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

Diagnosis: Cardiac/Circulatory Problems-Chest Pain
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This case involves a patient with a history of chronic heart failure with preserved ejection fraction (EF), coronary artery disease (CAD), coronary artery bypass graft (CABG), atrial fibrillation (AFIB), hypertension (HTN), hyperlipidemia (HL), chronic kidney disease (CKD), alcohol abuse, hepatitis C virus (HCV), peripheral arterial disease (PAD), sick sinus syndrome with prior permanent pacemaker (PPM), and history of intravenous drug use (IVDU), who presented to the emergency department (ED) with intermittent left sided sharp chest pain associated with shortness of breath for the last 2 weeks. He was mildly hypertensive. An electrocardiogram (ECG) showed normal sinus rhythm with right bundle branch block (RBBB). A chest x-ray (CXR) was clear. Brain (or B-type) natriuretic peptide (BNP) was elevated 2989 picograms per milliliter (pg/mL), but he was not volume overloaded. He was admitted to telemetry service under inpatient level of care to rule out acute coronary syndrome (ACS). Pacemaker interrogation showed no events. Echocardiogram showed normal cardiac function, moderate mitral regurgitation, and moderate pulmonary hypertension. He was ruled out for ACS then discharged home. 

No, inpatient level of care was not medically necessary in this case. The patient presented with chest pain with atypical features unlikely due to ACS, there were no new ECG changes, and cardiac troponins were not elevated. Cardiology service was consulted and stated that the patient's presentation was unlikely due to ACS. The patient remained hemodynamically stable and his chest pain did not recur. Ischemic evaluation with stress testing or cardiac catheterization was not needed during the hospitalization. Based on the well-validated HEART pathway and current American College of Cardiology (ACC)/American Heart Association (AHA) guidelines on the evaluation of chest pain and non-ST (section of the ECG) elevation syndromes, a lower level of care would have been medically appropriate and safe for evaluation of chest pain in this case (1-3).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries 
Treatment: Inpatient Hospital Stay 
The insurer denied the inpatient hospital stay. 
The denial is upheld.

The patient is a female who presented to the emergency department (ED) following a fall from her booster seat to the floor, hitting her face. Afterwards, her right lower extremity was tender to touch. There was no loss of consciousness. Vital signs included heart rate 147, respiratory rate 30, temperature 37.2. Examination was significant for no acute distress, full range of motion in all extremities, good perfusion. X-rays were obtained, revealing a distal transverse femur fracture. Orthopedics and Trauma were consulted to assist with management. She was placed in a right leg cast. Child Protective Services was also consulted and responded to the call. Recommendations included Social Services consultation, so the child was admitted pending completion of the investigation. Skeletal survey was ordered, revealing no additional injuries. Injuries were consistent with the stated mechanism, so the child was deemed safe for discharge with the mother. Outpatient follow-up was arranged. The subject under review is the medical necessity for the inpatient hospital stay.

The health plan's determination is upheld.

An inpatient hospital stay was not medically necessary; the patient could have been safely managed at a lower level of care status.

Most long bone (femur and humerus) fractures in later infancy and early childhood are related to falls. Other potential causes include non-accidental trauma and bone fragility (e.g. [for example], rickets, vitamin D deficiency, osteogenesis imperfecta). In the case of non-accidental trauma, other findings may be present including retinal hemorrhages, skull fracture, intracranial hemorrhage, and rib fractures. Most fall accidents are related to being carried.

This infant was admitted for completion of a safety evaluation after sustaining a femur fracture following a fall. She demonstrated no other injuries, she remained hemodynamically stable, she was eating well, and pain was well controlled. While it was essential to guarantee safe discharge prior to releasing the infant with her mother, there was no need for acute inpatient hospital admission. She could have been safely managed at lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

This female was hospitalized for chest pain. Her past medical history is pertinent for pericarditis and primary biliary cholangitis with portal hypertension. The patient's vital signs were stable. Her blood pressure (BP) was 141/68. Her heart rate was 66. Electrocardiogram (EKG) showed sinus rhythm (SR) and no acute changes. There were no arrhythmias or elevated troponin documented. Chest x-ray was negative. Chest computed tomography angiogram (CTA) was negative for pulmonary embolism (PE). Her symptom resolved and she was discharged to home the next day. 

No, the proposed treatment, inpatient hospital admission, was not medically necessary.

