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

Skin Disorder
Surgical Services  (All)

Diagnosis: nevus sebaceous 
Treatment: placement of a tissue expander in anticipation of resection and primary closure. The insurer denied placement of a tissue expander in anticipation of resection and primary closure. The health plan's determination is overturned. 

This female has a nevus sebaceous (NS) of the left scalp and mastoid area. Her surgeon recommends placement of a tissue expander and then subsequent removal of the expander, excision of the nevus sebaceous and flap closure.

The placement of a tissue expander in anticipation of resection and primary closure is medically necessary for this patient. The excision of the nevus is medically necessary to prevent a possible malignancy. The lesion size is large enough that tissue expanders will need to be placed to obtain sufficient skin to close the wound. Thus, to accomplish the goal of removing the nevus, placement of tissue expander is medically necessary.
According to review by Dunkin and colleagues,
"Sebaceous naevi are uncommon congenital skin lesions with a well-recognized potential for neoplastic change. They should be considered premalignant lesions as malignant degeneration, most commonly basal cell carcinoma and squamous cell carcinoma, occurs with a lifetime risk of between 5% and 22%."
Although the exact risk of malignant degeneration is debated, the multiple reports describing malignant degeneration support the practice of prophylactic removal of these tumors. Tumor removal will improve the appearance of the patient's forehead, but more importantly, it will eliminate the risk of malignant degeneration.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression, anxiety, and alcohol abuse

Treatment: inpatient hospital stay

The insurer denied coverage for inpatient hospital stay. The denial is upheld. 

This patient is a male with a past medical history significant for hypertension, diabetes mellitus, hypothyroidism, depression, anxiety, and alcohol abuse who presented to the Emergency Department for altered mental status. The patient was recently treated for a left elbow septic bursitis. The patient's vitals on ED presentation included: temperature-97.6 F, blood pressure-165/99, pulse-114, respiratory rate-18, oxygen (O2) saturations-96%. The patient's laboratory results included the following: white blood cell count (WBC)-6.14, Hgb-11.0, Hct-32.3, creatinine-0.49, glucose-372, and alcohol-301. 

The patient was admitted for possible change in mental status. The patient reported taking too many oxycodones for his pain. The patient also had rash believed to be "diffuse psoriasis", and antibiotics (Ancef) were held. The patient refused social service intervention for alcohol abuse. The patient remained afebrile, hemodynamically stable, and left hospital against medical advice (AMA). 

According to documentation, the patient was referred by visiting nurse for possible altered mental status (AMS). In the ED, the patient was described as "alert, oriented x3" and "AMS resolved." The patient was noted to have an elevated blood alcohol level and reported taking "too many oxycodones" for his pain. The patient was otherwise afebrile, hemodynamically stable and had no evidence for an acute infection by laboratory results. Based on above findings, patient met criteria for observation level of intervention. The patient did not fulfill criteria for acute inpatient hospitalization.  

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 inpatient hospital stay is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic migraines

Treatment: Emgality (300mg Dose) 100mg/ml SC SOSY

The insurer denied coverage for Emgality (300mg Dose) 100mg/ml SC SOSY. 

The denial is reversed. 

This patient is a female with a history of chronic migraines.   The patient was seen in the office for worsening migraines.  The patient reported having daily headaches with 4 to 6 debilitating migraines a month.  The patient reported that her migraines were associated with pain in the frontal region that was associated with photophobia at times.  The patient had not tolerated Maxalt or Imitrex.  The patient has trialed on amitriptyline, topiramate, Maxalt, magnesium, sumatriptan, and Relpax for her migraine headaches but received no benefit. The patient received a loading dose of Emgality and since receiving Emgality, the patient reported that her migraines had resolved.  The patient was no longer having daily headaches. The patient was given another pharmaceutical sample dose.

Based on the review of the medical record, the patient's chronic migraine headaches with 4-6 debilitating headaches per month had been non-responsive to several standard medications for migraine. The patient was trialed on Emgality with good response. The patient no longer had daily headache and debilitating migraines that typically occurred 4 to 6 times in a month. According to literature, Emgality (galcanezumab) is a human monoclonal antibody that binds to the CGRP ligand. Studies including several placebo-controlled trials have showed that this medication is effective for migraine prevention. And in this case, the patient's migraine headaches responded well to Emgality. After failing several preventive headache medications, this patient's optimal response to Emgality supports that this medication is medically necessary to treat this patient's medical condition. 

