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

Diagnosis:  Abdominal pain
Issue under review:  Inpatient admission

Determination:  The Inpatient admission was not medically necessary.

The patient is an adult female.  She underwent a full, acute hospitalization after a stay at an observation level of care.  The patient had presented with the complaint of intermittent right upper quadrant pain.  The patient had a medical history of hyperlipidemia, pulmonary embolus treated with Xarelto, migraine headaches, open heart surgery, hypertension and pneumonia. 

The patient's physical examination was noted to be normal.  The vital signs were reported as normal with no fever.  The white count, liver enzymes, and cardiac markers were within normal limits.  A urinalysis was normal.  A chest x-ray was normal. An ultrasound showed no cholecystitis and some sludge.  A CT scan of the abdomen and pelvis showed no acute findings.  The patient was seen in consultation by surgery and gastroenterology. 

The patient was admitted due to right upper quadrant pain of unknown etiology.  A HIDA (cholescintigraphy) scan was negative.  An endoscopy was unremarkable.  The patient received supportive care consisting of IV fluids, antacid medication and Tylenol.  The patient was discharged in stable condition.

There was no indication whatsoever for a full acute admission for this patient, as the findings were wholly normal for the evaluations undertaken. 

Despite the patient's presentation the care as provided could have been rendered in its entirety at a lower level of care.  The patient had an infection; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was not medically necessary.

The patient is a female with a past medical history of vertigo who presented to the hospital complaining of dizziness, nausea and right sided chest pain.  Upon arrival, vital signs were stable and physical exam revealed no abnormality.  Electrocardiogram (ECG) revealed no ST or T wave abnormalities. Serial cardiac enzymes were not elevated.  Head computed tomography (CT) was within normal limits and myocardial perfusion testing revealed no evidence of ischemia. The patient was treated with meclizine and released.

This patient presented with atypical chest pain and no significant past medical history.  Her pretest probability of coronary artery disease is low. (Reference 1)  Utilizing the HEART score she was considered low risk (one point). (Reference 2)  Utilizing the TIMI risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain, nausea, vomiting
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a male. His history includes HTN (hypertension) and spine surgery. He presented to the ER after complaining of severe pain and running out of Xanax and oxycodone x 5 days.  The patient was giving an inconsistent history.  He was also complaining of nausea and vomiting.  

The patient was noted to be at moderate risk for suicide.  His VS (vital signs) were as follows:  98.9  76  15  174/116  98%.  His CIWA (clinical institute withdrawal assessment) score was 6.  His exam was unremarkable.  His CBC (complete blood count) and CMP (comprehensive metabolic panel) labs were unremarkable.  His tox screen was positive for benzodiazepine.  His CXR (chest x-ray) revealed NAD (no acute disease).  His EKG (electrocardiogram) revealed NSR (normal sinus rhythm).  

The patient was admitted with drug withdrawal.  Plan included CIWA protocol, IVF, resume benzodiazepine and oxycodone, and psychiatry consult.  Psychiatry consult noted assessment of malingering drug seeking behavior.  The patient was discharged.  

This patient was admitted with drug withdrawal.  Evaluation showed the patient to be hemodynamically stable and afebrile.  There were no signs of severe withdrawal.  The patient did not have tachycardia, vomiting, perspiration, arrhythmia, or other signs of withdrawal that require inpatient treatment.  The patient had not failed a lesser level of care.  

Medically necessary services are those which are:
 safe 
 effective
 generally accepted national standard of medical practice 
 not provided primarily for convenience of the patient or the practitioner 
 the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The requested Inpatient admission was not medically necessary, because it was not in accordance with generally accepted national standard of medical practice for this patient's presentation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Misaligned tooth
Issue under review:  Braces and monthly visits

Determination:  The Braces and monthly visits are medically necessary.

The patient is a young female. 

