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

Diagnosis:  Abdominal pain.
Treatment:  Inpatient admission.

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

This is an adult female, who presented to the emergency department with a three-week history of worsening peri-umbilical abdominal pain, intermittent nausea, constipation and dysuria. Laboratory evaluation including a complete blood count (CBC), comprehensive metabolic panel (CMP), amylase, lipase and urinalysis were all normal. A computed tomography (CT) scan of the abdomen/pelvis showed a mildly enlarged appendix. General surgery was consulted and felt that the patient's presentation could be consistent with early appendicitis and recommended admission for observation. 

An esophagogastroduodenoscopy (EGD) only showed an incidental gastric polyp and recommendations were for routine post hospital gastrointestinal (GI) follow-up. 

The initial general surgical opinion, based on the patient's presentation and imaging, that overnight observation to see if the patient ultimately required surgery for potential appendicitis was appropriate. When it was determined that the patient did not indeed progress to a surgical abdomen, she no longer met criteria to justify an inpatient admission. 

As discussed above, based on the patient's clinical symptoms and imaging, it was reasonable to admit this patient in an observation status, to ensure she did not progress to true appendicitis requiring urgent surgical care. However, once it was determined that patient did not indeed progress to a surgical abdomen, she no longer met criteria per Milliman Care Guidelines (MCG) Inpatient and Surgical Care guidelines: (no evidence of peritonitis, inability to adequately control pain, inability to tolerate per oral (PO) intake) to justify an inpatient admission. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is an adult male who presented to the hospital with complaints of dyspnea, cough, orthopnea and pedal edema. Past medical history was significant for heart failure with reduced ejection fraction, paroxysmal atrial fibrillation, hypertension and former ethanol abuse. Upon arrival, vital signs were stable (Blood Pressure 112/58, Pulse 72). Physical examination was significant for bilateral crackles and pedal edema.  Serum blood testing revealed hyponatremia and an elevated B type natriuretic peptide (BNP) 2904. 12 lead electrocardiogram (EKG) revealed atrial fibrillation with left bundle branch block and a controlled ventricular rate.  Chest X-ray revealed pulmonary edema. The patient was admitted to the hospital and was treated medically with intravenous diuretics. Echocardiogram revealed a left ventricular ejection fraction of 10-15 percent (%) and a bicuspid aortic valve. Following significant diuresis, the patient was transitioned to oral medication and discharged home with cardiology follow up.

This patient presented with decompensated systolic congestive heart failure. American Heart Association/American College of Cardiology/Heart Failure Society of American guidelines recommend treatment of congestive heart failure with intravenous diuretic therapy in order to prevent worsening of heart failure and adverse outcomes. Masri et al. compared patient outcomes following treatment of acute congestive heart failure in observation and inpatient settings and demonstrated a significant readmission rate in patients managed in observation.  

Given this patient's presentation with acute on chronic congestive heart failure, hyponatremia and a severely depressed left ventricular ejection fraction, it was appropriate that treatment occurred in an inpatient setting.  Inpatient admission was medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital services is substantiated
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient who presented to the emergency department (ED) complaining of a few days of intermittent chest pain and dyspnea. On the day of presentation, she experienced a rapid heart rate and nausea. Her past medical history was unremarkable. Chest computed tomography (CT) angiography showed no evidence of pulmonary embolism. A chest x-ray was normal. The patient's serum magnesium level was 1.7 milligrams per deciliter (mg/dl). She was treated with intravenous ondansetron and magnesium and was admitted to the hospital. She reported that her chest pain had resolved. An electrocardiogram showed sinus rhythm at 79 beats/minute. An echocardiogram was performed and showed mitral valve prolapse with moderate to severe mitral regurgitation. The left ventricular ejection fraction was normal. She was discharged with plans for outpatient follow-up with a cardiologist. The medical necessity of an inpatient admission is at issue.

This patient presented with chest pain and tachycardia. She was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. There was no evidence of pulmonary embolism or decompensated heart failure. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism (F84.0)
Treatment: Occupational Therapy - 97530 (therapeutic activities) x 6
The insurer denied: Occupational Therapy - 97530 (therapeutic 
activities) x 6
The denial is upheld.

