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

This is a patient who presented to the emergency department (ED) with acute onset abdominal pain, nausea and vomiting (2-days duration).  The past medical history was significant for morbid obesity.  The heart rate at the time of presentation was elevated at 107 beats/minute.  The abdomen was tender and distended.  The white blood cell count (WBC) count was elevated at 13.6 thousand (K).  The patient was evaluated with a computed tomography (CT) scan of the abdomen and pelvis that showed dilated and edematous bowel and mesentery.  The health plan's determination of medical necessity is overturned in whole.
The submitted records support that this patient presented with an acute onset of abdominal pain, nausea and vomiting.  She had a leukocytosis of 13.6 K and pathology identified on a CT scan that indicated possible bowel obstruction.  She was monitored with daily examination and follow up lab assessment.  She underwent a colonoscopy on 12/6/18.  Her condition did gradually improve over 72 hours.  On 12/7/18 she reported less pain and there was improvement with regard to the abdominal pain.  Inpatient admission for the condition of intestinal obstruction was consistent with medical standards, as the period of inpatient confinement was anticipated to last more than 2-days.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Cholecystitis
Treatment: Inpatient Hospital Services

Summary: This patient was seen in the Emergency Department (ED) for complaints of chest pain and epigastric pain.  The patient had no past medical history.  She endorsed a couple episodes of vomiting on the previous day. She described the pain as going from the front to the back.  The patient had temperature of 98.1 with a heart rate of 48, blood pressure 166/65, respirations 20 and oxygen saturation 100%.  On examination, there was mild epigastric pain with a negative Murphy sign.  The patient had a white blood cell count of 15.3, platelets 286, hematocrit 44.7, sodium 138, chloride 100, blood urea nitrogen (BUN) 13, glucose 108, potassium 4.5, Bicarbonate (HCO3) 27 and creatinine 0.74.  An ultrasound revealed distended gallbladder with gallstones and mild gallbladder wall thickening.  The patient was admitted due to acute cholecystitis. She was to be given intravenous (IV) antibiotics and scheduled for a cholecystectomy.  The patient was given the option for elective cholecystectomy in six weeks versus urgent cholecystectomy. She elected the urgent cholecystectomy.  The patient then underwent a laparoscopic cholecystectomy.  She tolerated the procedure well and was taken to recovery in a stable condition.  The patient was then discharged home.

The insurer denied coverage for the inpatient hospital admission. The denial was upheld. 

The medical literature indicates that a cholecystectomy is an ambulatory procedure.  An extended stay may be indicated for patients who failed to achieve discharge status criteria or who have findings of systemic infection.  Extended Stay may also be indicated for patients who have to require care for active co-morbidities or complications from the procedure.  The documentation indicated that the patient underwent a cholecystectomy and following the procedure, she was stable.  There was no evidence that the patient had findings of a systemic infection or that the patient required care for active comorbidities.  There was also no indication that she had complications following the procedure to support the need for an extended stay.  Therefore, the prior determination is upheld.
Appeal type: Medical necessity
Decision: Upheld

No, the inpatient admission was not "medically necessary".

This patient presented with chest pain and T wave changes on ECG.  Cardiac enzymes were not elevated and the patient was had no cardiac abnormalities or hemodynamic instability on physical exam.  His HEART score was three, conferring a low short term risk of major adverse cardiac events.  (Reference 1,2).  The patient did not have an acute coronary syndrome.  ECG, laboratory testing and physical examination confirmed this.  Risk assessment of patients presenting with chest pain and no significant ST changes on ECG as well as negative cardiac enzymes was performed by Sanchis et al. (Reference 3).  Using their risk stratification schema, this patient would have a low risk of future myocardial infarction or death within one year.  This patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

This patient underwent anterior cervical discectomy and arthroplasty at Cervical (C) discs 6-7 in 2018.  The patient had sustained injuries to his neck and lower back in 2017 when he slipped and fell on ice.  He was subsequently found to have a C6-7 disc herniation causing moderate left foraminal nerve impingement and compression.  The patient tried conservative treatment to include physical therapy and cervical steroid injections.  The magnetic resonance imaging scan demonstrated a disc herniation to the left at C6-7. Anterior cervical arthroplasty at C6-7 was planned.

The insurer denied coverage for the cervical disc arthroplasty done in 2018. The denial was reversed.

