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

Diagnosis: Abdominal pain, appendicitis
Issue under review: 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. His medical history was negative. His surgical history included lumbar discectomy. He presented to an emergency room with a one-day history of abdominal pain and vomiting. 

The patient's vitals were temperature 98.7, pulse 72, blood pressure 127/86, respirations 19, and oxygenation 96%. Physical examination of the abdomen demonstrated tenderness in the epigastrium and right lower quadrant. Serum laboratories demonstrated a normal white-blood-cell (WBC) count of 9.2. Computed tomography demonstrated acute appendicitis. 

The patient was admitted with a diagnosis of acute appendicitis. He was made nil per os [NPO], and provided with intravenous fluids, antibiotics, and analgesics. The patient underwent laparoscopic appendectomy. Surgery and recovery were uncomplicated. 

Having returned to his baseline health and function, the patient was discharged home in good and stable condition with outpatient surgical follow-up and prescriptions for oral analgesics. 

According to several studies, the majority of patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely on outpatient or observational status [Gilliam et al; Cross et al; Cosse et al]. In fact, most patients can be discharged from the post-anesthesia care unit -- the recovery room [Mitchell et al; Dubois et al; Cash et al]. 

The patient underwent laparoscopic appendectomy. Surgery and recovery were uncomplicated. Therefore, for this patient, there was no need for admission at an acute inpatient level of care; he could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Community acquired pneumonia
Treatment:  Inpatient admission
The insurer is denied coverage for inpatient admission. 
The denial is upheld. 

The patient was then a female who presented to the Emergency Department (ED) with complaints of subjective fever, cough with productive yellow sputum and some chest pains. The patient had reported myalgia, some night sweats, shortness of breath and orthopnea for the prior 5 to 6 days. The patient had been seen at an Urgent Care center before and a chest x-ray revealed a right upper lobe lesion with some possible cavitary lesion. The patient had reported travel to Mexico. The patient's vital signs at presentation to the ED were: temperature 98.4 F, heart rate 106, respiratory rate 20, blood pressure 125/71, mm Hg and oxygen (O2) saturations 99 % on room air. On exam, the patient was in no acute distress, and her lung sounds were clear. The patient's lab results showed that her white blood cell count (WBC) was 11 K, her hemoglobin was 10.7, and her lactate was 1; the patient's electrolytes, liver function tests, BUN/ Creatinine were within normal limits. The patient's urinalysis revealed 11-20 WBC. The patient's urine toxicology was positive for cannabinoids. The patient's chest x-ray showed right upper lobe consolidation. The patient's computed tomography (CT) scan of the chest showed right upper lobe consolidation with small focal areas of cavitation. The patient was admitted to the hospital with diagnosis of community acquired pneumonia and possible urinary tract infection (UTI), and to rule out tuberculosis (TB). As inpatient, the patient was started on Azithromycin and Ceftriaxone along with Tamiflu. The patient was admitted to airborne isolation to rule out TB. The patient was continued on intravenous (IV) fluids, IV antibiotics, and pain medications. The patient's influenza screen was negative. The patient's quantiferon test was negative, which made TB diagnosis unlikely. The patient's sputum smears for AFB were sent. 

Based on the review of the medical record, this patient did not need acute inpatient hospitalization. The patient could have been placed in observation status while diagnostic testing and treatment were initiated. The patient remained stable after admission. The patient was afebrile and hemodynamically stable. The patient's sputum for AFB was negative for tuberculosis.  

This patient could have been discharged after a period of observation. The patient was stable and tolerating oral intake. The diagnosis of tuberculosis was ruled out by the following day of admission. The patient's diagnosis of community acquired pneumonia (CAP) was mild with a pneumonia severity score, CURB 65 score of zero. The patient could have been discharged on oral antibiotic with close follow up in outpatient setting. 
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 admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Issue under review: Inpatient admission
The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a female at the time of admission to the hospital, with a past medical history significant for hypertension (HTN), dyslipidemia, gastroesophageal reflux disease (GERD), presented to the ER with complaints of new onset chest pain. The patient was hemodynamically stable. The electrocardiogram (ECG) revealed ST depressions in inferior-lateral leads. The patient was placed in observation. Troponin was sent and was negative. The patient was referred for a stress test, which was abnormal, with evidence of ischemia. The patient was admitted for unstable angina and referred for cardiac catheterization, which revealed obstructive left circumflex lesion, which was stented. The patient was started on medical therapy for coronary artery disease (CAD) and was discharged home with a plan for outpatient follow-up.