The patient is a school aged male with a history of autism spectrum disorder. The patient has undergone an occupational therapy evaluation. Decreased visual perception skills and motor coordination skills have been reported. The patient's sensory profile has been reported to be abnormal. He has been recommended to undergo occupational therapy twice a week to achieve a variety of goals identified in the report. The patient has been receiving therapies for 3 years at both outpatient settings and with applied behavior analysis (ABA) providers. Following review, the occupational therapy services have been denied coverage by the health plan for the dates of service under review. A letter of appeal has been filed on behalf of this child.

The Occupational Therapy - 97530 (therapeutic activities) x 6 is not medically necessary.

In this case, the patient's medical records do not provide sufficient information for the need of the requested services. Clinical records do not demonstrate or show physician attestation for the requested services. The child is eligible to receive occupational therapy services at school-based settings, and both frequency and duration of suggested occupational services are not congruent with the standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck Pain 

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is a case of a patient who underwent anterior cervical discectomy and fusion (ACDF) at an outside hospital.  The patient was discharged home and returned to the Emergency Department (ED) the following day with worsening neck pain, swelling, fevers, and difficulty swallowing solids and liquids.  A computed tomography (CT) scan showed fluid in the left neck.  Ear, Nose and Throat (ENT) evaluated the patient and there was concern regarding possible complications from surgery including an esophageal tear. The patient was admitted to the hospital and a Gastrografin swallow study was done.  The study did not show an esophageal tear.  The patient was discharged home the next day.

The inpatient admission was considered medically necessary for this patient. The patient was admitted for work up of a possible esophageal tear. This was reasonable given that the patient had worsening and painful neck swelling, fevers, and increased white blood cell (WBC) count.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Esophagitis and Gastritis

Treatment: scope test (EGD) esophagogastroduodenoscopy (procedure code 43239)

The insurer denied coverage for scope test (EGD) esophagogastroduodenoscopy (procedure code 43239)

The denial is upheld 
 

The patient presented with bloating and reflux. The patient developed constipation and bloating after starting Ozempic a few weeks earlier. The patient had been on Pepcid and metoclopramide. There was mild abdominal tenderness. An endoscopy was scheduled. The endoscopy revealed esophagitis and gastritis. The patient was started on omeprazole.

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline 27th edition A-0203 for Upper Gastrointestinal Endoscopy. Gastrointestinal reflux disease is an indication for the procedure if an associated indication is present. Failure of medical therapy is an indication if there is a poor response to empiric twice daily proton pump inhibitor (PPI) treatment for 4-8 weeks. In this case, the patient did not receive a PPI and the Pepcid was listed as only being given for less than a month. Indications to do the endoscopy for dyspepsia include age over 60, dysphagia, failure of medical therapy, a first degree relative with upper gastrointestinal (UGI) cancer, involuntary weight loss, iron deficient anemia, and persistence of symptoms for 3 months or longer. In this case, the bloating and weight loss were attributed to Ozempic and had only been present for a few weeks.

This patient had reflux but did not have an adequate trial of empiric therapy. The patient did not meet MCG criteria for doing the UGI endoscopy. Since the chart did not document an adequate empiric trial of PPI therapy, doing an endoscopy at this time was not medically necessary. The health care plan acted reasonably and with sound medical judgment.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a scope test (EGD) esophagogastroduodenoscopy (procedure code 43239) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Dementia

Treatment: consumer direct personal assistance service - 80 hours per week

The insurer denied coverage for in consumer direct personal assistance service - 80 hours per week

The denial is overturned

This is an elderly patient with chronic medical problems including hypertension, glaucoma and progressive Alzheimer's dementia. The patient lives with their daughter in a private residence.  The insurer approved consumer directed personal assistance services (CDPAS) 63 hours per week and the request is for CDPAS 80 hours per week, leading to an external review.