The patient's upper left canine (tooth #11) is totally out of position.  It is buccal to tooth #12 (i.e. it is in front of tooth #12, towards the cheek).  The upper canines are very critical teeth, as when they are in their proper position they help guide the chewing motion of the lower jaw.  Without this tooth in its proper position, there will be a higher incidence of teeth not meshing properly, causing trauma to other teeth, during chewing.  Also, with this tooth so far out of position, there will be a higher chance of decay and/or gum disease, as it will be very difficult to keep clean.  The need for orthodontic treatment to correct this malocclusion is medically necessary.  Also the monthly visits are medically necessary to monitor the orthodontic progress.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever, Chest pain, cough
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The patient is a male whose inpatient admission is under review. The patient has a history of anxiety and presented with three days of cough, fever, dizziness, and myalgias. Temperature was to 104 at home. He had a non-productive cough, worse at night. He had a two pack year smoking history.

Examination revealed:
Temperature (T) - 100.6   
Pulse (P) - 123   
Blood pressure (BP) - 98/67    
Respiratory rate (RR) - 17 
Oxygen saturation (O2 sat) - 94%
General - no acute distress (NAD)
Head ears eyes nose throat (HEENT) - bilateral icterus
Chest - bilateral wheezing, left lower lobe (LLL) rales
Cardiovascular system (CVS) - tachycardia
Abdomen - normal

Laboratory assessment revealed:
White blood cell (WBC) - 21.6 (high)
Hemoglobin (Hg) - 12.6 (low)
Hematocrit (HCT) - 39.8 (low)
Platelets (PLT) - 197
Sodium (Na) - 137
Potassium (K) - 4.1
Chloride (Cl) - 101
Carbon dioxide (CO2) - 26
Blood urea nitrogen (BUN) - 14
Creatinine (Cr) - 1.18
Total (T) Bili - 1.6 (high)
Human immunodeficiency virus (HIV) - negative
Influenza - negative

The patient's chest x-ray (CXR) revealed hazy confluent airspace LLL consistent with pneumonia.

The patient was thought to have a community acquired pneumonia, and was treated with intravenous (IV) ceftriaxone and oral (PO) azithromycin. The patient improved after a few days and was sent home on PO cefpodoxime.

Although the patient was low risk according the Infectious Diseases Society of American (IDSA) guidelines at the time (1), the same guidelines state that, "Reasons for the admission of low-mortality-risk patients fall into 4 categories: (1) complications of the pneumonia itself, (2) exacerbation of underlying diseases(s), (3) inability to reliably take oral medications or receive outpatient care, and/or (4) multiple risk factors falling just above or below thresholds for the score." This patient, in addition to pneumonia had likely exacerbation of a chronic obstructive disease (wheezing on exam), and potential exacerbation of a liver disease (icterus). Thus, this admission was warranted, supported by standard of care and IDSA guidelines. Failure to admit such as a patient can lead to loss of function, respiratory failure, or death.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a male with a past medical history of right internal capsule stroke with resultant left hemiparesis. An external appeal for a MyoPro2 Myoelectric Upper Extremity Orthotic Device has been requested. The request was denied on the basis of insufficient data supporting the use of the myoelectric orthotic. The request was denied as being investigational or experimental for all uses. He indicates that the submitted documentation supports the use of this orthotic device. The goal is restoration of function. The updated myopro his neck sternly powered elbow, wrist and finger orthotic has replaced the prior e 100.

The health plan's determination is upheld. The MyoPro2 Myoelectric Upper Extremity Orthotic Device is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The available medical research is of insufficient quality to make a determination of the benefit of the proposed treatment in patients with upper motor neuron cerebrovascular accidents and hemiplegia.
The proposed treatment is neither the standard of care nor convincingly been shown to be superior to standard treatment for patients with cerebrovascular accident (CVA) and left hemiplegia. The assertions made by the requesting provider have not been convincingly demonstrated in the available medical literature. There is insufficient high-quality evidence to support a decrease in overuse syndromes in the uninvolved extremities, improved long-term function of the involved treated extremity and whether long-term use of the myoelectric orthotic improves any of the long-term health.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a male who suffered a right internal capsule stroke resulting in left sided hemiparesis. His left arm has remained non-functional despite static bracing. The provider stated that the patient was unable to bear weight throughout his arm with 1-2/5 strength. Under review is the MyoPro2 Myoelectric Upper Extremity Orthotic Device.

