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


Diagnosis: seizure
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

This case involves a man with a seizure history who was admitted to the hospital with seizures. The seizures occurred while the patient was in the shelter, lasting about 10 minutes, falling from the bed at the knee level height. He was brought to the emergency department for an assessment. The medical team evaluated the patient and found him awake and alert x 3, without recollection of the events. The patient reported typically having one seizure per week, as well as migraines twice a week. Chronic treatment includes Trileptal, Depakote, and oxcarbazepine, with poor compliance with both medications and neurologic follow-up.

The inpatient hospital admission was not medically necessary. The patient has a known seizure history, with weekly seizures presumed due to noncompliance with medications. He had a breakthrough seizure and was brought into the emergency department from a shelter for an assessment. He was not postictal and had no recurrence of seizures. The head CT (Computerized tomography) was unremarkable.
From a pneumonia standpoint, the patient had no evidence of hemodynamic instability, was on room air, and did not exhibit signs of sepsis. Young individuals without serious cardiopulmonary comorbidities no oxygen requirement, do not require hospitalization for treatment of pneumonia.
Therefore, the inpatient hospital admission was not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intermittent abdominal pain and diarrhea with high-fat foods
Treatment: computed tomography scan of the belly (Procedure Code 74178)
The insurer denied computed tomography scan of the belly (Procedure Code 74178).
The determination is overturned.

The patient is a female who has had intermittent abdominal pain and diarrhea with high-fat foods. The pancreatic elastase was low at 168.1 micrograms per milliliter (ug/mL). An ultrasound did not visualize the entire pancreas. A computed tomography scan of the abdomen and pelvis was normal and showed the lack of a pancreatic mass and pancreatic fluid collections. At issue is the medical necessity of the computed tomography scan of the abdomen and pelvis (Procedure Code 74178).

The computed tomography scan of the abdomen is medically necessary, but imaging of the pelvis is not. The request for computed tomography scan of the abdomen is supported by the submitted documentation (however, imaging of the pelvic is not). The patient had exocrine pancreatic insufficiency based on finding of a low pancreatic elastase and matching symptoms [1-4]. Exocrine pancreatic insufficiency can be caused by chronic pancreatitis, but also by pancreatic malignancy [1-3]. According to current medical literature, "Among cross-sectional imaging modalities, multi-detector computed tomography (MDCT) has been a cornerstone for evaluating chronic pancreatitis (CP) since it is ubiquitous, assesses primary disease process, identifies complications like pseudocyst or vascular thrombosis with high sensitivity and specificity, guides therapeutic management decisions, and provides images with isotropic resolution within seconds" [3]. A recent review states that "The diagnosis [of exocrine pancreatic insufficiency] is based on pancreatic calcifications, ductal dilatation, and atrophy visualized by imaging with computed tomography" [4]. American Gastroenterological Association guidelines further state that "Cross-sectional imaging (computed tomography scan, magnetic resonance imaging, and endoscopic ultrasound) cannot identify exocrine pancreatic insufficiency, although they play an important role in the diagnosis of benign and malignant pancreatic disease" [5]. For these reasons, and because the ultrasound performed in this case could not fully visualize the pancreas, the use of computed tomography scan of the pancreas (abdomen) is supported by current medical literature. However, the use of computed tomography scan of the pelvis was not supported by the submitted documentation, as computed tomography scan of the abdomen can fully visualize the pancreas.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Syncope.
Treatment:  Inpatient Hospital Stay.

The insurer denied inpatient hospital stay. The determination is overturned.

The patient is a male who initially presented to the emergency department with concerns about syncope. The pertinent history included cardiomyopathy status/post (s/p) implantable cardioverter defibrillator (ICD), congestive heart failure, hypertension, and diabetes mellitus. 

The initial examination documented the patient as alert, oriented, and without focal neurologic deficits. Melena was noted on a rectal exam. An electrocardiogram (EKG) was relatively unremarkable. A chest x-ray (CXR) was unremarkable. A computed tomography (CT) scan of the head was unremarkable. The emergency department physician documented high concern for blood loss anemia as the etiology of syncope. Intravenous fluids and a proton pump inhibitor were provided.

