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

This is a patient who presented with vomiting and diarrhea, who had 12-14 episodes of emesis as well as 1 episode of diarrhea. The patient also had decreased oral intake. Patient's mother was also ill with vomiting. On the day prior to presentation the patient was seen by her primary doctor and was given Pedialyte and Zofran. 
On presentation to the emergency department patient was described as appearing pale and weak, with poor skin turgor and capillary refill greater than 3 seconds. Patient was given 2 boluses of normal saline and was started on intravenous fluids. Patient was found to have a blood glucose of 55 and was also given a bolus of dextrose. Patient's bicarbonate was low at 12 millimoles per liter (mmol/L), and sodium was 133 mmol/L. The patient required 2 subsequent boluses of dextrose. The patient continued to have difficulty tolerating oral fluids and was admitted to the hospital on for moderate dehydration with hyponatremia and persistent hypoglycemia, for continued intravenous rehydration and monitoring of electrolytes and blood glucose.
On the hospital floor the patient required another bolus of dextrose for a blood glucose of 50. Subsequently, the vomiting and diarrhea resolved, and the patient was encouraged to take fluids. The endocrinology team was consulted and felt that the patient likely had ketotic hypoglycemia due to dehydration and gastroenteritis, and they didn't feel additional workup was needed at that time. The intravenous fluids were able to be discontinued, the laboratory values had normalized, and the patient was felt to be stable to discharge to home with follow-up with primary doctor in 2-3 days. The health plan's determination is overturned.

This is a very young patient who presented with significant vomiting and diarrhea as well as inadequate oral intake and decreased urine output. The patient continued to have these symptoms despite appropriate treatment as an outpatient. In the emergency department the patient was found to have poor skin turgor and capillary refill greater than 3 seconds, representing dehydration. The patient was also found to have a significantly low bicarbonate level as well as hypoglycemia and required multiple dextrose boluses as well as boluses of intravenous fluids. Despite this, the patient continued to have inadequate oral intake and required hospital admission for ongoing administration of fluids and glucose as needed, and for close monitoring in an inpatient setting.
The decision making at the time of admission for this patient with consistent with the patient's young age, the presence of dehydration with abnormal laboratory values and an inability to orally rehydrate, and the need for ongoing intravenous fluids with dextrose as needed along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain in the setting of pregnancy

Treatment: Inpatient admission

The insurer has denied inpatient admission. That denial was upheld.

This case involves a patient who presented to the hospital complaining of abdominal pain.  She was 30 weeks and 6 days gestation.  The patient denied vaginal bleeding, urinary symptoms, recent intercourse or loss of fluid.  She presented to triage complaining of abdominal pain.  The patient was put on a monitor with normal fetal heart tones and she was given fluids.  The patient underwent a urinalysis resulting in 2+ ketones as well as 2+ white blood cells.  The patient's pelvic exam revealed the patient was 1 cm dilated and 60% effaced.  It was recommended the patient receive IV medications.  The patient was noted to be having 2-3 contractions every 10 minutes and was admitted for preterm labor.  The following day the patient was resting comfortably without any other adverse events.  The patient was given medications to include Ampicillin as well as betamethasone.  She did not have any further complication and was discharged as the irregular contractions had stopped.

According to current literature a patient may be admitted if there is evidence of a condition requiring premature delivery or there is evidence of fetal distress or demise, preterm prelabor rupture of membranes, significant maternal disease identified requiring inpatient treatment, vaginal bleeding, complications of tocolytic treatment, continued fetal monitoring requiring inpatient care beyond the observational, or there is the inability to stop preterm labor.  

Within the documentation provided the above is not present.  While it was noted the patient continued to have contractions the following day, they did not increase.  The patient's pelvic examination also did not change.  The patient continued with medication administration and was noted to have a decrease in contractions with a cease in contractions within 48 hours.  The documentation does not detail the patient was appropriate to be admitted to inpatient services versus observational care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thyroid Nodule
 
Treatment: Inpatient Admission following thyroidectomy

The insurer denied the coverage. The denial was upheld.

The patient had a 2 centimeter Bethesda IV thyroid nodule with a positive ThyroSeq mutation, concerning for malignancy.  The patient had a thyroidectomy and was admitted to the hospital.

The insurer has denied coverage for the full hospital admission, as not medically necessary.  