According to Milliman Care Guidelines, cervical disc arthroplasty may be indicated in patients over 18 years of age with cervical degenerative disc disease between C3 and C7 when the placement of one artificial disc is planned and there are symptoms corresponding to the level at which disc degeneration has been identified as indicated by cervical radiculopathy and/or cervical spondylotic myelopathy.  There also needs to be failure of a 3-month trial of non-operative treatment and no cervical instability, anatomic deformity or malignancy, osteoporosis, previous cervical surgery at the affected level, or infection. The submitted documentation supports that the patient had cervical degenerative disc disease at C6-7 and placement of one artificial disc was planned.  The patient had symptoms that corresponded with C6-7 to include radicular pain and paresthesias along the left arm into the fingers.  The patient failed non-operative treatment for greater than 3 months and there was no evidence of instability, deformity, malignancy, osteoporosis, prior surgery at the planned level, or infection. Therefore, the patient met criteria for surgery.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with history of painful varicosities of his right lower extremity. The pain was refractory to compression stockings and leg elevation for six months. His weight was 273 pounds. The body mass index was 39.17. There was no hemorrhage, ulceration, or recurrent severe phlebitis. The medical necessity of endovascular ablation of the right greater saphenous vein is under review. The health plan's determination is upheld, in whole. Ablation of the right great saphenous vein is not medically necessary, as it is not established as a standard of care. Ablation of lower extremity veins for the treatment of varicosities includes exercise, weight loss (importantly), leg elevation, and compression stockings. For more severe cases where there is for example, hemorrhage, severe thrombophlebitis, or ulceration, venous ablation has been utilized for treatment. However, venous ablation for varicose veins, compared to the after mentioned conservative therapy, has not been definitively demonstrated to improve long-term varicosities outcomes or recurrences. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history  of  familial Mediterranean fever, nephrolithiasis, peptic ulcer disease, and chronic back pain . The patient presented to the hospital with complaints of back pain .The patient complained of increased urinary frequency and dysuria similar to the previous episode of renal colic. The patient denied fever, chills, nausea, vomiting, diarrhea, or muscle weakness. The patient was admitted to the hospital and treated with Tramadol,and a Lidocaine patch. The patient was evaluated by neurosurgery and was not recommended any procedure or surgery that would require an inpatient hospital stay.  The health plans determination of medical necessity is upheld in whole.The admission at an acute inpatient level of care was not medically necessary . An admission at a lower level of care to ensure clinical stability was appropriate.The patient had no progressive neurologic deficit or cauda equine syndrome, loss of bladder or bowel control, or any other signs of cord compression. There was no evidence that the patient required frequent administration of parenteral analgesics (every 2-4 hours).
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of methicillin-resistant staphylococcus aureus (MRSA) who presented to the emergency department (ED) with a 2 day history of right knee pain, swelling, redness, and limp. Symptoms began 4 days prior to arrival with a small pimple on the right knee, and progressed with time. 

The health plan's determination is overturned. The inpatient stay was medically necessary. Given the concern for septic joint with overlying cellulitis of the right knee and personal history of MRSA, this patient required IV antibiotics as initial treatment and close monitoring only available in an inpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Difficulty breathing and lower extremity edema
Treatment: Inpatient hospital admission
The proposed treatment, inpatient admission, was medically necessary.
The patient presented with an acute exacerbation of CHF, with recurrent atrial fibrillation with rapid ventricular response (RVR), signs of end-organ hypoperfusion - elevated lactate level. Also his WBC count was severely elevated, raising a suspicion of an acute infectious or inflammatory process. Given the presentation, uncontrolled atrial fibrillation, as well as acute CHF exacerbation, and possible infectious process, he would not be an appropriate candidate for an ED observation unit, and 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: Overturned

The patient presented to the hospital with complaints of dyspnea that had been going on for nearly 3 days prior to being seen in the patient's PCP's (primary care provider's) office. The provider noted that the patient had developed a rash on the patient's face/trunk etc...that was not present a day prior to admission. The patient also noted new onset swelling in the patient's lower extremities.

The health plan's determination is overturned. The inpatient stay was medically necessary for this patient. This patient was admitted with acute onset rash as well as progressive dyspnea. The patient was admitted with a drug reaction rash that required a cream to help correct. The patient also presented with dyspnea that initially required non-invasive ventilation. While the Noninvasive ventilation was able to be weaned, the patient was still having significant dyspnea. The inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with hypertension, coronary artery disease, previous myocardial infarction, coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) procedures, and diabetes.  He also has ischemic cardiomyopathy, chronic systolic heart failure with an ejection fraction (EF) of 15-20%, ventricular tachycardia (VT), and previous biventricular implantable cardioverter defibrillator (ICD) placement in 2011.  He was admitted for ICD generator replacement, as the device was at elective replacement time.  The device was beeping, and he was sent from his physician's office to the ER to be admitted for device replacement.  BP was 141/79 millimeters of mercury (mmHg), pulse 68 beats per minute (bpm), and respirations 18 in the emergency room (ER).

