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

Diagnosis: left atrial appendage, past medical history of hypertension, hyperlipidemia, anemia, prostate cancer status post radiation one year ago, right internal carotid stenosis (30-50%), moderate-severe aortic stenosis, history of gastrointestinal (G.I.) bleed and persistent atrial fibrillation

Treatment: Inpatient admission for a Watchman device

The insurer denied hospital services. The denial was upheld.

The patient presented for closure of left atrial appendage with a Watchman device.  According to the medical record, aggressive aortic stenosis associated with angio-dysplasia could have been the cause of his G.I. bleed.  His family denied any active bleeding or recent dark stools.  The patient denied chest pain, shortness of breath, dizziness or palpitations.  Due to the patient's history of G.I. bleed and atrial fibrillation, the patient was scheduled for a Watchman device placement.  On physical exam, he was described as being in no acute distress and there was decreased hearing bilaterally with the right being worse than the left.  Cardiac exam revealed an irregular grade 3 systolic ejection murmur at the left upper sternal border.  Both bilateral lower pulses were decreased to one plus and there was one plus pitting edema bilaterally.  

This patient was admitted to the hospital for an elective procedure, which was insertion of a Watchman device, which is used in patients with atrial fibrillation for stroke prevention when the patient cannot safely take full doses of anticoagulation.  This patient had evidence of gastrointestinal (G.I.) bleeding and was an appropriate candidate for this procedure.  It is now common practice to discharge patients on the same day following this type of procedure.  This patient was asymptomatic at the time of admission, had no complications during insertion of the device, and no evidence of complications following the procedure.  The patient could have been observed and as there were no complications noted, there was no need for acute inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient stay

Summary:
This child presented with several day history of abdominal pain and decreased appetite, without vomiting. She had low-grade fever in the urgent care. This constellation of symptoms prompted concern for acute appendicitis, and she was referred to the ED for further evaluation. The initial reading of the CT scan reported that the appendix was not visualized and there was possibility of acute appendicitis. She was admitted for monitoring and recurrent examinations. The surgeon subsequently evaluated the CT scan and noted both a normal appendix with non-occluding appendicolith, as well as significant mesenteric adenitis. She was observed, with improvement in her symptoms. While it was not unreasonable to monitor with serial exams, she was overall hemodynamically stable with no evidence of acute abdomen or sepsis. She did not require acute inpatient management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal cramping in the setting of pregnancy

Treatment:  Inpatient admission, Diagnostic evaluation and monitoring.

The insurer denied inpatient admission. That denial was upheld.

The patient presented at 23.4 weeks gestation with complaints of severe intermittent abdominal cramping and back pain.  She was status post rescue cerclage placement.  The patient was admitted to antepartum for pain control and observation.  Labs were normal, and the cerclage was in place, not on tension.  She received 2 doses of Celestone, and was medically cleared for discharge. 

This patient was complaining of abdominal pain.  She had a prior cerclage placed.  There was no evidence of cervical dilation and the cerclage was not under any tension.  In other words there was no evidence of cervical changes.

Preterm labor is an indication for admission and tocolysis.  Preterm labor is defined as uterine contractions with cervical changes.  Did this patient have preterm labor? During this admission, there was no documentation of any cervical changes.  So, the patient was not in preterm labor.  There was no bleeding, and vital signs were stable.  Fetal heart rate was reassuring.  There was no evidence of ruptured membranes.  The management that this patient received during her admission could have been easily done in a less acute setting.  Once the provider ascertained that there was no evidence of preterm labor, (no change in cervical status after few hours of observation) the patient could have been sent home after being hydrated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: New onset Diabetes, diabetic ketoacidosis

Treatment: Inpatient admission, diagnostic testing, blood sugar monitoring and patient/family teaching

The insurer denied inpatient admission. That denial was reversed.

The patient was referred to the ER from an urgent care center due to elevated blood sugar (blood glucose was over 700). She had reported polyuria and polydipsia for over 5 days. In the ER her blood glucose level was 327. The patient was admitted with new onset diabetes. She was continued on IV fluids and started on Lantus 4 units at night and Humalog sliding scale. Pediatric endocrinology consulted. The patient and parents received diabetic education. She was discharged home. 

Diabetes education consists of several components, nutritional counseling, self-monitoring of blood glucose and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components. [1-4] 

In type 1 diabetes, the initial hospitalization is to educate the patient and the family in self injection, drawing up and mixing of insulins, checking blood sugar, recognizing and responding to hyper and hypoglycemia, and evaluating ketosis, as well as nutrition education on carbohydrate counting because there is only one treatment option (insulin). Learning these skills is an overwhelming task for most patients and families and is the reason that this is done with a 2-3 day admission to the hospital. 

