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

Diagnosis: Pathologic fractures of the vertebrae  

Treatment: Inpatient admission

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

This patient is a female with no known past medical history.  She presented to the Emergency Department (ED) with back pain.  She was provided with Flexeril.  She had also taken Prednisone and Aleve.  Upon arrival, her temperature was 97.9F, her heart rate was 84 beats per minute, her blood pressure was 187/85, her respiratory rate was 16 breaths per minute, and her pulse oximetry reading was 99% on room air.  Her pain level was 9/10 on the pain scale. An imaging report demonstrated compression fractures to T8, T10 and L1.  The white blood cell count was 14.93. She was admitted to the hospital with pathologic fractures of the vertebrae. Consultations to specialists resulted in recommendations of osteoporotic workup, thoracolumbar orthosis and Lidoderm patch. Neurology services recommended a trial of steroids. Physical Therapy (PT) and Occupational Therapy (OT) were recommended.  She was discharged.

The medical record demonstrated that the woman was reported to have back pain for 1-2 weeks.  She was evaluated in the ED and admitted for pain management and magnetic resonance imaging (MRI).  There was no evidence of an acute condition to warrant the admission and length of stay.  Her physical examination was unremarkable.  Her vital signs were stable.  Laboratory testing was normal.  She had not received oral narcotic analgesics.  She did not require continued Morphine.  She was able to move about with PT on a specified date. The diagnostic testing did not demonstrate a condition to warrant more invasive procedures or surgery.  The findings were subacute.  There was no evidence of trauma.  She was able to tolerate oral medications.  There were no treatments required for an underlying medical condition. Her additional imaging studies and subspecialty consultations could have been completed in the ED or observation setting.  There were no extenuating circumstances provided to substantiate the admission and length of stay. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The inpatient hospital admission is not considered medically necessary for this patient. 

Based on the above, the medical necessity for the inpatient hospital services is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission

The Inpatient admission was not medically necessary.

This patient presented with atypical chest pain. Moreover, he had a history of previous myocardial perfusion studies that did not demonstrate abnormality.  His physical examination was unremarkable, and ECG failed to reveal specific findings consistent with an acute coronary syndrome. Serum blood testing did not reveal elevated troponin levels.  

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG as well as negative cardiac enzymes was performed by Poldevaart et al (Reference 1).  Using the HEART (History, EKG, Age, Risk factors, initial Troponin) score risk stratification schema, this patient would have a low risk of future myocardial infarction or death within one year. Other investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care (References 2, 3, 4). They found no significant difference in outcome at 30 days between the two groups.  Fernando Bellolio et al. noted that patients presenting with chest pain that were managed in an observation unit had similar 30 day myocardial infarction rates as those admitted to the hospital (Reference 3).  

Admission to the hospital to treat an acute cardiac event was not medically necessary.  In conclusion, this patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gynecomastia
Treatment: Reduction mammoplasty
The Reduction mammaplasty is medically necessary.

The patient has a developmental deformity, and surgery will normalize his appearance.  Teenage male breast enlargement is a source of embarrassment and low self-esteem. The medical literature confirms that breast reduction surgery improves psychological functioning in affected male teenagers.  

Studies by Rosen et al and Ridha et al found statistically significant improvements in psychological function following mastectomy surgery for gynecomastia.  According to a study by Kinsella et al, "Idiopathic adolescent gynecomastia is a psychological threat to normal self-esteem and sexual identity.  Patients presenting with this condition likely suffer an adjustment disorder subsequent to this anatomic stressor.  Surgeons should strongly consider referring their patients with gynecomastia for psychological evaluation and treatment as an adjunct to successful surgical management of this condition." According to Nuzzi et al, "Gynecomastia has a significant negative impact on primarily the psychosocial well-being of affected adolescent patients, specifically in regard to social functioning, mental health, and self-esteem.  Psychosocial impact was not affected by graded severity of disease.  Health care providers and patients should be aware of the psychosocial impairments associated with gynecomastia and consider early treatment for adolescents suffering from this condition, regardless of severity." 

Notes from the patient's PCP (primary care provider) document severe anxiety and depression that is partly related to his breast enlargement.  Surgical management and psychological support are the most appropriate treatments for this patient.

Because this patient has documented depression and anxiety related to his breast enlargement, surgery is the most appropriate treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: Comprehensive and periodic orthodontic treatment

The insurer denied coverage for comprehensive and periodic orthodontic treatment. The denial was reversed.

This patient is a female child who presented for evaluation for orthodontic care. The orthodontist identified crossbite, anterior crowding, protrusion, overbite and overjet and has recommended orthodontics. The orthodontist completed the HLD index attaining 26 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements having attained a score of 18 points on the HLD index.