The health plan's determination is upheld.

Inpatient admission is not medically necessary in this case.  The patient had an uncomplicated ICD generator replacement.  He was hemodynamically stable on presentation to the ER - sent from an outpatient office appointment when the device was noted to be at elective replacement indicator.  There were no immediate surgical complications.  He did have a hematoma at the incision site, but this did not require inpatient management.  He remained stable and did not require re-operation or transfusion.  The patient does have multiple comorbidities, as noted above, but none of these conditions were unstable or requiring acute treatment.

Per Milliman Guidelines, the usual length of stay for electrophysiologic (EP) study and ICD implant is ambulatory to one day post-operative.  In this case, the procedure is simpler than a new ICD implant, as leads were not replaced, only the generator.

Therefore, the patient could have been managed at a lower level of care status, inpatient was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cl I Molar; Class II Molar Left; Canine Class I, Canine Class II left; Moderate arch crowding; Moderately convex profile
Issue under review: Braces and monthly visits

Determination:
The braces and monthly visits are not medically necessary.

The patient does not have a handicapping malocclusion. She also only scored 19 on the Salzmann test, which is below the cutoff of 26 needed.
Appeal type: Medical necessity
Decision: Upheld

This patient who presented to the dentist's office for evaluation and treatment of tooth number (#3).  From the documentation provided, there is currently not evidence of decay nor fracture of the tooth.  There are no photographs showing craze lines nor fracture lines that exist. 

The requested health service/treatment of high gold content crown, tooth 3 is not medically necessary for this patient. As there is not definitive evidence that the tooth requires a crown due to decay, and as a tooth fracture is not supported, no therapy is indicated at this time.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Substance abuse, Major Depressive Disorder, Bipolar Disorder, and Borderline Personality Disorder
Treatment: Inpatient Residential Substance Use Treatment

Summary: This patient was admitted to inpatient substance residential treatment after a psychiatric hospital stay for mania as she had multiple reported relapses with multiple serious substances of use including benzodiazepines, cocaine, opiates, cannabis, and ecstasy. She had multiple inpatient detoxification and residential rehabilitation treatments and Partial Hospitalization Programs (PHP) with continued relapses. She also had manic and depressive symptoms reported. She had past withdrawal seizures and possible Delirium Tremens (DT's). She was taking psychotropic medications, was attending group and individual therapy, and had Dialectical Behavioral Therapy and Cognitive Behavioral Therapy.
 
The insurer denied coverage for the inpatient residential substance use treatment as not medically necessary. The denial was reversed. 

In this case this patient was considered in need of 24 hour residential treatment as she had continued multiple serious substances of use putting her at risk for accidental overdose, and she continued to relapse and could not maintain abstinence despite multiple past inpatient substance detoxification treatments and inpatient substance residential treatments as well as past PHP treatment. She had recent serious stressors including losing custody of her child and her husband trying to serve her divorce papers, and she continued to use substances despite these negative consequences and despite past serious withdrawal symptoms in the past including withdrawal seizures and possible DT's. She also had comorbid serious psychiatric symptoms including depressive and manic symptoms and past aggression as it was reported that she was removed from a past PHP due to aggression. She reportedly continued to use despite negative consequences, had difficulty coping and identifying triggers to use, and had limited supports. This patient needed to be in this 24 hour therapeutic residential treatment setting, to give her the best opportunity to stop using the multiple substances and maintain abstinence, work on increasing awareness and insight into use, build trust, learn better coping skills and relapse prevention skills, make healthier choices, better identify relapse triggers, and she still reportedly had urges to leave treatment and had obsessive thoughts but used the skills that she learned in this 24 hour therapeutic residential treatment setting to remain and work on these goals. She was a high risk for suicide, overdose, and decompensation with the likelihood of requiring an even more intense level of treatment if not in this setting for a lengthy period of time as she had multiple treatment failures after briefer stays in 24 hour residential treatment which was evidence that she required more time in this setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Degenerative hip disease with past medical history was significant for hypertension, depression and coronary artery disease

Treatment: Total hip replacement

The insurer denied the inpatient admission. The denial was reversed

This patient was admitted to the hospital for an elective total hip arthroplasty.  He underwent a total hip replacement (THR).  His post-surgical course was non-complicated.  He was discharged to home with arrangements made for him to go to a residential treatment center. 

