is thought necessary, this can be done as an outpatient procedure. There is little risk of neurovascular complication, significant blood loss, pain requiring intravenous (IV) medication, or other issues that would require intensive monitoring or treatment. Inpatient hospital admission is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned



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

This is the case of a male who presented to the emergency department (ED) with abdominal pain and vomiting. Symptoms were present for 1 year with acute worsening over the 2 days prior to presentation. There was an ED visit 1 week prior for similar, and the patient was prescribed Zofran, sucralfate, and hydroxyzine without relief.

The inpatient hospital admission was medically necessary.
According to the Milliman Care Guidelines (MCG) Vomiting guidelines, admission is warranted for vomiting that is severe or persistent. This patient had been to the ED previously with treatment and failed outpatient management. He returned with continued, intractable vomiting despite a second episode of treatment in the ED. Therefore, he required additional work-up and treatment to establish the discharge diagnoses. The inpatient admission was indicated.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Appendicitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient is a teenager who presented with abdominal pain. The patient was afebrile and the vital signs were stable. The admitting physical exam describes that the abdomen was soft and there was no rigidity. A computed tomography scan (CT) scan showed a dilated appendix with peri appendiceal inflammatory changes. The white blood cell (WBC) count was 11.2. A laparoscopic appendectomy was performed. No complications were reported. No abscess or perforation was found. 

Milliman Care Guidelines (MCG) P-20 reviews Appendectomy, without Abscess or Peritonitis, by Laparoscopy, Pediatric. A suspected acute appendicitis is an indication for the surgery. However, the operative status criteria is listed as ambulatory. 

The hospital has referenced MCG guideline MG-GAS for Gastroenterology. Nonoperative management of acute appendicitis is an indication for admission if there is a hemoperitoneum. In addition, an acute intra-abdominal process is an indication if there is hemodynamic instability, peritoneal sign, or intestinal obstruction or perforation. The patient did not have these conditions. 

This patient had an uncomplicated appendicitis. The patient required a laparoscopic appendectomy, but this could have been performed as ambulatory surgery. The patient did not meet MCG criteria for admission for Appendectomy, without Abscess or Peritonitis, by Laparoscopy, Pediatric or Gastroenterology. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: infected tooth
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

This is a female who has been on antibiotics for an infected tooth #32. The patient developed submandibular swelling and trismus. The computed tomography (CT) revealed a submandibular abscess with the floor of the mouth clear. The patient was afebrile and the WBC's (white blood cells) were normal. The patient was admitted and taken to the operating room (OR) and underwent an extraoral incision and drainage of the submandibular space and removal of tooth #32. 

The inpatient hospital stay was not medically necessary. Hospital admission criteria for a dental infection are threat to airways or other vital structures, need for general anesthesia, septic fever, marked swelling, need for inpatient control of a concomitant systemic disease, and need for intravenous antimicrobial treatment. This patient had a need for general anesthesia and IV antibiotics, however, this is true of orthognathic surgery patients and this treatment is routinely performed on an outpatient basis.
Oromaxillofacial infection can be expected to heal well initially by removing the infection source and performing proper drainage. This was accomplished. The patient had no systemic signs, was afebrile and had no medical problems as she was an American Society of Anesthesiologists (ASA) I. An inpatient admission would only have been necessary if the patient did not respond well to surgery. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who presented to the emergency department (ED). He was brought by ambulance due to chest pain and shortness of breath on exertion. The patient developed symptoms when he was seated in a chair earlier in the day. This was the first episode he felt. Emergency Medical Services (EMS) gave him aspirin and nitroglycerin with some relief. The patient has a history of anxiety, gout, depression and aortic aneurysm.