Based on the peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the Milliman Care Guidelines for Chest Pain, #M-89, criteria for inpatient hospital admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute cardiac tamponade, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. The care the patient received is routinely provided safely and effectively at a lower level of care. 

Therefore, based on the submitted information and the current published medical literature, the proposed treatment was not medically necessary for this patient.

Yes, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Outpatient Procedure (63048 x1 and 22867 x1)
The insurer denied the Outpatient Procedure (63048 x1 and 22867 x1)
The denial is upheld

The patient is a female with complaints of low back pain with radiation going into the right lower extremity.  The patient has a chronic right foot-drop secondary to previous lumbar surgeries. The patient had previous L4-5 (fourth and fifth lumbar spine vertebrae) discectomy.  Magnetic resonance image (MRI) of the lumbar spine showed a large right disc protrusion at L4-5 (fourth and fifth lumbar spine vertebrae) with associated spinal stenosis.  The physical exam showed no pain in the lumbar spine.  The patient has pain and paresthesias radiating into the right lower extremity.  Request is made for revision L4-5 (fourth and fifth lumbar spine vertebrae) laminectomy with Coflex implantation.  This is a review for the surgical procedure.

No, the proposed Outpatient Procedure (63048 x1 and 22867 x1) is not medically necessary.
The patient has been recommended for revision lumbar discectomy with stabilization with the coflex device.  The scientific literature indicates a consensus among experts that a fusion is indicated after the third discectomy.  However, in this case, the patient has been recommended for a distraction device without fusion.  This device has not been showed to be effective for treatment after a third discectomy procedure and would not be considered medically necessary or standard of care.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
The use of this device has not been shown in the scientific literature to be effective and safe.  The standard treatment would be a discectomy and fusion procedure.  The use of this device would not be considered standard of care and thus the denial of the device was in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld


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

The patient is a male who initially was directed to the emergency department for concerns of anemia. Pertinent history included chronic anemia, asthma, hypertension, diabetes mellitus, seizure disorder, obstructive sleep apnea, and morbid obesity. Initial vital signs revealed a temperature of 100 (degrees Fahrenheit), heart rate (HR) 95, blood pressure (BP) 135/65, respiratory rate (RR) 20, and peripheral capillary oxygen saturation (SpO2) 96% (percent) on room air. Initial examination documented the patient as alert and oriented. Initial laboratory testing revealed a Hemoglobin (HGB) 6.8, mean corpuscular volume (MCV) 65, blood urea nitrogen (BUN) 15, and Creatinine 0.79. An electrocardiogram (EKG) was without acute ischemic changes. The patient was placed in the hospital thereafter with an impression of anemia.

Based on the clinical documentation provided, evidence based literature and standards of care, the inpatient hospital admission was not medically necessary. In this particular situation, the patient had a history of unspecified chronic anemia and was directed to the emergency department after outside laboratory testing revealed anemia. He denied any symptomatology or active bleeding. Initial evaluation found the patient to be alert, hemodynamically stable, and with a HGB 6.8. Treatment plan included iron supplementation and transfusion of packed red blood cells with improvement in repeat HGB. Following observation care, the patient was deemed medically stable for discharge with outpatient follow-up. No other issues or complications requiring acute inpatient services were documented. Moreover, clinical indications for admission to inpatient care were not met. In addition to being hemodynamically stable, the patient did not have documented active hemolysis, active bleeding, altered mental status, syncope, cardiac arrhythmia of immediate concern, decompensated heart failure, or other severe signs or symptoms secondary to anemia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unexplained weight loss

Treatment: Current procedural terminology (CPT) code 74177, CT (computed tomography) scan of the abdomen and pelvis

The insurer denied coverage for CPT code 74177, CT scan of the abdomen and pelvis
The denial is upheld

The patient lost 20 pounds in a year. She was not having bowel problems or gastrointestinal bleeding. The abdominal exam was benign. Her physician has recommended an endoscopy, colonoscopy, and abdominal CT scan. Neither the endoscopy nor colonoscopy found a cause for the weight loss. 

MCG (Milliman Care Guidelines) ACG: A-0013 lists indications for Abdominal/Pelvic CT scan. These indications include staging of a known cancer, inflammatory bowel disease, jaundice, an abdominal mass, evaluation of abdominal pain, evaluation of pancreatitis or a pancreatic mass, small bowel bleeding, and evaluation of abdominal trauma. The patient did not have these conditions. 