It is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 26 points to justify orthodontic care.  This reviewer concurs with the index completed by the orthodontist attaining a total of 26 points on the HLD index (3 overjet, 5 overbite, 10 anterior crowding, 8 labiolingual spread) which is at the threshold of 26 points to support orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

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

Based on the above, the medical necessity for comprehensive and periodic orthodontic treatment is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Chest Pain
Inpatient Hospital

The patient was sent by her primary physician for intermittent chest pain starting on the day of admission. The pain was described as sharp and lasting for one hour. Cardiac cath showed no obstructive coronary artery disease (CAD). The patient had a history of diabetes, hypertension, and hyperlipidemia. An electrocardiogram (ECG) showed interventricular conduction delay although it was read as left bundle branch block. Serum troponin was normal. The patient was admitted. Myocardial infarction (MI) was ruled out by serial biomarkers. An Echocardiogram and nuclear stress test were performed. The latter showed primarily fixed defects with minimal ischemia. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. All the services performed were indicated but they could have been performed at a lower level of care. The patient had chest pain that may have been an acute coronary syndrome, although it was somewhat atypical. It was not unreasonable to place the patient on observation for several hours to rule out an acute coronary syndrome and perform electrocardiographic monitoring. However, a full inpatient admission was not medically necessary. The echocardiogram and stress test could have also been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, vomiting, abdominal pain
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

The patient is a female patient who had presented to the emergency department of the facility filing the appeal with the complaint of abdominal pain, anorexia, emesis and nausea. The patient had a concurrent medical history of asthma, constipation, leukocytosis, and gastritis. The patient evidenced a potassium of 3.2 and mild hypertension. A computed tomography (CT) scan showed distal esophageal wall thickening possibly due to esophagitis. The patient received intravenous (IV) fluid, Zofran, Reglan, and antacid medication.

The treatments as provided were medically appropriate but not medically necessary at the level at which they were provided.

While the treatment as provided was appropriate, the care did not require an acute level for its provision. The care as provided could have been rendered in its entirety at a lower level of care. The patient had abdominal pain and emesis; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. The patient improved while in the emergency department and the care as rendered could have continued at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient has a past medical history significant for arthritis and Arnold-Chiari syndrome with spina bifida.  The provider has been prescribing Oxycontin for chronic pain since 2014.  The plan determined that the medication was not medically necessary.  The use of Oxycodone Extended Release is under review.

The health plan's determination is overturned.  Oxycodone Extended Release is medically necessary for this patient.  The standard dose would be 1 tablet every 12 hours (15mg q12 hours).  The patient has been on this medication for years.  The patient is tolerating the medication and not showing significant increase in amount of opioid required.  The patient is not having any drug-drug reactions.  In addition, the provider actually noted that the patient was tapering Tylenol #3 which is appropriate, as the hope is that an extended release opioid will provide her appropriate 24-hour coverage.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's disease
Treatment: Entyvio infusion

The proposed treatment of Entyvio infusion was not medically necessary.

The patient is a male with severe fistulizing Crohn's disease status post (s/p) ileostomy. He had previously been treated with Remicade, and had failed 6-MP and prednisone. In early 2019, the patient had been treated with Entyvio 300 milligrams (mg) every eight weeks, and had persistent symptoms and low drug levels. The physician has requested to increase Entyvio to 300 mg every four weeks.

At the beginning of the year, the patient had previously been treated with Remicade, so it was reasonable to not use Remicade again due to the possible development of antibodies.  The appeal letter states that Entyvio was used over the plan preferred Humira as the patient wanted to avoid self-injections. There is no documentation that the patient was a primary non-responder to Remicade. Infusion reaction to Remicade/antibodies to Remicade is not a reason to not try Humira. It is stated that the provider and patient did not want to try Humira as they wanted to avoid self-injections, but then the patient was put on Stelara, which is a self-injection.

Using the plan preferred Humira as a treatment option was an appropriate choice. Wanting to avoid injections is not a reason to bypass the plan preferred Humira.

Therefore, based on the health plan preferences, the requested Entyvio was not medically necessary, over the plan preferred Humira.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  ESRD
Issue under review:  Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult male with end-stage renal disease (ESRD) on hemodialysis, obstructive sleep apnea, obesity status post laparoscopic banding, and diverticular disease status post recent partial colectomy.  He presented after having missed his most recent five dialysis sessions, and his dialysis facility declined to dialyze him for this reason. 

The patient had missed his most recent five dialysis sessions, but he did not have severe acidosis, florid pulmonary edema, or uremic symptoms.  Emergent dialysis was not required.  The patient had only a mild degree of hyperkalemia without evidence of electrocardiographic changes, ventricular arrhythmia, or muscle weakness.  There was no evidence of hypertensive emergency.  