The Inpatient Hospital Admission was not medically necessary for this patient. The patient presented with chest pain which was more typical for pleuritic chest pain than for angina type chest pain. His electrocardiogram (ECG) did not reveal acute ischemic changes and his troponin remained minimally elevated without significant peak and drop. His echocardiogram did not reveal any wall motion abnormalities. His computed tomography angiography (CTA) was negative for acute abnormality. Based on above, the patient's condition and management did not meet criteria for inpatient admission. A lower level of care would have been more appropriate.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: Post surgery (ERCP)
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male with a medical history of Crohn's disease, status post ileostomy, hiatal hernia, lower extremity edema, osteoporosis, and rectal cancer and perianal fistula status post proctectomy. He underwent endoscopic retrograde cholangiopancreatography with ampullectomy, biliary sphincterotomy, placement of a common bile duct stent, and placement of a pancreatic duct stent; minor ampullectomy bleeding was treated with coagulation graspers and three hemostatic clips. He was admitted for post-procedure monitoring. He did not have abdominal pain, nausea, vomiting, or dyspnea. His vital signs were unremarkable.  He was discharged. At issue is the medical necessity for the inpatient level of care.
The inpatient level of care was not medically necessary. The patient presented for outpatient endoscopic retrograde cholangiopancreatography with ampullectomy, biliary sphincterotomy, placement of a common bile duct stent, and placement of a pancreatic duct stent; he had reportedly minor bleeding related to the ampullectomy, which was addressed with hemostatic clip placement. He did not have abdominal pain, nausea, vomiting, or bleeding during his post-procedure stay; although his lipase was elevated, he was not diagnosed with post-procedure pancreatitis [1-7]. Additionally, he did not have complications such as hepatic or abdominal abscess, biliary obstruction, ascending cholangitis, peritonitis, or sepsis, which would require a higher level of care [1-10]. The care provided, including monitoring, labs, and gradual advancement of diet, could have been performed without the need for the inpatient level of care, at a lower level of care.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Cardiovascular disease. 
Treatment: Toprol xl, 100 mg (milligrams) tab ER (extended release) 24H (hours). 
The insurer denied coverage for Toprol xl, 100 mg tab ER 24H. 
The denial is overturned. 
 
The insurer indicates that coverage for a brand name medication is provided in situations where documentation has been provided that the brand product has "formulation differences in the inactive ingredients...which, per the prescriber, would result in a significant allergy or serious adverse reaction." The cover documentation, and an Emblem Health form entitled "Toprol Xl Tab extended release (Er) 24 hour (H)" - Section A - both indicate that Toprol XL (metoprolol succinate)100 milligrams (mg) is being used to treat cardiovascular disease. No other clinical documentation has been submitted for review. 

The patient's doctor indicated that the patient "did not tolerate other formulations" and "she develops prolonged headaches on metoprolol." 

It appears that the formulary drug, generic metoprolol succinate, would cause the patient to experience a prolonged headache, based upon the submitted documentation. 

It appears that the formulary drug, generic metoprolol succinate, was ineffective. This conclusion is based upon the submitted documentation, which indicates that the generic formulation causes the patient to experience a prolonged headache. 

The branded version, Toprol XL, has been well-tolerated, while the documentation supports the conclusion that the generic version, metoprolol succinate, causes the patient to experience prolonged headaches. 

Therefore, the requested drug would be more effective, due to the absence of prolonged headache with the branded version. Given the presumptive diagnosis of cardiovascular disease, there is significant benefit to her remaining on a beta blocker. 

In summary, it appears that branded Toprol XL would be more appropriate than generic metoprolol succinate for the patient at this time. 

This is consistent with the documentation submitted for review. 

The formulary drug is expected to cause adverse effects. 

The formulary drug was tried and the patient did have an adverse reaction. 

The formulary drug is expected to be ineffective because it does provoke an adverse reaction in this patient. 

The non-formulary drug is expected to be more effective because it does not cause headaches in this patient. 

The carrier's denial of a request for a Formulary Exception for Toprol xl, 100 mg tab ER 24H to treat cardiovascular disease is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Continued Partial Hospital Substance Use Disorders Treatment.
The insurer denied Continued Partial Hospital Substance Use Disorders Treatment.
The determination is overturned.

The patient is an adult male who presented for partial hospital program (PHP) treatment in order to address severe substance use disorder with alcohol and co-occurring anxiety and depressive disorders best characterized as generalized anxiety disorder and moderately severe major depressive disorder. Additionally, the patient has a trauma history and symptoms of posttraumatic stress disorder (PTSD) in association with his job. 
The patient had been sober with a relapse five months prior to presentation using large quantities of alcohol with a binge pattern of use with up to 10 beers.  He was prescribed Xanax and Adderall with no report of misuse of these medications. 
He has been treated most recently with outpatient therapy and medication management.
The patient has a strong family history of alcoholism reflecting genetic predisposition.
At the time of admission for Partial Hospitalization Program (PHP) level care, the patient had intense craving, anxiety and depression rated at 5/10 and insomnia.
The treatment included focus on coping skills, development of relapse prevention techniques with identification of triggers, education about the disease model of addiction, and the opportunity for family-focused sessions to address sober supports and issues within the family constellation, as well as ongoing peer support and involvement with 12-step recovery groups. 
The patient was provided treatment with intensive services, sober supports, monitoring, and structure provided within the PHP treatment program.  
At issue is the medical necessity of Continued Partial Hospital Substance Use Disorders Treatment.