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

The carrier's denial of coverage for Emgality (300mg Dose) 100mg/ml SC SOSY should be reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth pain
Treatment: D3330 - Nerve treatment on molar tooth, Tooth #3
The insurer denied the D3330 - Nerve treatment on molar tooth, Tooth #3.
The denial is upheld.

The D3330 - nerve treatment on molar tooth, tooth #3 is not medically necessary.

The x-rays presented do not show an infection in tooth #3, necessitating a root canal procedure. There are no PA (periapical) x-rays presented, which would clearly show the apex of the tooth and whether or not it has an infection. Only bitewing x-rays and a Panorex where presented. Bitewing x-rays do not show root apices, and the Panorex is not clear enough to make out any infection. There is no narrative explaining any symptoms either, so therefore, there is no reason for the root canal procedure at this point.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg Weakness (bilateral paraplegia) and Fever. 
Treatment: Inpatient admission. 

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

The patient is a male with a history of diabetes, hypertension, and opioid use disorder who presented with the complaint of acute bilateral lower extremity weakness and confusion. At the time of presentation, he was febrile and was found to have a systemic leukocytosis. Leg weakness was noted to have resolved spontaneously. 

No, the proposed inpatient level of care was not medically necessary. 

The patient presented with confusion and bilateral lower extremity weakness, both of which resolved without treatment. This was not consistent with acute cord compression or epidural abscess. Moreover, he had already been evaluated recently for similar complaints of lower extremity weakness. Therefore, the diagnostic studies, clinical evaluation, monitoring and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient ischemic attack
Treatment: Inpatient hospital level of care
The insurer denied coverage for an inpatient hospital level of care.
The denial is upheld.

This is a female patient with a medical history that includes hypertension, polycythemia vera, and breast cancer. She presented to the emergency department (ED) with complaints of slurred speech and memory loss. According to the patient's daughter, she has been having "these episodes several times a month. Physical examination revealed that the patient was able to answer questions correctly. The patient was alert and responsive. There were no neurological abnormalities noted. There was 5/5 muscle strength. The physician recommended the patient undergo laboratory and diagnostic studies. An electrocardiogram (EKG) revealed a normal sinus rhythm. She had improving symptoms according to the physician. A computed tomography (CT) scan of the head revealed no acute intracranial pathology. The patient had a negative urinalysis and it was noted that she was treated for a urinary tract infection 2 weeks prior. She had no further significant laboratory findings. The Neurology consult noted a normal neurological exam and magnetic resonance imaging (MRI) of the brain was normal. She was discharged on day 2 of admission. 
The patient presented with slurred speech which apparently had been recurrent for several weeks.  On evaluation in the ED, neurologic exam and CT were both unremarkable and the MRI was similarly normal. This evaluation of a stable patient with chronic symptoms could have been accomplished during a period of observation.

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

Based on the above, the medical necessity for the inpatient hospital level of care is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient Hospital Stay. 
The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient presented to the emergency department complaining of chest pain and dyspnea. His medical history was remarkable for nonischemic cardiomyopathy, diabetes, hypertension and implantation of an implantable cardioverter defibrillator. A previous coronary angiography had shown normal coronary arteries. He reported noncompliance with his prescribed medical regimen. In the emergency department, his blood pressure was 150/94 millimeters of mercury (mmHg) with a heart rate of 95 beats/minute. His respiratory rate was 18/minute with a room air oxygen saturation of 98%. His physical exam was remarkable for pulmonary rales. An electrocardiogram showed an atrial sensed/ventricular paced rhythm. His serum troponin level was minimally elevated at .05 nanograms/milliliter (ng/ml). A chest x-ray showed mild pulmonary vascular congestion. The patient's brain (or B-type) natriuretic peptide (BNP) level was 3401 picograms per milliliter (pg/ml). His serum creatinine level was normal. He was treated with a dose of intravenous furosemide and admitted to the hospital for management of a heart failure exacerbation. A repeat troponin level was unchanged. The patient reported improvement in his dyspnea. He had pulmonary rales on exam. An echocardiogram showed a left ventricular ejection fraction of 21-25%. His serum troponin level was .07 ng/ml. The cardiology consultant recommended switching his furosemide to oral. The patient was discharged. The medical necessity of an inpatient admission is at issue. 

