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

Diagnosis: COPD Exacerbation
 
Treatment: Inpatient Hospital 

The insurer denied the Inpatient Hospitalization. The denial was upheld.

The patient is a female patient with a history hypertension, arrhythmia, anxiety, obstructive sleep apnea (OSA) non-compliant with Continuous Positive Airway Pressure, chronic obstructive pulmonary disease (COPD), hypothyroidism, hyperlipidemia, and lung nodules, who presented to the Emergency department (ED) in early 2019 with complaints of shortness of breath, chest pain, some fevers and productive cough of yellowish sputum. The patient's vital signs at presentation were Temperature 98.4, respiratory rate 23, blood pressure 142/79, and heart rate 105. Oxygen saturation on room air was 87%. The patient was awake and alert with some wheezing on lung exam. WBC was 10.6K, Hb was 13.9, electrolytes were within normal limits, CO2 30, BUN/ Cr 8/0.45, Troponin was < 0.01, ABG 7.39/43/54/17  89%, rapid respiratory viral panel was positive. Upon admission patient's history and physical revealed Temperature 98.4, heart rate 94, respiratory rate 20, blood pressure 144/77, and oxygen saturation 90%. The patient was not in acute distress. She was speaking in full sentences. There was mild wheezing in the right upper lobe. The rest of the lungs were clear. There was no cyanosis, clubbing or edema.
The patient was awake and alert. The neurological exam was non focal. CT angiogram revealed no pulmonary embolism, stable sub centimeter nodules. Chest x-ray - no acute infiltrates.
The patient was treated with Duo Nebs, oxygen by nasal cannula, intravenous (IV) steroids - initial 125mg in ED followed by 40 mg daily. She was afebrile and hemodynamically stable and responded to treatment in ED. They recommended switch to oral steroids and taper, bronchodilators via inhalers, and OSA re-evaluation as outpatient. The patient remained stable after admission, was tolerating oral intake and was discharged the next day after admission with outpatient follow-up.

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

Diagnosis:  UTI
 
Treatment:  Inpatient admission, IV fluids, medications, monitoring

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

This patient presented to the Emergency Department (ED) with right lower quadrant (RLQ) abdominal pain radiating to the back.  The pain was associated with dysuria, urgency and frequency.  The white blood cell (WBC) count was 14,030.  A CT scan of the abdomen-pelvis was negative for renal stones or hydronephrosis.  The patient was admitted with diagnosis of complicated urinary tract infection (UTI).  The patient was treated with intravenous (IV) fluids and IV Levaquin.  She improved clinically and was discharged home on oral Levaquin for seven more days.

Per MCG Health (22nd Edition) Urinary Tract Infection (UTI) RRG, the patient fails to meet clinical indications for admission to inpatient care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute cholecystitis
 
Treatment: Inpatient admission, diagnostic treatment, monitoring

The insurer denied the inpatient admission. The denial was reversed.

This case involves a patient who presented to the emergency department with past medical history of type 2 diabetes mellitus, hypertension and recent stent placement.  The patient was seen for epigastric pain x2 days with radiation to the back on both sides with nausea and no vomiting or fever.  The patient had a temperature of 36.3 C, heart rate 110, blood pressure 151/73, respirations 20 and oxygen saturation 100%.  On examination, there was tenderness to the epigastrium.  Ultrasound showed cholelithiasis and acute cholecystitis.  The patient was started on IV Ancef.  There was concern for bleeding due to recent stent placement, aspirin and Plavix medication, so nonsurgical management was preferred.  The patient underwent a cholecystostomy catheter placement.  The patient was then discharged home.

The inpatient admission would be appropriate due to the placement of a cholecystostomy catheter for treatment of the patient's acute cholecystitis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's disease with dyskinesia and risk for falling
 
Treatment: Medication-Gocovri 

The insurer denied coverage for Gocovri. The denial was upheld.