The requested health service/treatment of partial hospitalization mental health treatment was medically necessary for this patient.
The patient in this case was using alcohol with a binge pattern of use in the context of co-occurring psychiatric disorders and decline in functioning, as well as associated symptoms of anxiety, depression, and insomnia, and trauma related symptoms. The patient was at high risk for relapse and had limited coping skills, and a recovery environment that was deficient, as well as poor impulse control in view of continued use of alcohol despite severe consequences with regard to family and occupational domains. These factors and treatment dimensions did warrant the continued PHP level services with sober support housing, and intensive rehabilitation therapy.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: coronary artery disease
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a female with hypertension (HTN), HLD (hyperlipidemia), diabetes and family history for coronary artery disease (CAD) (her father died from myocardial infarction (MI) at the age of 51) who presented for coronary angiography with possible percutaneous coronary intervention (PCI).

The Inpatient Hospital Admission was not medically necessary for this patient. The patient with angina like symptoms presented for scheduled in advance, elective procedure. Her status prior to coming for procedure was stable, with symptoms functional class II. Her physical examination was unremarkable. Her labs were normal.
During the procedure, a stable obtuse marginal lesion was found. The procedure was uneventful, and the patient tolerated it well. She was observed after the procedure according to protocol and discharged home in stable condition. The patient did not have indications for inpatient admission. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, cough. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The determination is upheld. 

The patient is a male who initially presented to the emergency department with concerns for a fever, cough, diarrhea, and frequent urination. The pertinent history included orthotopic heart transplant, ischemic cardiomyopathy, chronic combined congestive heart failure, coronary artery disease, atrial fibrillation and hypertension. Initial examination documented the patient as alert and oriented. Initial laboratory testing revealed a normal white blood cell count, normal lactate, and elevated troponins. A chest radiograph revealed left lower fluid collection. A computed tomography (CT) scan of the chest was unremarkable for pneumonia. Intravenous fluids were provided with normalization of hemodynamics. Empiric antibiotics were administered. 
The patient was admitted to the hospital. The patient was afebrile, hemodynamically stable, and without hypoxia. There were no new issues. The admitting physician had an impression of suspected urosepsis. Empiric antibiotics were continued, home medications were continued, and additional diagnostic testing was pursued. A cardiac catheterization was pursued which revealed nonobstructive disease. There were no events on telemetry. He was afebrile and hemodynamically stable. He had relatively unremarkable laboratory testing. He was afebrile and hemodynamically stable. Antibiotics were discontinued due to a largely unremarkable work-up. The patient was discharged. At issue is the medical necessity of an inpatient stay. 
Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care. 
The patient had a history of a heart transplant on immunosuppressants and initially presented to the emergency department with concerns of a fever, cough, and diarrhea. Initial examination documented the patient as afebrile, alert, oriented, hypotension, tachycardia, and without hypoxia. Initial laboratory testing was largely unremarkable with the exception of a mildly elevated troponin. An electrocardiogram (EKG) did not reveal acute ischemic changes. Intravenous fluids were provided in the emergency department with resolution of hypotension and tachycardia. Following hospitalization, treatment included empiric antibiotics and a cardiac catheterization which revealed nonobstructive disease. The patient remained afebrile and hemodynamically stable throughout. There was no evidence of transplant rejection and antibiotics were discontinued due to an unremarkable infectious work-up. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Strep throat.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

This is the case of an otherwise healthy male, who presented to the emergency department (ED) with 1 day of sore throat, fever, and chest pain (resolved). He had difficulty swallowing. There was an episode of excessive coughing the day prior to admission, and the patient admitted to twice daily marijuana smoking.

The inpatient hospital admission was not medically necessary. This otherwise healthy teen presented with sore throat and fever, plus resolved chest pain after heavy coughing. He was found to have Strep throat and pneumomediastinum. Vital signs were stable except for fever which was attributed to Strep throat. There was no ongoing cough and no vomiting or inability to tolerate oral intake. He could have safely and appropriately been managed at a lower level of care, given the good prognosis for spontaneous resolution of pneumomediastinum.