An inpatient level of care was not medically necessary. 
This patient presented with mildly decompensated heart failure. He had been noncompliant with his medical regimen and responded well to a dose of intravenous furosemide in the emergency department. He was hemodynamically stable and was not tachypneic or hypoxic. There was no evidence of a significant acute kidney injury. His serum sodium level was normal. While his troponin level was minimally elevated, this is a common finding in patients with congestive heart failure, even in patients, like this patient, with normal coronary arteries. In stable heart failure, such patients have shown that a lower level of care is safe and effective, with similar outcomes, including readmission, repeat emergency department visits and 30 day mortality, when compared to those treated as inpatients. Thus, in this case, an inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction. 
Treatment: Substance Abuse Inpatient. 
The insurer denied the inpatient hospital stay. 
The denial was upheld in whole. 

The patient is a male with past medical history of alcohol abuse, prior seizure per patient, cholelithiasis, hypertension (HTN), and suboxone use, who presented to the emergency room (ER) with concerns for alcohol withdrawal with reports of concern for alcohol abuse, vomiting, anxiety, and possible seizure per patient.

On presentation, he was afebrile with blood pressure 181/114, respiratory rate (RR) 24, heart rate in the 90s, saturation 99% on room air (RA). Exam otherwise noted him to be anxious. Labs resulted with white blood cell (WBC) 4.4, hemoglobin (HGB) 16.7, platelets 87, sodium 137, potassium 3.6, blood urea nitrogen (BUN) 17, creatinine 0.16, aspartate aminotransferase (AST) 397, alanine aminotransferase (ALT) 190, Alkaline phosphatase 110, T. Bilirubin 1.1, troponin undetectable. Chest x-ray and right upper quadrant ultrasound showed no acute process. The patient was admitted with concerns for alcohol withdrawal and plans for scheduled Librium in addition to scheduled clonidine, Ativan and Zofran as needed (prn).

The next day, he was noted to be afebrile with pulse rate 80s, blood pressure 140s/100s, respiratory rate 20, oxygen saturation normal on room air. He was noted to be alert and oriented without clear tremors and without documentation of ongoing nausea or vomiting. He was asking for increased pain medications. When he was not offered suboxone, he decided to leave against medical advice.

The issue in question is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

This is a patient who presented with concern for alcohol withdrawal. He was alert and oriented on presentation with nausea, elevated blood pressure, tachycardia, and tachypnea. He improved rapidly with emergency department treatment with benzodiazepines and after the ER was noted to have hypertension but otherwise be hemodynamically stable without tachycardia, vomiting, or persistently high Clinical Institute Withdrawal Assessment (CIWA) scores. Documentation provided also does not suggest that he was requiring frequent intravenous (IV) benzodiazepines for withdrawal. It is noted that he left against medical advice, but documentation does not clearly state why ongoing care at the inpatient level of care was medically necessary in the absence of hemodynamic instability, altered mental status, or persistent vomiting.

The inpatient stay was not medically necessary, and the patient could have been treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission
The denial is overturned.

The patient is a female child with a history of a premature birth at 30 weeks gestation. The patient had a history of 2 previous episodes of Emergency Room (ER) visits for respiratory distress and had been diagnosed as being pneumonia. The patient has been sick with fever and vomiting for 5 day. The patient was seen by her pediatrician and prescribed albuterol, Motrin and azithromycin.  The patient was treated with albuterol twice at home, but when her respiratory distress did not improve with treatment and she could not tolerate oral fluids, the patient's mother brought the patient to the ER for further treatment. In the ER, the patient was noted to have respiratory distress with retractions and evidence of increased work of breathing.  The patient had a low oxygen saturation of 89% and on physical examination, she had abdominal and intercostal retractions with bilateral wheezing.  The patient was treated with 3 doses of duoneb and Decadron with no clinical improvement.  The patient's blood test was significant for a BUN of 47 which was concerning for prerenal dehydration.  The patient also was treated with oxygen and intravenous (IV) fluids.  The patient's chest x-ray was significant for hyperinflation.  When the patient's respiratory symptoms did not improve with treatment in the ER, the decision was made to admit the patient with a diagnosis of status asthmaticus and for ongoing treatment with albuterol every 2 hours.   

Based on the review of the medical record and literature, the patient was treated appropriately in the Emergency Room (ER) for a cough, wheezing and respiratory distress. Following treatment, the patient continued to have ongoing respiratory distress with persistent wheezing and increased work of breathing. The patient also required oxygen supplementation for hypoxemia and IV fluids to treat her dehydration and intolerability to hydrate orally.  It was appropriate and consistent with the standard of care to admit the patient to the hospital for ongoing treatment with albuterol every 2 hours.  The patient had failed outpatient management of her asthma and had a history of two previous ER visits for asthma in the past.  The patient was at high risk for respiratory failure and was not stable enough to be sent home or managed at a lower level of care. Thus, inpatient admission was medically necessary for this patient.  