The patient presented with new onset chest pain, suggestive of unstable angina. The ECG was abnormal, with ST depressions, consistent with ischemia. Stress test was also abnormal, with findings confirming ischemia. The patient underwent catheterization and required PCI of the culprit lesion. Given this presentation, suspicion for an acute coronary syndrome, as well as risk factors for CAD and findings on non-invasive testing, it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest and epigastric pain
Issue under review: Inpatient admission 
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He has a past medical history significant for HTN (hypertension), diabetes mellitus type II, chronic gastritis, dyslipidemia, GERD (gastroesophageal reflux disease), and drug abuse. He presented to the ER for evaluation of chest and epigastric pain of several days' duration. The pain was described as constant, non-exertional, non-radiating. The patient was recently evaluated and was diagnosed with gastritis and discharged two days prior. 

The patient was hypertensive on admission. ECG (electrocardiogram) revealed no acute ischemic changes. Cardiac troponin was negative. There was epigastric tenderness on exam. The patient was admitted to rule out ACS (acute coronary syndrome). 

The patient's hypertension was felt to be due to non-compliance, and his oral BP (blood pressure) medications were restarted, with BP improving. His BUN (blood urea nitrogen)/creatinine levels were elevated, consistent with dehydration, and he was given fluids. Chest x-ray was unremarkable. He had had an echocardiogram which was unremarkable. Urine toxicology was abnormal for cannabinoids, opiates and barbiturate. 

The patient was counselled on discontinuation of drug use. Protonix was given for gastritis. The patient signed out from the hospital against medical advice (AMA).

No, the inpatient admission was not medically necessary.

This patient presented for evaluation of epigastric and chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. The patient was hydrated, and his oral medications were restarted. He was treated for gastritis. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. 

The standard of care for patients presenting with chest discomfort, and in whom the diagnosis of acute coronary syndrome is unclear, is observation in ED or chest pain unit with serial cardiomarker measurements to rule out an acute myocardial infarction, followed by a non-invasive ischemic workup (stress test, CT angiogram). This standard of care is in concert with ACC/AHA clinical guidelines. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at a lower than inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain 

Treatment: Inpatient admission 

The insurer is denied coverage for inpatient admission.

The denial is upheld. 

The patient was then a female with no past medical history who presented to the Emergency Department (ED) from the Urgent Care center with complaints of abdominal pain.  The patient denied nausea, vomiting, and diarrhea.  The patient's blood pressure was 147/93 and her temperature was 98.1.  The patient was admitted for abdominal pain.  The patient's physical examination revealed diffuse tenderness to palpation in the abdomen. The patient's creatinine was 1.22.  The patient's computed tomography (CT) scan of the abdomen and pelvis revealed an intraluminal lipoma within the terminal ileus, but the appendix was not able to be visualized.  Gynecology service was consulted, and their clinical impression of this patient's abdominal pain was non-gynecological in origin. The Surgical service was also consulted, and they had a low index for acute appendicitis. The patient's electrocardiogram (EKG) showed sinus bradycardia at 57 bpm.  The patient underwent treatment with intravenous (IV) fluid boluses, IV ondansetron, IV glycopyrrolate, and a mineral oil enema.  The patient was admitted for abdominal pain.  The blood pressure at admission was 125/85.  The patient was stabilized and discharged.
  
Based on the review of the medical record and literature, the medical necessity of the inpatient admission was not established. The patient presented with non-specific abdominal pain, and the patient's initial evaluation in the Emergency Department was unremarkable. The patient was hemodynamically stable, and did not have any concerning lab results or clinical signs of sepsis. The patient's computed tomography (CT) scan of the abdomen showed no surgical causes that required inpatient admission. The patient's clinical presentation did not meet the criteria for inpatient admission.  Observation status would have been appropriate to manage this patient's abdominal pain.