The Uniform Assessment System (UAS) was reviewed.  The patient's cognition is described as "Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times." The patient reportedly requires extensive to maximal assistance for completing Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient also reportedly requires maximal assistance for bathing, lower body dressing, locomotion, toilet transfer/use and ambulation. Extensive assistance is reportedly needed for personal hygiene, upper body dressing and bed mobility. Limited assistance is reportedly needed for eating. The patient is reportedly frequently incontinent of bladder and occasionally incontinent of bowel. The patient's ability to perform activities of daily living (ADLs) and self-sufficiency have declined and deteriorated, respectively, over the prior 90 days.  There have been no reported falls over the prior 90 days.

Based on the documents submitted for review, the patient's medical condition/functional deficits are substantial, progressive and unpredictable as to require the requested increased CDPAS from 63 to 80 hours/day. The letters from the patient's treating medical providers as well as from the daughter were particularly persuasive.  Again, based on the documented submitted for review, the patient's health and safety are more appropriately provided and maintained at home with the requested increase CDPAS of 80 hours/week.   

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for increase in consumer direct personal assistance service - 80 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This adult male patient was hospitalized for syncope. He presented to the emergency department for evaluation following syncope while at home in the setting of alcohol use and after going to the beach. His past medical history is remarkable for hypertension, hyperlipidemia, and asthma. In the emergency department, the patient's vital signs were stable, and he was alert and oriented. Electrocardiogram (EKG) showed sinus rhythm (SR), a lone premature ventricular contraction (PVC) and no acute changes. The patient was up and about, and the telemetry monitor showed sinus rhythm and no arrhythmias. Serial cardiac enzymes were negative. Chest film and transthoracic echocardiogram were normal. The requested coverage for Inpatient Hospital Admission was denied based on policy, and the patient is appealing the decision.

The requested health service was not medically necessary.

Based on the current standard of care, including the Milliman Care Guidelines (MCG) criteria for syncope, the requested service for inpatient hospital stay was not medically necessary. There was not a medical need for the acute inpatient hospital stay because criteria for inpatient stay are not met. The severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. There was no suspicion of imminently dangerous cause, like pericardial tamponade, pulmonary embolism, or syncope causing injury requiring hospitalization; inpatient admission required rather than observation care because of a significant finding or clinical condition judged too severe or too persistent to be within scope of observation care, such as hemodynamic instability that is severe or persistent, cardiac arrhythmias of immediate concern, acute coronary syndrome or myocardial infarction, structural cardiac disorder like severe aortic stenosis; or suspected as cause that requires immediate correction, respiratory distress, stroke, seizures, altered mental status, severe electrolyte abnormalities requiring inpatient care or other significant finding or clinical condition requiring inpatient hospital care. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient stay. The care the patient received for uncomplicated syncope like in this case is routinely provided safely and effectively at a lower level of care. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Posterior cervical lymphadenopathy.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient is a female who presented to the emergency department (ED) for posterior cervical lymphadenopathy. The review of systems was negative for additional symptoms.
The physical examination was remarkable for posterior cervical lymphadenopathy. Liver function tests (LFTs) were within normal limits.
The patient was admitted for posterior cervical lymphadenopathy and suspected mononucleosis. The patient was seen by ear, nose, and throat (ENT) and it was recommended that she continue antibiotics and symptomatic management. The patient was treated with Unasyn and Toradol. Hyponatremia was thought to be related to a possible Syndrome of Inappropriate Antidiuretic Hormone (Secretion) (SIADH). At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient hospital admission was not medically necessary. The care could have been safely rendered at a lower level of care.
The patient was admitted for posterior cervical lymphadenopathy and suspected mononucleosis. Typically, the treatment of mononucleosis is supportive. The documentation does not support inpatient admission given that the patient was hemodynamically stable, responded to treatment with improvement, and did not have any need for ear, nose, and throat (ENT) surgical intervention. The patient was not at risk for respiratory failure and had no signs of distress.
Infectious mononucleosis is a common, usually self-limited disease. Serious complications during the acute phase of the primary Epstein-Barr virus (EBV) infection are rare. Hospitalization is typically warranted for patients with acute hepatitis and transaminitis, respiratory failure, splenic rupture, or airway compromise. In this case, the patient had normal LFTs and no evidence of respiratory distress.
The patient's hyponatremia improved with intravenous (IV) fluids and oral intake.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Issues. 
Treatment: White Glass with Metal Crown, Teeth 12 and 13. 