Total hip arthroplasty can be complex and extensive.  His physician reported 200cc blood loss.  He required a Foley catheter.  The post-surgical visits report Foley to be removed but urinary output should be monitored.  His hematocrit had decreased which would be expected.  Additional laboratory testing demonstrated stabilization of hemoglobin (HB).  This type of operation requires hospitalization until all goals for discharge are met. 

It is not an ambulatory type procedure and requires the post-surgical monitoring as provided. These services cannot appropriately be obtained as an outpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Melanoma of the right helix  

Treatment:84999 DecisionDx-Melanoma 07/02/2018

Summary:
In summary, there is insufficient evidence to evaluate the clinical validity and clinical utility of the DecisionDx-Melanoma test. Additional study is required to further validate if gene expression profiling of cutaneous melanoma will accurately identify which individuals are likely to have aggressive disease, and how the results of testing would alter treatment plans and improve health outcomes in the surveillance, and treatment of high-risk cutaneous melanoma.
Appeal type: Medical necessity
Decision: Overturned

Other
Prescription medication

This is a patient with ankylosing hyperostosis (Forestier), site unspecified spondylopathy, unspecified vs. inflammatory disease. The patient also has gout. The patient has tried and failed Motrin, ibuprofen, Aleve, naproxen and Enbrel. Patient has also tried physical therapy (PT) and does stretching exercises. Per chart review patient is human leukocyte antigen B27 and inflammatory markers are normal, new findings of (sacroiliac)si joint (jt) ankylosis/sacroiliitis. The health plan's determination of medical necessity is overturned in whole. The patient has tried and failed conservative treatment with Motrin, ibuprofen, Aleve, naproxen and PT. The patient has even tried Enbrel. The provider believes there may be an inflammatory component to the back pain, which is why the provider tried Enbrel and is now requesting Cosentyx. Per chart review, the patient has sacroiliitis in which case a trial of Cosentyx is a reasonable next step in the treatment of this patient. According to the literature, in patients with AS who often have sacroiliitis, "secukinumab at a subcutaneous dose of 150 mg, with either subcutaneous or intravenous loading, provided significant reductions in the signs and symptoms of ankylosing spondylitis at week 16" (3).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle cell disease
Treatment: Inpatient admission
The proposed inpatient admission was medically necessary.
The patient is a girl with medical history significant for sickle cell disease, hepatomegaly, jaundice, umbilical hernia status post repair, and cholecystectomy status post repair who presented to the emergency department (ED) with four-day history of intermittent generalized pain, including difficulty breathing during pain episodes.  She rated the pain ten out of ten (10/10) despite treatment with ibuprofen, Tramadol, and gabapentin.  Laboratory evaluation was significant for anemia with hemoglobin 7.9.  She experienced some desaturations, so chest x-ray and supplemental oxygen were ordered.  The chest x-ray revealed very low lung volumes and no obvious consolidation.  Repeat chest x-ray was obtained for concern of a retrocardiac infiltrate, and the repeat chest x-ray was normal.  She was treated with fluids, Toradol, Cymbalta, parenteral Tylenol, and one dose of oxycodone.  The pain persisted, so she was given a second dose of oxycodone. 
At the time of hematology evaluation, the patient reported that she was still in pain and was not able to get up to use the bathroom.  The hematologist recommended hospitalization for further pain management and did not recommend transfusion.   Admission orders included parenteral Tylenol, ibuprofen, and gabapentin round-the-clock, oxycodone as needed, regular diet, intravenous (IV) fluids, continuation of home medications, and Miralax for constipation.  Pain Management was consulted because of the diffuse and extreme nature of her pain.  They recommended continuation of parenteral Tylenol for 24 hours then transition to enteral Tylenol, parenteral ibuprofen for three days then transition to enteral ibuprofen, round-the-clock gabapentin, and oxycodone immediate release (IR) as needed every four hours. 
Psychiatry was consulted for anxiety.  Neurology was consulted because of gasping episodes with concern for seizure.  Throughout the admission, the patient continued to complain of pain in various locations.  She was having difficulty walking, so Physical Therapy was consulted for treatment.  She was eventually able to walk with a walker.  She was transfused for hemoglobin 6.4.  She had no further pain crisis episodes and remained stable overnight.  The patient was discharged the following day on her home medications and a methadone taper. 
This patient was admitted for pain crisis.  She was treated aggressively and monitored for a long time in the ED without significant improvement.  It took the full duration of her hospital stay incorporating recommendations from multiple consultants until she was appropriate for discharge.  She could not have been managed at a lower level of care.