Additionally, a patient with polyuria, polydipsia, ketosis, and a glucose of 727 ought to receive rehydration and insulin therapy to achieve the fastest and best control of her diabetes in addition to the diabetes education component. 

The level of care was consistent with generally accepted standards of medical practice. The entire admission is medically necessary as the family required this duration to learn all the skills necessary to take the child home and administer the appropriate amount of insulin.
Appeal type: Medical necessity
Decision: Upheld

This patient received inpatient rehabilitation level of care for the use of heroin, alcohol, and cocaine. The patient had initially been admitted to treatment 6 days earlier for detoxification. Initial urine drug screen at that time was positive for opiates, cocaine, and alcohol. Additionally, the patient was stated to have unspecified bipolar disorder. He was taking psychiatric medications including Seroquel, Trileptal, Bupropion, and Vistaril, and melatonin. The health plan's determination of medical necessity is upheld. The patient was not experiencing significant withdrawal symptoms during the dates of service in question. Clinical documentation does not establish that he was experiencing urges or cravings to use. The patient did not have serious medical or psychiatric symptoms that required inpatient rehabilitation. There was no clear risk of using drugs and hazardous situations if this level of care was discontinued. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) tool, the patient does not meet criteria for continuing in this level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Back pain
Treatment:  Inpatient admission
The proposed treatment, inpatient admission, is not deemed medically necessary. 

This is a male patient with a past medical history pertinent for hypertension, heart failure and COPD who presented to the ER for further evaluation/management of low back s/p mechanical trip and fall injury.  Intake vitals were afebrile, hemodynamically stable with no evidence of profound tachycardia, hypotension or hypoxemia.  Examination, labs and imaging were unremarkable for significant abnormalities, including no evidence of focal neurologic deficits or end organ damage.  Medical records indicate the patient was admitted solely for observation/monitoring and treated with prn analgesics with significant improvement in symptoms.  There is no evidence of intensification of services throughout the course of this patient's hospital stay.  Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.  For these reasons, the proposed treatment of inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This patient presented to the hospital with symptoms of left sided abdominal pain of 2-days duration. The patient had recently undergone treatment for cholelithiasis and choledocholithiasis with cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP)/sphincterotomy/stent placement. The patient had a surgical drain in place at the time of emergency department (ED) presentation.Computed tomography (CT) scan showed post-surgical changes of cholecystectomy and stent placement. Initial treatment included intravenous (IV) fluid and pain medications. The existing surgical drain was removed. The progress notes document normal vital signs. The patient was started on a diet. The patient's pain resolved and the patient was discharged from the inpatient setting. The health plan's determination is upheld.

Based on the submitted clinical documentation, an inpatient level of care was not medically necessary in this case. The patient was 5-days status/post (s/p) laparoscopic cholecystectomy and subsequent ERCP/stent placement for common bile duct (CBD) stones. Vital signs and lab data did not identify unexpected pathology at the time of presentation. The vital signs remained normal during the period of hospitalization until discharge. The submitted medical records support that the patient could have been managed at a lower level of care, which would have provided for the necessary evaluation in the ED and follow up care.
Inpatient level of care was not medically necessary. The patient was clinically stable at the time of presentation and remained so during the period of overnight monitoring as supported by the corresponding medical records and progress notes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Panniculus
 
Treatment: Panniculectomy

The insurer denied the Panniculectomy. The denial was upheld. 

This is a female patient who underwent an abdominoplasty and liposuction in early 2019 by a plastic surgeon.  Per the letter from late 2018, the patient has a long-standing history of back pain due to diastasis recto and pressure of abdominal weight and remaining skin after weight loss.  The patient had an extensive work-up, including an MRI and no other cause was seen for her pain.