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

The carrier's denial of coverage for inpatient admission should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive system/Gastrointestinal Abdominal/stomach pain
Treatment: Inpatient hospital

The insurer denied the inpatient hospital stay. The denial is upheld in whole.

The patient with a past medical history significant for diabetes mellitus type 1 who presented to the emergency department with complaints of non-bloody non-bilious vomiting and epigastric discomfort that had been going on for 2-3 days. No, the inpatient hospital stay was not medically necessary for this patient. There was no compelling clinical reason the patient could not have safely and appropriately received evaluation and treatment at a lower level of care rather than admission to an inpatient level of care. 

Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. There were no alarming features on the physical examination, in the laboratory studies, and on diagnostic tests. The patient's symptoms resolved quickly to the point that the patient was able to be discharged home on the very next day after the day of admission. 

The patient presented to the hospital with complaints of abdominal discomfort, nausea, vomiting, subjective fever, and chills. Even though the patient had diminished oral intake, there was no evidence of severe dehydration or significant electrolyte abnormalities. The patient's hypokalemia and hypophosphatemia were mild and corrected quickly during this short hospital stay. There was no evidence that the patient had diabetic ketoacidosis. 

The results of the physical examination and imaging studies showed no overwhelming evidence that the patient had unstable or dangerous clinical conditions that would meet medical necessity for the admission at the acute inpatient level of care. The patient was afebrile and hemodynamically stable. The dehydration was mild and was corrected quickly during the short hospital stay. The hypokalemia and hypophosphatemia were very mild and could have been corrected in a lower level of care setting. Regardless, the symptoms resolved within one day of hospitalization and the patient tolerated the diet without difficulties. 

Taking into consideration all these facts, neither the severity of the patient's condition nor the complexity of the services provided were medically necessary at an acute inpatient level of care. An admission at a lower level of care was indicated to treat the symptoms and provide supportive care, to rule out serious reasons for the symptoms, and to ensure adequate hydration and hemodynamic stability.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and vomiting 
Treatment: Inpatient admission 

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

No, the inpatient admission was not medically necessary. 

The patient is a male. He has PMH (past medical history) of H. Pylori, sciatica, gall stone, smoker, and multiple lipomas. He presented to ER with generalized abdominal pain, nausea, and non-bloody vomiting for five to six days. The patient noted two days prior to arrival he had a fever between 100-101 degrees Fahrenheit and was unable to keep anything down, felt dehydrated. He was seen by his PMD prior to arrival to ER and he was referred to ER for evaluation of abdominal pain to rule out small bowel obstruction. He noted abdominal pain as crampy, spasmodic, moderate in nature but denies radiation, also had cough and constipation. 

The patient's physical exam revealed normal vitals, diffuse tenderness of abdomen with guarding and bowel sound was present. EKG (electrocardiogram) was unremarkable. He was tested positive for Influenza A and RSV (respiratory syncytial virus). Electrolytes were normal but transaminases were elevated. Ultrasound showed gallstone without biliary ductal dilatation or evidence of cholecystitis. 

The patient was admitted in-patient with a diagnosis of Influenza and gastroenteritis. He was started on Oseltamivir, acetaminophen, IV fluid, and also started on PO (oral) diet as tolerated. The patient's liver enzymes trended day after admission, abdominal pain improved and he was able to tolerate PO regular diet without any problem. 

He was advised to continue with Oseltamivir and Omeprazole as an outpatient, and also was recommended to follow with his primary physician in two weeks. 

The patient presented with history of abdominal pain, fever, vomiting, inability to eat, and was feeling dehydrated. Vitals and physical exam were unremarkable except diffuse abdominal tenderness. Work up was significant for positive Influenza A and elevated transaminases but electrolytes and other workups were unremarkable. The patient was admitted with a diagnosis of Influenza A. He was given IV fluid, Oseltamivir, and as needed Acetaminophen. Subsequently he was discharged a day after admission. 

As noted in Annals of Internal Medicine, hospitalization should be considered for influenza patients with significant dehydration and severely ill persons who have complications of suspected or laboratory-confirmed illness, especially those with respiratory distress, hypoxemia, impaired cardiopulmonary function, or altered mental status. Likewise, patients who have an uncertain clinical course or are frail at baseline might require admission for close observation. Given that this patient had no comorbidities, he was clinically stable including vitals upon arrival and was able to tolerate oral diet without any problem, therefore inpatient admission was not medically necessary. The patient could have been managed at a lower level of care.