Based on the submitted information it would be appropriate for this patient to have been discharged on the day of surgery.  No major co-morbidities were identified preoperative, there were no intraoperative complications and the patient was hemodynamically stable, ambulating, pain controlled a few hours after surgery and not experiencing symptoms of hypocalcemia.  Per the references listed below performing total thyroidectomy as ambulatory surgery would be medically appropriate and reasonable as there is a low incidence of complication and need for inpatient services.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of hypertension, hyperlipidemia, coronary artery disease, diabetes and recurrent C. difficile colitis.  The patient presented with chest pain radiating to her L (left) arm, associated with dyspnea.  Per the appeal letter, she had new onset of chest pain with minimal exertion, walking about 6 feet, relieved with rest or nitroglycerin. 

The health plan's determination is overturned.  The inpatient admission was medically necessary.  The patient had multiple coronary risk factors and known mild to moderate coronary artery disease (CAD) by previous cardiac catheterization.  She presented with unstable angina.  The Inpatient admission is indicated.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented with multiple episodes of emesis.
He had developed multiple episodes of nonbloody, non-bilious vomiting. His family noted that he vomited 8 times the day prior to admission, and 4 times on the day of admission. He was not tolerating any oral intake. He also had a fever which was treated with ibuprofen. He was brought to the emergency department due to persistent vomiting. The health plan's determination of medical necessity is overturned. This is a young child who presented with a significant amount of emesis. He was not able to keep any fluids down, and he continued to vomit despite receiving an intravenous bolus in the emergency department as well as intravenous Zofran. He was also febrile with an elevated white blood count. Concern for an infectious etiology was elevated because of recent travel. He required inpatient admission for continued intravenous hydration as well as ongoing monitoring with further diagnostic evaluation and treatment as needed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiolitis
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
This young male infant had been diagnosed with RSV the day prior to presentation, and presented with increased work of breathing. He had no oxygen requirement and no episodes of apnea, but was admitted for ongoing observation in anticipation of worsening symptoms. He remained hemodynamically stable, with no oxygen requirement and no significant respiratory distress. He did not require acute inpatient admission, and he could have been safely managed at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: RUQ abdominal pain
 
Treatment: Inpatient admission, surgical procedure, monitoring

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

This patient presented to the emergency department with right upper quadrant pain.  The patient had bariatric surgery at beginning of the year. The patient's pain was 10/10 in the emergency department. CT scan, sonogram and HIDA scan were negative.  Intravenous fluids were started and he was admitted. The patient's diet was resumed but he vomited. Two days after admission he underwent a laparoscopic cholecystectomy. The findings indicated the patient had chronic cholecystitis. Post-operatively, he was treated with intravenous fluids and his diet was advanced as tolerated.  The patient was stabilized and discharged home the day after surgery.

According to MCG, a cholecystectomy by laparoscopy is indicated when the patient has symptomatic gallstone disease with evidence of disease as indicated by stones on imaging. The procedure is generally performed on an outpatient or ambulatory basis unless exceptional factors are noted. 

The patient could have been observed prior to the surgical intervention.  The records failed to support the patient had a necessity for inpatient admission.  The patient was not noted to have complications. He could have been discharged from the post-anesthesia care unit after the surgical intervention was completed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right hand cellulitis with lymphangitis
 
Treatment: Inpatient hospital admission

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

The patient is a male with a benign past medical history who was referred to the emergency department with complaints of erythema of the right hand following an insect bite. The patient was admitted for cellulitis of his right hand with lymphangitis. He was started on intravenous antibiotics (vancomycin and Levaquin). Blood cultures were negative. Infectious Diseases consulted. He remained febrile, hemodynamically stable, and clinically improved. The patient was discharged to continue oral antibiotics as an outpatient.

According to the documentation, this patient presented with right hand swelling and erythema. Otherwise, he was afebrile and hemodynamically stable with unremarkable laboratory results including a normal WBC. Additionally, he had no co-morbid risk factors and had not failed a trial of outpatient intervention. Based on the above findings, the patient met criteria for observation level of care. Therefore, the health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.   