It should be noted that as per the American Society of Plastic Surgeons (ASPS), panniculectomy and abdominoplasty as of 2007 have separate CPT codes. Also, the operative report clearly states the patient had abdominoplasty and liposuction.
Neither panniculectomy-the code used to bill the procedure- or as noted in the operative report -  abdominoplasty was medically necessary.    Abdominoplasty was the procedure performed.  While it is possible that the procedure if accompanied by a rectus plication would improve the patient's back pain, preoperative testing to determine if the procedure will be helpful has not been done.  A retrospective study by Ramirez reviewed the author's personal experience with 104 abdominoplasty procedures.  Of this group, 26 had moderate or severe back pain, and all were improved following abdominoplasty with a specialized myofascial release technique to reconstruct the abdominal wall.  This study was not prospective or randomized and, in addition, employed a unique technique for abdominal wall plication that is not generally a part of the standard abdominoplasty procedure. There are no prospective, controlled or randomized clinical trials that support this procedure as an acceptable treatment for back pain. Following a systematic review of functional outcomes following abdominoplasty, Stallesen, et al. "concluded that the quality of evidence of positive health effects for patients having abdominoplasty is very low concerning all studied outcomes."  Lastly, as per the ASPS an abdominoplasty as reported in the operative report is considered cosmetic and not medically necessary. 

The carrier's denial of coverage for panniculectomy is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a history of type 1 diabetes mellitus (DM) who was admitted on 2/2/19 for diabetic ketoacidosis. He was found to have a glucose of 421, anion gap of 23, ketones in the urine, betahydroxybutyrate in blood, and a potential hydrogen (pH) of 7.23. He was subsequently admitted to the Intensive Care Unit (ICU), started on intravenous fluids and an insulin drip.
The health plan's determination is overturned in whole. The patient presented to the emergency room (ER) with nausea and vomiting, vomiting 3 times on the day of admission. His glucose was 421, beta-hydroxybutyrate was 5.27, carbon dioxide (CO2) 18, sodium 138, chloride 97, creatinine 1.3, and pH 7.23 on venous blood gas. That would mean that his anion gap was 23. His numbers are confounded by the fact that he was vomiting which means that he had a combined acid base disorder of an anion gap metabolic acidosis and an additional metabolic alkalosis; his acidosis being the DKA. His alkalosis likely from the vomiting which caused the bicarbonate and pH to look more normal than they otherwise would and masking the severity of his illness. Based on InterQual criteria, he meets inpatient admission with a pH 7.25-7.35, glucose greater than (>) 250, ketones in urine and blood, and a CO2 of 15-18.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plagiocephaly

Treatment: Cranial Remolding Orthosis

The insurer denied Cranial Remolding Orthosis

The patient was born premature at 33 weeks, a twin, spent 2.5 weeks in the Neonatal Intensive Care Unit (NICU), has a preferential sleeping position with flattening of the back of the head.  Head shape was not improving with repositioning (there is no mention or documentation of physical therapy).  Twin sister is also noted to have plagiocephaly and undergoing helmet therapy.  He was noted with flattening of the right occipital area and left frontal area, with a tight anterior ear shift. 

The patient was 6-months-old of age at time of evaluation for Cranial Remolding Orthosis for Plagiocephaly.  Measurements obtained noted Cranial Vault Asymmetry Index (CVAI) of 5.6 (Minimal deformity) and Cranial Vault Asymmetry of 8mm (Moderate deformity). 

The long-term functional consequences of untreated positional plagiocephaly remain unknown.(1-7)  Cognitive deficits have been demonstrated for children with positional plagiocephaly, but it is unknown whether treatment will improve these deficits.(7)  Other deformities including Temporomandibular joint (TMJ) dysfunction, ear infections, respiratory and vision problems and migraine headaches have been attributed to positional plagiocephaly, but it is not clear from the literature if these problems are caused by positional plagiocephaly or are simply associated with this diagnosis.  

This child has a mild to moderate skull asymmetry, Per the evaluation report, the patient had a Cranial Vault Asymmetry Index (CVAI) of 5.6 (Minimal deformity) and Cranial Vault Asymmetry of 8mm (Moderate deformity). The 2016 guidelines from the Congress of Neurological Surgeons state, "Helmet therapy is recommended for infants with persistent moderate to severe plagiocephaly after a course of conservative treatment (repositioning and/or physical therapy). Strength of Recommendation: Level II-uncertain clinical certainty." The documentation did not include any physical therapy notes.  The cranial remolding orthosis provided is not considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: S/P accident
Issue under review: Continued SNF Admission

Determination:
Continued SNF Admission was medically necessary.

The patient in this case had multiple medical problems as a result of his accident that required a resource-rich, multidisciplinary rehabilitation program to promote his recovery.  His treatment course was complicated by anemia, pain, constipation, and exposure to influenza that required management.  The available clinical notes show that the patient made continual progress with his mobility and self-care function during the hospital stay both before and after he was cleared for full weight bearing as tolerated on the right lower limb.  There was no documentation that he had plateaued in terms of his response to treatment, was not fully participating, or had reached all of his treatment goals.