The health plan's determination is upheld. The MyoPro2 Myoelectric Upper Extremity Orthotic Device is not likely to be more beneficial than and standard treatment or treatments. While a myoelectric elbow-wrist-hand-orthosis may be beneficial for people suffering from severe weakness resulting from a neurological injury the research is still in an investigational stage. For example, the provider referenced "Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature" but upon review of this article it concluded that "We found that when the duration/intensity of conventional therapy (CT) is matched with that of the robot-assisted therapy (RT), no difference exists between the intensive CT and RT groups in terms of motor recovery, activities of daily living, strength, and motor control" and while "extra sessions of RT in addition to regular CT are more beneficial than regular CT alone in motor recovery of the hemiparetic shoulder and elbow of patients with stroke; gains are similar to those that have been observed in intensive CT."
Also larger studies, such as the one discussed in "Three-dimensional, task-specific robot therapy of the arm after stroke: a multicentre, parallel-group randomised trial" was from Switzerland. Also, while "Giving Them a Hand: Wearing a Myoelectric Elbow-Wrist-Hand Orthosis Reduces Upper Extremity Impairment in Chronic Stroke" did show that use of such device resulted in "increased gross manual dexterity and performance of certain functional tasks" the number of participants was 18.
Appeal type: Experimental/Investigational
Decision: Upheld

Central Nervous System/Neuromuscular Disorder
Durable Medical Equipment (DME) (including Wearable Defibrillators)

The patient is a man who suffered a right internal capsule stroke. Since that time, he has had left sided hemi-paresis with left upper limb strength noted to be 1-2/5 throughout all major muscle groups. For this reason, he has no functional ability throughout the left upper limb and remains non-independent with activities of daily living (ADL) / Instrumental activities of daily living (IADL). He has completed a course of both inpatient and outpatient rehabilitation without notable improvement in left upper limb function. Under review is a myoelectric left upper limb prosthetic device to help maximize his function.

The health plan's determination is overturned. The MyoPro2 Myoelectric Upper Extremity Orthotic Device is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has already completed the standard treatment for his physical impairment and unfortunately did not show significant functional improvement. Myoelectric prosthetic devices are rapidly becoming standard of care for individuals with an upper motor neuron lesion/impairment as may arise from a traumatic brain injury and or stroke. There is robust scientific evidence in the form of randomized controlled trials that support their clinical use within these populations. These devices certainly hold promise for individuals who have not seen functional gains with traditional rehabilitation approaches (i.e. Bobath, constraint induced movement therapy, neurodevelopmental therapy, etc).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal 
Treatment: Inpatient Hospital 

This is a patient with no significant medical history, and a surgical history of an abdominoplasty. She presented to the emergency department with three days of left lower quadrant abdominal pain, a low-grade fever, and mild diarrhea. Lab results showed leukocytosis with an elevated white blood cell count of 13.2 thousand per cubic milliliter (K/uL). A computed tomography scan of the abdomen and pelvis showed acute diverticulosis of the sigmoid colon, diverticulosis of the left descending colon, small gallstones, mild thickening of the gallbladder, hepatic steatosis, and a linear calcific density in the right hepatic lobe. She was treated with intravenous fluids, Ciprofloxacin, Metronidazole, and Toradol. She had persistent mild abdominal discomfort. Labs showed a normal white blood cell count. A gastroenterology consultation concluded that she had diverticulitis, and recommended a clear liquid diet, intravenous fluids, and continued intravenous antibiotics. An infectious disease consultation recommended Zosyn, and discontinuation of Ciprofloxacin and Metronidazole. A pain medicine consultation recommended oral Tylenol for pain. The patient had controlled abdominal pain, and a physical examination noted a nontender abdomen; she was advanced to a soft diet. Lab results showed a normal white blood cell count. A cardiology consultation did not recommend any further cardiac workup. She had improved abdominal pain and was tolerating a diet. Lab results showed a normal white blood cell count. She had changed to oral antibiotics. The patient was discharged home with Ciprofloxacin and Metronidazole and a plan for primary care follow-up. 

The health plan's determination is upheld. The patient improved on intravenous antibiotics (by two days after admission, she had improvement in symptoms) and was discharged on oral antibiotics. No other cause for the inpatient level of care, such as peritonitis, toxic megacolon, bowel obstruction, or sepsis was found. In this case of diverticulitis without a peritonitis, abscess, fistula, sepsis, or other complication, the inpatient level of care was not supported as medically necessary. 