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

This is a patient with no significant past medical history who presented with right lower quadrant pain with a concern for appendicitis. His father reported that on the morning of presentation, that he experienced intense pain in his right groin area to the point where he was unable to walk. He brought him to the urgent care center and he was referred to the emergency room for a concern of appendicitis. The health plan's determination of medical necessity is upheld in whole. It was discovered in the ER that this patient would not need emergent surgical intervention. His inflammatory markers were not elevated and his radiological studies were normal. He responded well to oral over-the-counter (OTC) analgesic of Motrin and he was discharged within approximately 12 hours of admission. He did not receive or require any highly skilled or technical care while admitted for 12 hours. This service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: DVT
 
Treatment: Inpatient admission, medications, monitoring

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

The patient presented to the Emergency Department (ED) after pre-op testing for knee replacement revealed a right lower extremity deep vein thrombosis (DVT). The patient has a history of DVTs, but was not on any anticoagulation treatment. The patient's past medical history included traumatic brain injury (TBI) at age 13, right hemiparesis, osteoarthritis status post total knee replacement, contractures and multiple surgeries; recent right knee infection 2 months ago with placement of antibiotic spacer.

The patient denied fever, chest pain or shortness of breath, was in no acute distress and was awake and alert.  Vital signs at presentation included a temperature of 97.9F, a blood pressure of 146/89 mmHg, a heart rate of 76, and a respiratory rate of 16.  Oxygen saturations were 98% on room air.  Lungs were clear. There was no clubbing, cyanosis or edema and no calf tenderness. The patient was admitted and placed on subcutaneous Lovenox.  A CT angiogram was negative for a pulmonary embolism.  

The patient did not need acute hospitalization.  He could have had a pulmonary embolism excluded by a computed tomography angiogram (CTA) either in the Emergency Department (ED) or in observation status.  The patient was afebrile and hemodynamically stable and was not hypoxic.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a medical history of alcohol abuse, asthma, erosive esophagitis, gastritis, hypertension, and epilepsy. She presented to the emergency department  with severe vomiting since that morning, subsequent diffuse abdominal pain with dry heaves, and alcohol intoxication after binge drinking the night before. The health plan's determination of medical necessity is upheld. The patient had abdominal pain consistent with multiple possible etiologies such as acute gastritis or gastroenteritis. However, the objective findings were not consistent with pathology such as gastrointestinal perforation, pancreatitis, abscess, toxic megacolon, or obstruction, and no workup for these was performed. Additionally, the patient did not have definitive evidence of clinical gastrointestinal bleeding, peritonitis, sepsis, or other complications warranting inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sudden onset of ataxia 