The patient clearly required ongoing medically supervised rehabilitation services and was making continued progress while in the hospital that was providing his care.  There is no evidence that he no longer required the services that were being provided or that he was not making progress with his treatment program.  There was no evidence to show that he would continue to progress at the same rate in a less intensive treatment setting or that he was not fully participating in the treatment program provided.
Appeal type: Medical necessity
Decision: Upheld

The patient with a history of coronary artery disease (CAD) status post percutaneous coronary intervention (PCI) and hypertension presented to the hospital with a chief complaint of syncope. The patient reported two episodes of syncope. The patient stated that while going to the bathroom the patient experienced nausea and dizziness and subsequently lost consciousness. The patient walked to the living room afterward and had a second episode of syncope. 
On physical examination, the patient was awake and alert, there was a laceration involving the right lateral eyebrow region, neck was nontender, heart was regular, breath sounds were normal, and the pelvis was tender bilaterally.  Head CT was negative for acute stroke. Imaging was negative for acute fracture. Chest x-ray was negative for pneumonia. The patient was admitted for syncope. Neurology saw the patient and recommended echocardiogram and electroencephalogram. Cardiology recommended an electrophysiology evaluation. Brain magnetic resonance imaging (MRI) was also performed and was negative for acute abnormalities. The echocardiogram showed diastolic dysfunction and stress testing was negative for acute ischemia. Electrophysiology recommended loop recorder placement. The health plan's determination is upheld. 

Based on the available documentation, the patient was hemodynamically stable, had no evidence of sepsis, no acute evidence of recurrent syncope, negative cardiac enzymes, no acute abnormality seen on echocardiogram, no acute abnormalities seen on EKG, and largely unremarkable labs. The patient needed further evaluation, but it could have been safely and effectively provided a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiomyopathy, hypertension, hyperlipidemia, and diabetes mellitus

Treatment: LifeVest

The insurer denied the LifeVest. That denial was upheld.

The patient has a medical history notable for cardiomyopathy with an ejection fraction < 35%. She was found to have non-obstructive coronary artery disease at the time of cardiac catheterization, where her ejection fraction was noted to be 25%. She was treated with medical therapy. She was discharged home with a request for ongoing use of a LifeVest. She had previously been approved for the LifeVest for three months. 

The LifeVest is Food and Drug Administration (FDA) approved for prevention of sudden cardiac death; however, the use of LifeVest for the dates under review is not medically necessary. The patient was diagnosed with non-ischemic cardiomyopathy with an ejection fraction of 25%. This patient had already been prescribed a LifeVest. For the dates under review, the use of LifeVest is not medically necessary. There were no contraindications to implantation of an implantable cardioverter defibrillator (ICD) at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Viral illness in the setting of substance use and withdrawal

Treatment: Inpatient admission, diagnostic testing, medication management, and detox protocol 

The insurer denied inpatient admission. That denial was reversed.

This patient was admitted due to cough, shortness of breath, yellow phlegm with blood, hand tremors, tongue fasiculation, body aches, malaise, emesis, tachynea, mildly elevated blood pressure, and agitation. The patient was in no acute distress; however the chest x-ray showed some increase interstitial markings and the patient was treated for possible pneumonia with intravenous antibiotics. She had a CIWA score of 8. She was reportedly drinking 1-2 pints of vodka and brandy for the previous week. She was started on Librium 25 mg q 8 hours. She also was given IV fluids, potassium, magnesium, Phosphorus, thiamine, and folate.  

In this case this patient was drinking a large amount of alcohol including 1-2 pints of vodka and brandy and was at risk of severe or life threatening withdrawal and also had medical issues so she required 24 hour hospital treatment. According to the LOCADTR she did require 24 hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting as she needed detoxification medication (Librium) to modify withdrawal from alcohol, and she needed 24 hour treatment then as she was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including possible life threatening withdrawal such as delirium tremens which can occur 3-4 days after cessation of alcohol use. She had multiple medical problems as well and there was a rule out for a pulmonary embolism. She also had cough, shortness of breath, yellow phlegm with blood, tachypnea, and mildly elevated blood pressure. She had alcohol withdrawal symptoms including hand tremors, tongue fasciculation, elevated blood pressure, body aches, malaise, agitation, and emesis. 

Inpatient hospital admission for detoxification treatment from 1/23/19-1/24/19 was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left renal colic
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
An acute inpatient level of care was not medically necessary.  Care could have been provided at a lower level of care.  The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  He did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, severe vomiting.  Pain control, IV antibiotics and IV fluids followed by stent placement in a non-toxic patient can be provided at a lower level of care.