In patients with uncomplicated diverticulitis (without complications such as abscess or perforation), outpatient management or observation can be appropriate [1]. The safety and efficacy of outpatient management of acute uncomplicated diverticulitis has been demonstrated [2]. A prospective randomized trial demonstrated that patients can be given intravenous antibiotics in the Emergency Department and then be discharged with oral antibiotics [3]. A systematic review of the literature underscored this [4]. However, there was no protracted fever or hypotension to suggest that antibiotics were ineffective. There had been no evidence of abscess on imaging [6,7].
Appeal type: Medical necessity
Decision: Upheld

The patient is a male who was diagnosed with prostate cancer and received androgen deprivation therapy consisting of Lupron and Xtandi. A bone density was recommended but no report is available. Calcifediol (25-Oh Vitamin D-3) testing was ordered. The subject under review is the medical necessity for the testing.

The health plan's determination is upheld.

The requested health service of calcifediol (25-Oh Vitamin D-3) testing is not medically necessary for this patient.
There are few data regarding screening for vitamin D deficiency in asymptomatic adults. Most experts agree that it is not necessary to perform broad-based screening of serum 25 (OH) D level in the general population. Normal risk adults do not need assessment. In individuals who are in high risk groups, however, such as older persons confined indoors, individuals that are dark skinned, obese, or taking certain medications that accelerate metabolism of vitamin D, hospitalized on a general medical service or institutionalized, limited sun exposure, osteoporosis, or with malabsorption syndromes, it is appropriate to measure such levels. The patient does not meet high risk criteria testing of vitamin D levels.  He has no evidence of osteoporosis.  There is no data to support vitamin D testing to ensure appropriate vitamin D supplementation to lower the risk of osteoporosis in patients receiving androgen suppression therapy. Lupron can be associated with low bone mass in less than (<) 1% of patients in post marketing and/or case reports. 
There is no documentation of any of these high risk characteristics in this patient and, therefore, measurement of the assay is not the standard of care and is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Family history of cancer
Issue under review: Genetic testing

Determination:
The Genetic testing was not medically necessary.

The patient is an adult female with no personal history of cancer. She has a maternal aunt with ovarian cancer, several cousins with thyroid/melanoma/cervical cancer and a paternal aunt with endometrial cancer.  

The patient's attending physician performed genetic testing. Her cousins have undergone testing and all reportedly tested negative.  

This patient's family has already undergone genetic testing and reportedly tested negative. There would be no role for further testing at this time, especially as this patient has no personal history of cancer.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Left shoulder labral repair and neck pain
Treatment:  97140 (manual therapy) x 3 (1 unit for each service date)

The 97140 x 3 - Manual therapy was not medically necessary.

The patient is a male.  The patient has a history of left shoulder labral repair and neck pain.  He returned to physical therapy for a re-evaluation with left-sided neck pain, having received lidocaine injections into the upper back.  He had neck pain and stiffness during the day and when turning his head.  Range of motion at the neck was reduced.  This was therapy visit #9.  He received therapy for three dates of service.

As of visit #13, the patient was reporting decreased, but not resolved, symptoms.  He performed exercises and received manual therapy.  Therapy continued.  Therapy sessions were providing temporary relief, with symptom return afterwards.

There is generally a dearth of high-quality data informing the management of neck pain.  Muscle relaxants and NSAIDs (nonsteroidal antiinflammatory drugs) are generally considered effective for acute neck pain.  For chronic neck pain, practice is generally guided by the treatment of other general chronic, benign musculoskeletal pain conditions, where the focus of treatment revolves around patient education, self-care, various analgesics, independent exercise and remaining active.  The benefit of formal therapy services, including manual therapy, beyond education and training with an aim for self-management is not established in the medical literature.  There is no proven marginal benefit of passive modalities such as massage/manual therapy provided in a formal setting on pain, health or functional outcomes over self-massage (e.g., using foam rollers, massage balls, etc.) and topical treatments such as ice or heat applied independently.  

Although the patient had persistent symptoms, there was no reasonable expectation that the services in question would have produced a marginally significant improvement in the patient's clinical course or outcomes over an independent exercise and soft-tissue management program.  There are no objective indications, moreover, that the manual therapy that the patient received provided any clinically significant benefit.  The manual therapy services in question were not medically necessary.