The insurer denied White Glass with Metal Crown, Teeth 12 and 13. 

The health plan's determination is upheld. 

The female patient is seeking treatment for teeth number (#)12 and #13. Included for review are letters of appeal and denial, radiographic images, clinical images, and American Dental Association (ADA) claim forms. 

A White Glass with Metal Crown, Teeth #12 and 13, is not medically necessary for this patient. Nothing in the provided documentation supports the necessity of the treatment, neither from the radiographic images nor the clinical image. There is no supporting documentation to show any reason for the failure of the current restorations, recurrent decay, or fracture of the existing restorations.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Uveitis
Treatment: Infectious Agent Detection by Nucleic Acid (DNA or RNA) Herpes Simples Virus, Quantification (87530)
The insurer denied: Infectious Agent Detection by Nucleic Acid 
(DNA or RNA) Herpes Simples Virus, Quantification (87530)
The denial is overturned.

The patient is an adult male for which anterior chamber paracentesis and polymerase chain reaction (PCR) testing for herpes virus is being appealed. The patient presented with elevated intraocular pressure of 45 and 2+ anterior chamber reaction. Visual acuities were 20/30 in the right eye (OD) and 20/20 in the left eye (OS). Intraocular pressures were 17 right eye and 14 left eye. Visual field testing showed superior arcuate defect and inferonasal defect right eye and full left eye. Exam showed pigment endothelial deposition and optic nerve pallor right eye. In a letter, the Provider stated that the patient presented with high eye pressures in the right eye along with inflammation. An anterior chamber paracentesis was performed to harvest the aqueous humor and polymerase chain reaction testing was performed for herpetic viruses, which is a standard of care for the diagnosis of herpes. This test was essential for further diagnosis and management of the patient's condition. In a letter, the Provider noted that the patient presented with features concerning for herpetic uveitis that can be either caused by cytomegalovirus (CMV), herpes simplex virus 1 (HSV1), herpes simplex virus 2 (HSV2), or varicella-zoster virus (VZV). The Provider noted that the features are all are potentially blinding.

The health plan should cover the proposed treatment.

The patient presented with signs of elevated intraocular pressure and intraocular inflammation, which is concerning for herpetic eye disease. The procedure of anterior chamber paracentesis and polymerase chain reaction (PCR) testing was medically indicated for the patient's diagnosis of disease and management of the disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Uveitis
Treatment: Infectious Agent Detection by Nucleic Acid (DNA or RNA) Herpes Simples Virus, Quantification (87530)
The insurer denied: Infectious Agent Detection by Nucleic Acid 
(DNA or RNA) Herpes Simples Virus, Quantification (87530)
The denial is overturned.

The patient is an adult male with the diagnosis of uveitis. A request is made for coverage of polymerase chain reaction (PCR) testing of the aqueous humor - Infectious Agent Detection By Nucleic Acid (deoxyribonucleic acid [DNA] or ribonucleic acid [RNA]) Herpes Simples Virus, Quantification (87530). The prior reason for denial is that the service was considered experimental/investigational. The provider appealed the decision in a note stating that the patient had vision threatening inflammation and high eye pressure, requiring polymerase chain reaction testing to be performed for diagnosing the condition and treating.

The health plan should cover the proposed treatment.

The standard of care for diagnosing uveitis due to herpes simplex virus (HSV) is by obtaining a sample from the area of active inflammation, in this case the aqueous humor, and obtaining polymerase chain reaction (PCR) testing to demonstrate the presence of the virus (2,3). Additionally, the Aetna plan policy #0650, "Polymerase Chain Reaction Testing: Selected Indications" states that testing is medically necessary for "Herpes Simplex virus (HSV), for diagnosis of HSV infection for active lesions or symptoms of active disease." Therefore, the health plan should cover the proposed treatment.