This male patient has a diagnosis of Parkinson's disease with dyskinesia and risk for falling. Multiple trials of medication have either failed to control symptoms, caused intolerable adverse effects, or have difficult dosing schedules. He has tried Amantadine. Gocovri (amantadine) extended release capsules are Food and Drug Administration (FDA) approved and indicated for treatment of dyskinesias.
A letter states the patient has a diagnosis of Parkinson's disease with dyskinesia and risk for falling. Multiple trials of medication have either failed to control symptoms, caused intolerable adverse effects, or have difficult dosing schedules. He has tried Amantadine. Gocovri (amantadine) extended release capsules are Food and Drug Administration (FDA) approved and indicated for treatment of dyskinesias. 
The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The patient has dyskinesias in the setting of Parkinson's disease. He has tried Amantadine in the past but the reason for stopping was not given. It would be appropriate to determine the reason for stopping Amantadine prior to starting Gocovri which is extended release Amantadine. Also, additional information is needed as to whether the patient was having dyskinesias at the time Amantadine was prescribed.      
Based on the above, the medical necessity for Gocovri 137 mg CAP ER 24h is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

The patient has sleep apnea. The apnea hypopnea index (AHI) is 17.4 The body mass index (BMI) is 28.4. The patient cannot tolerate continuous positive airway pressure (CPAP) or an oral appliance. Sleep endoscopy did not reveal concentric collapse at level of oropharynx or hypopharynx.
A Hypoglossal nerve stimulator (HGNS) is being requested and is the subject of this review.

The health plan's determination is overturned. The Outpatient Surgery Services: Upper Airway Stimulation is medically necessary for this patient. The patient has sleep apnea and cannot tolerate CPAP. The patient has an AHI between 15 and 65 and a BMI less than 32. Sleep endoscopy did not reveal oropharyngeal or hypopharyngeal concentric collapse. The treating provider does not feel that there are reasonable surgical alternatives. Based on the patient not being able to tolerate the first line therapy for sleep apnea, CPAP, and that there are no reasonable surgical options, the hypoglossal nerve implant is a medically necessary treatment. There is good literature demonstrating safety and efficacy. It is likely that the patient will have significant improvement in his sleep apneas symptoms and decreased long term morbidity if the implant is placed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe anxiety
Treatment: Continued inpatient stay

Summary:
The continued inpatient stay was medically necessary. This is a male patient who complained that he experienced daily anxiety in his body, with constant pacing, palpitations, and feelings of restlessness. He described having panic attacks on the unit secondary to thoughts that he was able to identify as catastrophizing. 

The patient remained unstable, with subjective distress and anxiety. His insight, judgment, and impulse control were all considered impaired. Discharge the following day would have placed the patient at risk. In the interest of safety, he required continued inpatient monitoring and treatment.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for polycythemia vera with known associated splenomegaly, as well as a mood disorder who presented to the emergency department with a chief complaint of left upper quadrant abdominal pain accompanied by nausea for the past 5 days. He denied fevers, chills, dysuria, diarrhea, or other complaints.

On presentation to the emergency department, he was noted to be mildly hypertensive with other vital signs within normal limits. His exam was otherwise significant for left upper quadrant (LUQ) tenderness without rebound or guarding. The health plan's determination is upheld.
Acute inpatient hospitalization was not medically necessary. This patient presented with a splenic infarct in the setting of polycythemia vera, the treatment of which is assessing the etiology (which is frequently cardioembolic but in this case secondary to polycythemia) as well as pain control unless a surgical complication such as an abscess or rupture develops. This patient's pain was well controlled with oral Percocet.
In the absence of severe uncontrolled pain failing observation level of care, an acute inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain and bloating
Issue under review:  Inpatient admission

Determination:
The inpatient admission was not medically necessary.

The patient presented with early signs and symptoms of a small bowel obstruction that resolved within 24 hours of admission.  In addition, there was no objective finding of compromised bowel.  Most patients with small bowel obstruction (SBO) but no indication for immediate surgery can safely undergo initial nonoperative management. Nonoperative management resolves symptoms in many patients with SBO, but success rates depend upon the etiology.

There were no signs or symptoms of bowel compromise.  Given the patient's hemodynamic stability and clinical resolution of the partial obstruction within 24 hours of medical management, this patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient has severe crowding and an anterior crossbite involving teeth 7-10. The patient presents with a skeletal Class III malocclusion. She is treatment planned for orthodontics with Reverse Pull headgear to address her anterior crossbite. D8080: Pediatric Orthodontic Treatment for 24 Months is under review. 

The health plan's determination is overturned. The requested Orthodontic treatment (D8080) is medically necessary for this patient. If treatment is deferred until the patient is done growing the only option to correct this anterior crossbite is a combination of orthodontics and orthognathic jaw surgery.This patient presents with an anterior and crossbite, severe crowding, and a skeletal jaw imbalance. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. These problems are much more time consuming and difficult to correct than the patient's existing orthodontic problem.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
 
Treatment: Inpatient Substance Treatment 

The insurer denied the Inpatient Substance Treatment.  The denial was reversed.   