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 admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: New onset diabetes

Treatment: Inpatient hospital admission 

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

This patient was female with past medical history of gallstone and enlarged left kidney who was admitted for new onset diabetes.  The patient presented with polyuria, polydipsia, weight loss of 20 pounds and blurry vision. The patient's blood glucose was 444 mg/dL, hemoglobin A1c was15.5, and serum osmolarity was 298. The patient was afebrile, heat rate was 78, and blood pressure was 101/67.  The patient received intravenous (IV) fluid and insulin and was discharged on basal bolus insulin.

Based on the review of the medical record and literature, this patient presented with new onset, Type 2 diabetes. The patient did not present with diabetic ketoacidosis, and did not meet the criteria for hyperosmolar state, which is met by osmolarity > 325; the patient's serum osmolarity was 298.

Based on literature review, this patient's clinical presentation only justifies for Emergency Room (ER) treatment with intravenous IV fluids for a few hours, and then discharge home on basal insulin and Metformn.  This patient's hospital admission is not justified based on the data submitted for review. 

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 admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic renal failure (chronic kidney disease stage lll), renal parenchymal hypertension

Treatment: Cinacalcet Hydrochloride 30 milligrams tablets
The insurer denied coverage for Cinacalcet Hydrochloride 30 milligrams tablets. The denial is overturned.

This patient is a male with a history of chronic renal failure (chronic kidney disease stage lll), renal parenchymal hypertension, and immunosuppressive management after 1st deceased donor kidney transplantation; disease of the native kidneys was due to focal and segmental glomeruloscerlosis (FSGS). Treatment with Cinacalcet has been advised.
	
Based on the review of the medical record and literature, Cinacalcet Hydrochloride 30 milligrams tablets are considered medically necessary for this patient. The patient had hypercalcemia secondary to hyperparathyroidism which could cause further kidney damage due to nephrocalcinosis and kidney transplant failure. The other options to treat this patient's hyperparathyroidism were not feasible due to the side effects of hypercalcemia. If this patient's condition is not treated, kidney function will deteriorate and may require dialysis or a second kidney transplant. Therefore, per standard of care, Cinacalcet is medically necessary to treat this patient's condition.

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

Based on the above, the medical necessity for Cinacalcet Hydrochloride 30 milligrams tablets is substantiated. The insurer's denial should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive system/Gastrointestinal/Appendicitis
Treatment: Inpatient Hospital stay  
The insurer denied the inpatient hospital stay. 
The denial is upheld in whole.

The patient presented to the emergency department (ED) with a history of progressively worsening abdominal pain of 1-day duration.
No, inpatient care was not medically necessary in this case. The records indicate that this patient presented to the emergency department (ED) with acute appendicitis and underwent appendectomy.
The pre- and post-surgical course was uncomplicated. Vital signs remained normal. Diet progression was tolerated following surgery. The records support that this patient could have reasonably and appropriately been treated with a lower level of care. This lower level of care would have permitted pre-surgical assessment, operative treatment, post-surgical monitoring, diet progression, overnight care (if required), and provision of antibiotics.
Generally accepted practice standards support that a reasonable and appropriate goal length of stay is ambulatory or 1 day postoperative. These standard guidelines support that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, GI obstruction or surgical complications, the procedure may be performed with an ambulatory level of care. In this case the patient tolerated oral hydration, diet and medication and pain was well controlled. A lower level of care would have appropriately provided for pre-surgical assessment, laparoscopic appendectomy, and post-surgical monitoring. The inpatient hospital care was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Supranormal IgG levels; immunosuppressant status 

Treatment: Gammagard

The insurer denied coverage for Gammagard. The denial is overturned.

This patient is a child who has had an extremely complicated course including cardiac transplant status and lymphoid dysplastic/neoplastic disease treated with rituximab, RSV, C Diff, bacillus megaterium in the lung and bowel perforation requiring TPN. There is also a history of sepsis and pneumonia. 

Labs have consistently shown normal or supranormal levels of IgG with no decreases in IgA or IgM. At least 2 sets of pneumococcal titers have been reported both showing completely non-immune status. Other antibody titers have shown protective titers including tetanus diptheria and HiB(dates of these tests are not stated). Gammaglobulin treatment was apparently initiated possibly explaining why some IgG levels have been supranormal. These data imply that the child has had normal non-live immunizations appropriate for her age and immunosuppressant status. Pneumococcal vaccination is currently recommended for children less than 2 years of age as well as in children at risk for invasive pneumococcal disease because of other medical conditions such as solid organ transplantation. It would be highly unlikely that this child would not have received pneumococcal vaccination. The complete absence of detectable pneumococcal titers for any serotype is consistent with functional antibody deficiency, which signifies severe impairment of functional antibody production regardless of IgG or IgG subclass titers. 