UpToDate has an article titled "Approach to the patient with unintentional weight loss." The article discusses diagnostic testing. The basic diagnostic evaluation should consist of CBC (complete blood count), electrolytes, glucose, calcium, renal and hepatic function, TSH (thyroid stimulating hormone), stool hemoccult, Hepatitis C, chest x-ray, and age- appropriate cancer screening. There should also be an evaluation for malabsorption.

This patient has unexplained weight loss but no other associated gastrointestinal complaints. An endoscopy and colonoscopy did not find the cause of the weight loss. However, neither the MCG guideline for abdominal and pelvic CT scan nor the UpToDate article on the workup of unexplained weight loss, advise that a CT scan should be done unless there are other gastrointestinal findings. Therefore, the health care plan acted reasonably and with sound medical judgment. The CT scan of the abdomen and pelvis is not medically necessary. 

The denial is upheld.

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

The insurer's denial of coverage for current procedural terminology (CPT) code 74177, computed tomography (CT) scan of the abdomen and pelvis is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory - cardiomyopathy. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Stay. 
The denial is overturned.

The patient is a male with a past medical history significant for nonischemic cardiomyopathy, aortic valve endocarditis, left bundle branch block, hypertension, hyperlipidemia, obesity, and ulcerative colitis who was followed by the heart failure transplant center. He presented to the hospital with ventricular tachycardia.
Per Emergency Medical Services (EMS), the patient's wife called paramedics due to acute onset of palpitations and lightheadedness. The patient tried to feel his pulse but was unable to. He tried to walk across the room but due to his symptoms lowered himself to the floor.
When paramedics arrived, the patient was pale and diaphoretic. The initial rhythm analysis was suggestive of ventricular tachycardia, therefore the patient was shocked twice by EMS and converted back to normal sinus rhythm. Subsequently, he received 150 milligrams (mg) of Amiodarone administered by EMS.
The patient was admitted to the hospital with a diagnosis of ventricular tachycardia. It was reported that his thyroid stimulating hormone (TSH) and free thyroxine (T4) were within normal limits. It was also reported that he underwent defibrillation twice in the field for ventricular tachycardia. He was admitted to the telemetry floor and started on Amiodarone drip. He was also given oral Metoprolol. Echocardiogram was performed. Another clinical problem was acute kidney injury.
In the hospital, the patient was seen by a cardiologist and underwent implantation of a biventricular implantable cardioverter defibrillator (ICD). During the hospital stay, the patient remained in stable clinical condition. Therefore, he was discharged from the hospital.

The health plan's determination is overturned in whole.

The inpatient stay was medically necessary as the patient had symptomatic life-threatening arrhythmia, which required definitive treatment including infusion of antiarrhythmic medications as well as placement of automatic implantable cardioverter defibrillator (AICD). The complexity of treatment completely justified inpatient care status.
This patient was admitted to the hospital due to a near syncopal episode when he had to lower himself to the ground. This was associated with ventricular tachycardia, which was a life-threatening arrhythmia.
Before admission, the patient received 2 electric shocks and was started on Amiodarone infusion.
During the hospital stay, the patient underwent placement of automatic implantable cardioverter defibrillator (AICD) due to severe cardiomyopathy.
According to the nationally accepted standards of care, the severity of the patient's condition and the complexity of services provided including intravenous infusion of Amiodarone, continuous cardiac monitoring, and implantation of AICD completely justified admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a male who presented to the hospital with complaints of sharp chest pain that started one day before his presentation. The patient stated that the pain worsened when he took a deep breath. At home, the patient took Tylenol which did not relieve the pain, therefore he went to an urgent care center. The chest x-ray performed in the urgent care center demonstrated bilateral lung infiltrates. The patient was admitted to the hospital with community-acquired pneumonia and atelectasis.

The acute inpatient level of care was appropriate, considering the presence of acute chest syndrome that was evident based on the patient's symptoms and diagnostic studies. The nationally accepted criteria support this admission at the acute inpatient level.
In this clinical case, there was a high probability that the patient had acute chest syndrome. He had new lung infiltrates on the CT scan of the chest. This was associated with sharp chest pain, which was the main reason for the patient's presentation to the hospital, as well as relative hypoxemia.
This coincides with Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 25th Edition Inpatient and Surgical Care 25th Edition criteria for Sickle Cell Disease. The patient definitely met these criteria, justifying admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obstructive Sleep Apnea.
Treatment: Adjustable Electric Power Bed With Wave Massage.
The insurer denied the Adjustable Electric Power Bed With Wave Massage.
The denial is upheld.