This is a male patient with a history of alcohol and heroin/cocaine use for almost 2 decades. He reports having been in substance detoxification treatment programs in the past. He has a past history of hospitalization for a stab wound and liver disease. He presented to a facility for detoxification and rehabilitation for alcohol, opioid, and cocaine use. While in treatment he received Clonidine and Depakote. The patient left against medical advice (AMA) prior to the completion of his treatment.

He required treatment to monitor and prevent severe, complicated, and life threatening withdrawal as he was considered at risk for that 3-4 days after cessation of use and he could not stop use or get treatment for alcohol and substances without being in a sober, structured, supervised therapeutic inpatient substance detoxification and rehabilitation treatment as it was not likely that he could safely be managed in an outpatient setting. He lacked the coping skills and relapse prevention skills also to maintain abstinence outside of this 24 hour inpatient substance detoxification and rehabilitation treatment. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also reports that patients using large amounts of alcohol or benzodiazepines are at a higher risk of having delirium tremens (DT's) 3-4 days after cessation of use. It also states that patients with co-morbid medical conditions complicating that management of withdrawal are candidates for inpatient hospital treatment.

As a result, the determination is to reverse the previous decision and approve coverage for inpatient hospital treatment. It did not appear that the health care plan acted reasonably and with sound medical judgment or in the best interests of the patient.  

The carrier's denial of coverage for the inpatient rehabilitation services is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who underwent a sleep evaluation in preparation for bariatric surgery. She had a history of excessive daytime sleepiness for many years.  Her current sleep history was as follows.  Bedtime was 9:00 PM.  She slept through the night.  She woke up at 6:00 AM.  Because of excessive daytime sleepiness she took multiple naps during the day.  Sleepiness appeared to have become worse with weight gain.  She snored mildly.  She had been told of witnessed apneas. 

The health plan's determination is overturned.  This patient satisfies criteria as laid out in ICSD-3 for diagnosis of idiopathic hypersomnia.  According to the American Academy of Sleep Medicine (AASM) practice parameters for treatment of narcolepsy and other hypersomnia's of central origin (Reference 2), modafinil may be an effective treatment of daytime sleepiness due to idiopathic hypersomnia.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with moderate persistent asthma maintained on Singulair, inhaled steroids, and prn albuterol. He was brought to the emergency department (ED) with an upper respiratory infection (URI), cough, and wheezing that was not better after three albuterol treatments at home. On arrival, he was afebrile, respiratory rate (RR) was 24, and oxygen saturation 98% on room air. The physician note states he is in no apparent distress, speaking in full sentences, with normal respiratory effort, normal breath sounds, no respiratory distress, no wheeze, no rhonchi, and no rales. The health plan's determination is upheld. This patient with moderate persistent asthma presented with a mild pulmonary exacerbation from a URI. He was well hydrated and perfused. He did not have hypoxemia, retractions, or anything more than very mild tachypnea. There was no concern regarding his caregiver's ability to manage him at home or concern that he might tire. The hospitalization appears to have occurred to extinguish his wheezing, which did not require acute inpatient management absent other reasons, such as significant distress or hypoxemia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vomiting and diarrhea
 
Treatment: Inpatient admission, IV fluids, monitoring

The insurer denied the inpatient admission. The denial was reversed.

The patient is an infant with a history of inguinal hernia repair and speech delay.  He presented to the Emergency Department (ED) for evaluation of vomiting and diarrhea x 3 days, and dehydration.  Intravenous (IV) fluids were administered and the patient voided a small amount.  Abdominal ultrasound ruled out intussusception; x-ray of the abdomen showed a non-obstructive bowel gas pattern. Blood cultures were negative.  The patient was admitted for management of dehydration and acute gastroenteritis.  The patient continued to have emesis and diarrhea and was not taking solid foods.  On day #3 he was tolerating oral intake.  IV fluids were discontinued and patient was discharged.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain, possible acute coronary syndrome
 
Treatment:  Inpatient admission, monitoring

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

This patient had a past medical history notable for diabetes mellitus, hypertension, hyperlipidemia, and hypothyroidism.  She presented to the Emergency Room (ER) with complaints of chest pain, which radiated to her left arm.  She was at her primary care provider's office and tried to see a Cardiologist, but she was not able to get an appointment.  Therefore, she presented to the ER.  She was chest pain free in the ER.  Cardiac biomarkers were initially negative.  An EKG showed no concerning findings.  She was admitted for possible acute coronary syndrome.  She remained clinically and hemodynamically stable, and the decision was made for her to be discharged home the same day.