The patient was admitted to the hospital with an impression of syncope, gastrointestinal bleeding, and congestive heart failure. The treatment plan included serial hemoglobin checks, an echocardiogram, and consultations. Cardiology consulted and noted a hemoglobin decrease from 14.4 a month ago to 9.4 on the repeat Hgb check. Recommendations were to hold antiplatelet therapy and pursue a gastroenterology consult. Gastroenterology consulted and recommended pursuing an endoscopy after being cleared from a cardiology perspective. Cardiology documented the syncopal episode was felt to be related to hypotension from new onset anemia and cleared the patient for an endoscopy. Proton pump inhibitor infusion was continued. The colonoscopy was performed and did not reveal high-risk lesions or active bleeding. Subsequently, the esophagogastroduodenoscopy (EGD) was performed, revealing diffuse moderate inflammation in the entire stomach and one non-bleeding cratered duodenal ulcer with no stigmata of bleeding in the duodenal bulb. The patient was discharged. At issue is the medical necessity of an inpatient stay.

Based on the clinical documentation provided, evidence-based literature, and standards of care, acute inpatient level of care was medically necessary for the entire admission.

The patient had a history of coronary artery disease on antiplatelet, which is not easily reversible, and presented with concerns of syncope. The emergency department physician documented high concern for syncope related to blood loss anemia and initiated a proton pump inhibitor. Serial checks after that documented a continued drop to 8.9. Cardiology documented syncope was likely related to hypotension from blood loss anemia in the setting of antiplatelet therapy. Gastroenterology was consulted, and an urgent endoscopy was recommended. The endoscopies did not reveal active bleeding or bleeding stigmata but did not have a large duodenal ulcer. The patient was promptly discharged after that. Clinical indications for admission to inpatient care were met. The patient had evidence of ongoing active bleeding (e.g., melena and decreasing hematocrit) in the setting of antiplatelet therapy that is not quickly reversible.[2]
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: fever and left knee pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.
 

Patient is an adult female with past medical history significant for hypertension, diabetes mellitus, hyperlipidemia, morbid obesity, sleep apnea, anxiety, and recent left total knee arthroplasty (TKA) who presented to the emergency department (ED) with complaints of fever and left knee pain. She had been discharged with a peripherally inserted central catheter (PICC) line for home antibiotics (vancomycin and cefepime).

Vitals on presentation included: Temperature-100.5 degrees Fahrenheit, Blood Pressure-101/67, Pulse-105, Respirations-18, oxygen saturation-99% (percent). Laboratory results included the following: White blood cells (WBC)-4.3, Hemoglobin (Hgb)-12.3, Hematocrit (Hct)-38, creatinine-0.71, glucose-133, procalcitonin-0.13, C-reactive protein (CRP)-38.78.

Patient was admitted for possible left knee prosthetic joint infection. She was started on intravenous (IV) antibiotics (daptomycin and meropenem). Infectious Diseases was consulted, and antibiotics adjusted. X-ray of left knee showed post-surgical changes with interval placement of ethyl methacrylate beads. Cultures were sent and returned negative. Doppler ultrasound was negative for deep vein thrombosis (DVT). Orthopedic surgery deemed no surgical intervention was required. Patient remained afebrile, hemodynamically stable, and was discharged to continue outpatient management.

According to documentation, patient presented with fever (100.5 degrees Fahrenheit), tachycardia (heart rate-105) and left knee pain despite outpatient intravenous antibiotics for a prosthetic joint infection. Laboratory values showed low WBC (leukopenia). Infectious Diseases switched antibiotic therapy. Based on above findings including failure of outpatient management in a patient with recent orthopedic surgery, hospital admission was medically necessary for administration of intravenous antibiotics and further evaluation. 

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

The medical necessity for the full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Paraplegia, transverse myelitis, pressure ulcers, pain, back spasms, and heart failure.
Treatment: Personal Care Aide 7 Days x 24 Hours (live in)
The insurer denied: Personal Care Aide 7 Days x 24 Hours (live in)
The denial is overturned.

The patient is an adult male. His medical conditions that include paraplegia, transverse myelitis, pressure ulcers, pain, back spasms, and heart failure. He was a long-term skilled nursing facility (SNF) resident. Denial of personal care aide 7 days x 24 hours (live in) is being appealed. The health plan approved personal care aide 6 days x 6 hours and 1 day x 8 hours, total 
44 hours per week. The patient's Uniform Assessment System (UAS) evaluation completed 5 months ago shows independent cognition and functional status requires extensive assistance to total dependence with all activities of daily living (ADLs), except limited assistance with personal hygiene and independent with phone use and eating. He is non-ambulatory and uses a wheelchair or scooter. He is incontinent of bowel and bladder.
Medical records show the patient is wheelchair bound. He has osteomyelitis of hip and stage 4 coccygeal pressure ulcer and a pressure ulcer on his right heel.