The health plan's denial on the basis of inadequate laboratory and vaccination documentation is in part inaccurate since IgA and IgM values that were said to be missing actually were reported. Even without documented pneumococcal disease history, it would be prudent to treat with immune globulin (such as Gammagard) to prevent invasive pneumococcal disease in this already immunocompromised child. 

Gammagard is medically necessary for this patient. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Gammagard is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental health
Treatment: Inpatient hospital admission 
The insurer denied coverage for inpatient hospital admission. 
The health plan's determination of medical necessity is upheld in whole.
The inpatient admission was not medically necessary.

This is a patient who presented with alcohol intoxication and withdrawal with initial tachycardia to the 130s with tremor. Patient was treated with valium and IV fluids in the emergency department with improvement of  heart rate to the 100s. Otherwise did not have uncontrolled hypertension, altered mental status, ongoing vomiting or diaphoresis noted, and had mild tachycardia with minimal benzodiazepines required after the date of admission. Patient furthermore was not noted to have any history of delirium tremens or seizures making him higher risk for adverse event secondary to alcohol withdrawal. In the absence of ongoing significant tachycardia after emergency department treatment (heart rate >120), altered mental status, inability to take oral medication in the setting of nausea/vomiting, history of delirium tremens or seizures when withdrawing from alcohol, or other acute medical issue requiring inpatient care, with the patient stabilizing quickly and requiring minimal benzodiazepines after presentation, it is unclear why the patient could not have been safely cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Melanoma

Treatment: Decision DX Melanoma Test, code 81599

The insurer denied the Decision DX Melanoma Test, code 81599. The denial was upheld. 

The is a female patient with a diagnosis of stage 1 melanoma who underwent a biopsy of a melanoma on the left shoulder with greatest depth of 0.7 mm, stage t1a.  A DecisionDx-Melanoma Gene Expression Profile test was performed that revealed Class I, Sub-Class 1A, which was associated with the lowest risk of recurrence within 5 years.  

Decision dx is a gene expression profile test that is used to stratify risk of metastasis in patients with melanoma.  Gene expression profiling like that undertaken by this provider has not yet been accepted as standard of care in treating cutaneous melanoma patients.  The American Joint Committee on Cancer (AJCC) and National Comprehensive Cancer Network (NCCN) guidelines for clinical decision making and follow up for patients with cutaneous melanoma do not currently incorporate gene expression profiling.  In fact, at the NCCN Guidelines for Melanoma V.1.2018 Panel Meeting on 06/28/17, there was a 22 out of 22 dermatologists who voted "no" to include decision dx in the NCCN guidelines.

These assays are not recommended in clinical guidelines, and the data pertaining to this assay's use is not yet accepted.  The 2019 melanoma guidelines from the American Academy of Dermatology state that the information gleaned from the assay itself should not affect the treatment or follow up approach for cutaneous melanoma.(Swetter, et al.)

Per Sondak & Messina (2016), "The clinical value of this test remains unclear, and the National Comprehensive Cancer Network (NCCN) Guidelines for Melanoma state 'while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low- versus high-risk for metastasis, routine (baseline) genetic testing of primary cutaneous melanomas (before or following SLNB) is not recommended outside of a clinical study (trial).' This admonition seems sound, particularly if we apply the same stringent criteria for validation that Mahar et al. applied to clinical prognostic tools that also claim to demonstrate independent prognostic value.  Nevertheless, practicing surgical oncologists are encountering patients with clinically localized invasive melanomas who have already undergone this test at the time of referral.  For the time being, until far more detailed data derived from prospective evaluations are available, there is insufficient evidence to propose that routine clinical management, including decision making regarding [sentinel lymph node biopsy (SLNB)], should be altered by the results of gene expression profiling, although to reassure patients who have already received and are concerned about a 'high-risk' determination, more intensive surveillance may be justified."

The carrier's denial of coverage for the laboratory services (Decision DX Melanoma Test, code 81599) is upheld.  The medical necessity is not substantiated.