Treatment: IV fluids and diagnostics

The insurer has denied inpatient admission. That denial was upheld.
This child presented to the hospital ER with ataxia after a febrile seizure the previous night. The patient had experienced flu-like symptoms one to two weeks prior and had been prescribed medications at a different ER. Upon arrival, she was febrile with an unsteady gait. She received a bolus of intravenous (IV) fluids x 2, and was subsequently admitted for further evaluation of ataxia, status post febrile seizure. An MRI was negative. Her gait had improved. She was discharged with instructions to follow up with neurology if there was no symptom resolution in a few days. 
This patient's MRI showed no abnormalities to account for the patient's symptoms; fluid in the middle ear cavities and mastoid air cells were noted, and much of the visualized paranasal sinuses were opacified. The patient's gait had improved. The current literature indicates a pediatric patient may be admitted when there is evidence of a metabolic disorder persisting despite observation; a recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe persistent, or evidence of hemodynamic instability. While the patient continued to have ataxia during the post ictal period, documentation does not detail a trial and failure of care at a lower level, such as observation; nor was there an indication that the patient could not have undergone imaging while in an observation level of care.
Based on the above, the medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient presented with a request for detoxification and substance-related services. The patient has a history of severe substance use disorders with alcohol class substance of abuse. The patient had recent substance use disorder treatment but relapsed and was using large quantities of alcohol on a continuous daily basis. The patient had prior substance use disorder treatment including an interval of sobriety for 11 years while in a healthy relationship with family. At the time of presentation, the patient was also requesting referral for rehabilitation substance use disorder treatment. He denied legal issues and indicated that he had housing and support from family despite strained relationships due to his substance-related problems.
The patient was admitted for inpatient treatment with detoxification protocol and withdrawal management and supportive measures, as well as evidence based psychosocial interventions. The patient received tapering dosages of Librium and replacement of vitamins with the availability of nicotine replacement and smoking cessation counseling and comfort medications and as needed (prn) medications prescribed for pain, anxiety, and insomnia. The patient's hospital course progressed without incident. Vital signs normalized, and the patient reported tremor, anxiety, restlessness and insomnia with mild symptoms of withdrawal that diminished over the course of time. The patient was socially withdrawn but participating in counseling and educational sessions. The patient was participating more readily in group, educational and counseling sessions, and was receiving individual counseling with case management to enhance motivation to proceed to rehabilitation treatment.
Arrangements were being made for a direct referral to rehabilitation substance use disorder treatment which was achieved at the time of discharge. Again, the patient received active treatment together with monitoring that had occurred without incident, and the patient attended groups sessions and received counseling with recommendations and planning for clinically appropriate aftercare.
The health plan's determination is overturned. 
The continued inpatient detoxification could not have been safely or effectively provided at a lower level of care in this case. The patient in this case was using large quantities of alcohol on a daily continuous basis that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. Detoxification, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department of Hospital A, where she was determined to have severe three vessel coronary artery disease and a left ventricular ejection fraction of 25%. A decision was made to transfer the patient to a facility capable of advanced mechanical circulatory support, such as a left ventricular assist device. The patient was flown by air ambulance to Hospital B. The health plan has denied the air ambulance as not medically necessary. The health plan's determination is upheld. While air ambulance transport was necessary, the records do not indicate that there was a medical reason for transfer to Hospital B, versus the nearest appropriate facility.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented for evaluation and treatment of tooth number (#) 19 and #30. Based on the documentation provided the patient has missing teeth #19 and 30 resulting in the diagnosis of partial edentulism as well as diminished posterior support. The issue for review is the medical necessity of the requested dental procedures.
The health plan's determination is overturned. With the diagnoses of partial edentulism as well as diminished posterior support, the only therapy capable of addressing both diagnoses is that of implant therapy as it is anchored within the bone offering complete support stability and retention for a tooth prosthesis. After the implants have integrated they will require restorations in the form of abutments and crowns in order to complete the tooth replacement. CT scans are common presurgical diagnostic procedures that allow for selection of the proper implant dimensions as well as avoidance of vital structures such as nerves and arteries. Prophylaxis is required prior to implant surgery to allow for proper flap closure and protection from opportunistic infection. This is standard in tooth replacement involving implants.
Appeal type: Medical necessity
Decision: Upheld

The patient has a diagnosis of anorexia nervosa, restricting subtype (ANR). The question is whether Residential Mental Health Treatment (RMHT) is medically necessary. Case notes document that the patient began her food restriction at age 11. The patient's symptoms worsened at age 13. The patient was admitted to RMHT and has not had prior therapy at a lower level of intensity of care

The health plan's determination is upheld. Residential mental health treatment is not medically necessary for this patient. While this patient undoubtedly struggles with eating, and has a diagnosis of ANR, the patient has not been treated unsuccessfully in a less restrictive setting. The does not have any behavioral symptoms or mental health symptoms that mandate RMHT.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with multifocal hepatocellular carcinoma (HCC) and good performance status who presented for a palliative radio-embolization procedure with Y-90 TheraSphere. Abdominal pain and some fatigue were noted.
The patient has a history of previous right hepatic surgery; partial right hepatectomy. The patient had a previous cholecystectomy, has good liver function and no contraindications noted. The health plan's determination of medical necessity is overturned.  The patient has HCC that is recurrent and requires liver directed loco-regional therapy to control disease and preserve liver function. This patient with good performance status and no contraindications to liver directed loco-regional therapy will have expected good efficacy from Y-90 TheraSphere treatment, as planned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Atrial fibrillation
Treatment:  Inpatient admission
The proposed treatment, inpatient admission, was not medically necessary.
The patient presented for evaluation of atrial fibrillation.  The patient was hemodynamically stable.  There was no evidence of acute myocardial infarction, acute myocardial infarction (ACS), decompensated congestive heart failure (CHF), cerebral vascular accident (CVA), malignant arrhythmia or hemodynamic instability.  The patient underwent a stress test, which was abnormal.  Subsequent catheterization revealed non-obstructive CAD.  Based on the clinical information provided in the record submitted for review there was no medical necessity for an inpatient admission, and the care required could have been provided at a lower level of care.