The patient is a male with a history of OSA (obstructive sleep apnea). There is also a history of deviation in opening and closing of the mandible, articular disc disorder of left temporomandibular joint, pain in other specified joint and myositis, unspecified. There is a history of previous nasal surgery. Treatment for the OSA (obstructive sleep apnea) has included CPAP (continuous positive airway pressure), BiPAP (bi-level positive airway pressure), UPPP (uvulopalatopharyngoplasty), and oral appliance.

The request is for an Adjustable Electric Power Bed With Wave Massage. The request was previously denied coverage by the health plan as not medically necessary. The denial is being appealed.

No, the Adjustable Electric Power Bed With Wave Massage is not medically necessary.
All records were reviewed. The patient is requesting an Adjustable Electric Power Bed With Wave Massage to treat OSA (obstructive sleep apnea) with head of bed elevation. While HOB (head-of-bed) positioning can help patients with OSA (obstructive sleep apnea), there is no evidence in the scientific literature supporting that the requested bed has greater efficacy than standard and basic measures for raising the HOB (head-of-bed), including bed blocks and using multiple pillows. Therefore, based on the information provided, the medical necessity of the Adjustable Electric Power Bed With Wave Massage cannot be confirmed.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient, as the requested bed is not confirmed as medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems-Arrhythmia/Irregular Heart Rhythm.
Treatment: Inpatient Hospital Stay.
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This patient presented to the hospital for catheter ablation of symptomatic premature ectopic beats; the origin of the ectopy was unclear at the time of presentation. His medical history was remarkable for hypertension, hyperlipidemia, diabetes, rheumatic fever and moderate to severe aortic insufficiency. Electrophysiologic testing revealed that the patient's ectopic beats were premature atrial beats. The focus for these beats was ablated. The procedure was uncomplicated. The patient was admitted to the hospital post-procedure and was discharged later in the day. Medical necessity for an inpatient admission is at issue.

Based on the documentation provided an inpatient level of care was not medically necessary.
The patient presented for elective catheter ablation of frequent ectopic beats. Electrophysiologic testing revealed a supraventricular site of origin for the ectopy, which was successfully ablated. The limited information provided does not indicate that his post-procedure management required an inpatient level of care. The procedure was uncomplicated, and the rhythm ablated, though symptomatic, was not life-threatening. The patient remained hemodynamically stable, recovered from sedation uneventfully and had no significant arrhythmias post-ablation. He was discharged home after six hours of bedrest and an additional hour of observation. Same-day discharge following a brief period of observation at a lower level of care after uncomplicated ablation of supraventricular arrhythmias has been shown to be safe and cost-effective. The documentation provided does not justify the need for inpatient care. The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care/increase in personal care services from 56 hours per week to 24 hours per day (live in).  
The insurer denied increase in personal care services from 56 hours per week to 24 hours per day (live in). 
The denial is overturned.

The patient is a female with past medical history of metastatic breast cancer, hypertension, osteoarthritis, obesity, anxiety, bipolar disorder, and chronic low back pain who had been assigned Personal Care Assistance (PCA) services 28 hours/week based on the assessment that the patient required at maximum assistance with tasks of meal preparation, ordinary housework, stairs, and shopping while extensive assistance with tasks of transportation and bathing. With tasks of dressing upper/lower body and transfer toilet the patient was assessed at limited assistance while set up only with tasks of managing finances, managing medication, and phone use. The patient was assessed as independent with tasks of walking, locomotion, toilet use, bed mobility, and eating. Notes stated the patient used a Rollator walker and was occasionally incontinent of urine but was continent of bowel. Subsequently the insurer provided initial adverse determination denial notice partially denying request to increase PCA hours with increase in 28 hours/week to 56 hours/week. The subject under review is whether the request for 24 hours per day live in services are medically necessary.

The health plan's determination is overturned.

The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). There is also documentation from rehabilitation that patient has risk of bilateral heel ulceration and requires assistance with repositioning. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, live-in, 7 days/week, are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.