The patient presented with chest pain; however, the initial evaluation in the ER was unremarkable, including negative cardiac troponin and a nondiagnostic EKG.  In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing.  Further evaluation was warranted; however, inpatient admission criteria were not met.  Although the patient had a new onset of symptoms, medical necessity criteria were not met for any other additional extenuating circumstances.  There were no other high-risk co-morbidities.  

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

Diagnosis:  Endometriosis
 
Treatment:  Inpatient admission, monitoring

The insurer denied the inpatient admission.  The denial was reversed.

This patient had a history of endometriosis and underwent a laparoscopy with extensive resection of endometriosis, including repair of ileum, repair of colon, repair of bladder and resection of the right ureter.  Post-operatively, she was admitted for observation for any bowel or bladder issues.

According to MCG, Inpatient and Surgical Care, Laparoscopic Gynecologic Surgery, including Myomectomy, Oophorectomy and Salpingectomy, laparoscopic procedures are ambulatory procedures.  Inpatient stay may be needed for complex surgery, older patients, conversion to abdominal procedures, surgical complications, or co-morbidities.

This patient had a very complex surgery with a Urologist, a Gynecologist and a Colorectal surgeon involved.  Because of the different organs involved, admission and observation for adequate bowel movement and any voiding problems were medically necessary and standard of care.

Based on the above, the acute care admission was medically necessary.  The carrier's denial of coverage for the inpatient hospital services is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain
Treatment:  Inpatient hospital

This is the case of a male with past medical history of cerebrovascular accident (CVA) with residual left-sided weakness, coronary artery disease (CAD) status/post (s/p) percutaneous coronary intervention (PCI), hypertension (HTN), diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), and asthma, who presented to the emergency room from rehab with left-sided chest pain radiating to his arm and a report of passing out.

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  This is a patient with history of known cardiovascular disease and CVA, who presented to the ED with chest pain radiating to his arm and report of passing out.  He was asymptomatic after presentation with undetectable troponin and EKG that was not suggestive of acute ischemia.  In the setting of known cardiovascular disease, concern for cardiac chest pain, and reports of possible syncope, he required further work-up with serial troponins, telemetry, and monitoring for further chest pain and syncopal events.  However, in the absence of ongoing chest pain, troponins or EKG suggestive of acute ischemia, telemetry indicative of arrhythmia, or recurrent syncope, it is unclear why care at the inpatient care was medically necessary.  A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain and vomiting
 
Treatment: Inpatient admission, medication, monitoring

The insurer denied the inpatient admission. The denial was reversed.

This is a female child with a history of constipation and recent upper respiratory tract infection that presented for evaluation of abdominal pain with eating past 6 days. She was experiencing vomiting x 1 day. This was the third ED visit in 4 days. Work-ups at the prior visits had been non-revealing. There was no associated fever, bleeding, dysuria or diarrhea. Attempts at pain relief with ibuprofen were insufficient. The patient's vitals on arrival were Heart Rate 108, Temperature 96.3 F., Respiratory Rate 20, Blood Pressure 112/66.  

The abdomen was soft with peri-umbilical / right upper quadrant tenderness to palpation without guarding, distension, rebound, or masses. Bloodwork showed white blood cell count 23.2 K, with a left shift (neutrophils 81%, no bands), platelets 517, aspartate aminotransferase (AST) 42, alanine aminotransferase (ALT) 20, bilirubin 0.3 and erythrocyte sedimentation rate (ESR) 35. Urinalysis was notable for specific gravity 1.015, pH 5.5, and dip was positive for ketones.  An abdominal flat plate showed an unremarkable gas pattern without obstruction, and an abdominal sonogram was unremarkable without visualization of the appendix. An oral challenge led to recurrent abdominal pain.  She was evaluated by pediatric surgery who stated there was no concern for intussusception or appendicitis, but recommended admission for pain control, serial abdominal exams, and observation.  She received Toradol, steroids and acid suppression.  Her symptoms improved and she was discharged home 2 days later.

The pain was not managed adequately as an outpatient resulting in three different Emergency Department visits in four days.  She did not tolerate an oral challenge and her pain required parenteral medications having failed oral agents. Therefore she met criteria for inpatient management. As parenteral pain medications would not be appropriate for the outpatient setting, the acute care admission is warranted and medically necessary to manage her condition. 

The carrier's denial of coverage for the inpatient admission is reversed. The medical necessity is substantiated.