In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post stent placement- left main coronary artery

Treatment: Inpatient admission

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

This patient is a male with a past medical history of coronary artery disease status post coronary artery bypass graft (CABG), cerebral vascular accident (CVA) with residual left-sided weakness, diabetes mellitus, hypertension, hyperlipidemia, obesity, and sleep apnea. He presented for an elective cardiac catheterization. This revealed severe coronary artery disease and a drug-eluting stent was placed to the left main coronary artery. There were no procedural complications, and the patient was then admitted for further monitoring. The patient remained hemodynamically stable, was ambulatory, and was tolerating oral intake. There were no vascular access complications. The patient was subsequently discharged home after an uneventful, brief overnight hospital stay.

The acute inpatient admission was not medically necessary. Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient one. The clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization and attempted angioplasty. 

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Issue under review: Inpatient admission

Determination: 
The Inpatient admission was medically necessary.

The patient has a history of DM (diabetes mellitus) and retinopathy. He presented with left leg pain for five days. The patient does inject Trulicity into his thigh weekly.

The patient meets the initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (1), as he had systemic signs of infection (fever, tachycardia, and leucocytosis). Thus, this admission was warranted, supported by IDSA guidelines. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, Abdominal pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

This patient presented with atypical chest pain. She had no significant past medical history. Her pretest probability of coronary artery disease (CAD) is low (Reference 1). Utilizing the HEART (History, EKG, Age, Risk factors, initial Troponin) score, she was considered low risk (Reference 2).  Utilizing the TIMI (thrombolysis in myocardial infarction) 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.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  

In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Other-Sepsis
Inpatient stay

The infant patient was referred by the pediatrician to the emergency department  at 30 days of age for evaluation of possible sepsis. Patient had fever to 102 some nasal congestion/sneezing, slight decrease in feeding, decreased activity, and increased fussiness. Birth history was unremarkable. Patient was too young to receive routine vaccinations. The brother had upper respiratory infection (URI) symptoms. Vital signs included temperature 101.7, heart rate 191, respiratory rate 51, and 100% saturation in room air. Examination was significant for irritability, uncomfortable ill appearance, moist mucous membranes, tachycardia, palpable pulses, clear lungs, non-tender abdomen, and good muscle tone. Full septic work-up was planned. Patient was treated with Tylenol, a normal saline bolus, a dose of ceftriaxone, and maintenance intravenous (IV) fluids before admitting to the pediatric floor for further management of possible serious bacterial infection. The Health Plan's determination of medical necessity is overturned in whole. With the introduction of various vaccines, the epidemiology of acute febrile illness in infants and young children up to 36 months of age has changed. There has been a dramatic decrease in serious infections due to Streptococcus pneumoniae and Haemophilus influenza type b. Urinary tract infections are now the most common bacterial infection in young infants under three months of age, and pneumonia is most likely in infants and children three to 36 months. The most important means of determining if a fever represents a serious infection is the physical exam. For neonates that present with fever, inpatient management is universally recommended with use of empiric antibiotics pending culture results. Ampicillin and either gentamicin or cefotaxime are the accepted antibiotic choices. For infants/children one to 36 months that show signs of serious illness (as listed above), inpatient management is indicated. For infants one to three months, full septic work-up and empiric antibiotic treatment is appropriate pending culture results. . In general, ill appearing patients or those with high fevers should be monitored more closely, typically in hospital. This infant was referred to the ED by the pediatrician because of high fever, irritability, and decreased activity. Full septic work-up was performed in the ED and empiric therapy started with ceftriaxone. The patient was admitted for antibiotic therapy pending culture results as well as close monitoring for decompensation. Patient was also noted to have a significant murmur (3/6 systolic ejection murmur), with history of some sweating with feeding and occasional perioral cyanosis. Both electrocardiogram and chest x-ray were unremarkable. This level of care is most consistent with acute inpatient management, and the hospital stay was medically necessary at that level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out appendicitis

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay. The denial was upheld.

This patient is a female child who presented to the emergency department by way of referral from the primary medical doctor to rule out appendicitis. The patient had abdominal pain starting the day prior to presentation. The pain was persistent the morning of the presentation. The patient vomited once. The pain was so bad that the patient could not walk.  The patient also had pain lying down. The physical examination revealed the abdomen was soft and mildly tender in the suprapubic, pubic, and right lower quadrant. The patient's temperature was 99.3 F. The patient's heart rate was 133. The patient's white blood cell count was 15.7 K.  

The patient was treated with intravenous fluids, and intravenous antibiotics. The patient underwent a pelvic ultrasound CT scan of the abdomen which revealed acute appendicitis. The patient was admitted for acute appendicitis. The patient was admitted under surgery for further management. The patient underwent a laparoscopic appendectomy the day following admission. The patient was stabilized and was discharged home.

The literature regarding this scenario is consistent, and supports outpatient treatment for this condition. The health plan acted reasonably and with sound judgment and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital stay is not substantiated. The insurer's denial is upheld.