The requested Personal Care Aide 7 Days x 24 Hours (live in) is medically necessary.

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transferring, turning/positioning, or feeding. Denial of personal care aide 7 days x 24 hours (live in) is being appealed. The health plan approved PCA (personal care aide) 6 days x 6 hours and 1 day x 8 hours, total 44 hours per week. This patient has paraplegia and transverse myelitis. He was a long-term skilled nurse facility (SNF) resident. The patient's Uniform Assessment System (UAS) evaluation completed 5 months ago shows the patient requires assistance with all activities of daily living, except phone use and eating. He is non-ambulatory and uses a wheelchair or scooter. He is incontinent of bowel and bladder. Medical records support the patient's need for assistance with activities of daily living. He has pressure ulcers on his coccyx and heel. The information provided shows that this patient has significant limitations in functioning. The patient's need for assistance with all activities of daily living cannot be met with the approved PCA (personal care aide) 44 hours per week. The requested personal care aide 7 days x 24 hours (live in) is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dental malocclusion

Treatment: D8080 braces and D8670 monthly visits x 12

The insurer denied coverage for D8080 braces and D8670 monthly visits x 12

The denial is upheld

 
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, and overbite, ectopic eruption (#5, 18, 31) and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index attaining 31 total points to support orthodontic care. 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 on the HLD index attaining 21 points by internal reviewers. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. 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 31 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 21 points on the HLD index (2 overjet, 6 overbite, 10 anterior crowding, 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

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

The medical necessity for D8080 braces and D8670 monthly visit x 12 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 Braces and D8670 Monthly Visit
The insurer denied: D8080 Braces and D8670 Monthly Visit
The denial is overturned.

The patient is an adolescent male. The request is for orthodontic benefits with monthly visits. He has a skeletal Class I malocclusion with severe upper and lower crowding, as well as a deep bite. The health plan denied coverage of the request due to the patient having a handicapping index score of 20 points. The denial is being appealed.

The D8080 Braces and D8670 Monthly Visit are medically necessary.

The patient has two anterior teeth in crossbite (reverse bite). Teeth #7 and #10 are behind the lower teeth, which is reverse to how they should be. There is clinical attachment loss as well as 
recession of the gingival margins. These two things are both automatic qualifiers for treatment according to the handicapping index scale. This case has medical necessity, and the monthly 
visits are needed to make sure the treatment progresses properly.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain.
Treatment:  Inpatient Admission.

The insurer denied coverage for inpatient admission. The denial is upheld.
 
Asked to review the case of an adult male with a past medical history of hypertension, transient ischemic attack, and polysubstance abuse that presented to the hospital with chest pain and dyspnea on exertion. He noted left-sided chest pain while exercising on a treadmill. Workup performed five months earlier, including stress testing, revealed no significant abnormalities. On arrival at the hospital, vital signs were stable. Physical examination revealed no major abnormality. A 12-lead electrocardiogram (ECG) revealed sinus rhythm without evidence of ischemic ST or T-wave abnormalities. Serum troponin levels were not elevated. The echocardiogram demonstrated a normal left ventricular ejection fraction (LVEF) with no evidence of valvular abnormalities or segmental wall motion abnormalities. The patient eloped before admission to the hospital.

This patient presented with atypical chest pain and a past medical history of hypertension. His pretest probability of coronary artery disease was low. (Reference 1) Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score, he 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 History, Electrocardiogram, Age, Risk Factors, and Troponin (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. A recent American College of Cardiology expert consensus statement for treatment of acute onset chest pain places this patient in a low-risk group and eligible for outpatient workup. (Reference 4) In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary.

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

The medical necessity for inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease 
Treatment: Inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld.

The patient is a male with a history of two vessel coronary artery disease who presented to the hospital for planned percutaneous coronary intervention for stenoses in his left anterior descending (LAD) and first diagonal coronary arteries. He had previously undergone stent placement in his distal left circumflex artery. His medical history was otherwise remarkable for hypertension, hyperlipidemia and obesity. Upon presentation, his serum creatinine level was 1.5; intravenous fluid and n-acetylcysteine were administered. Atherectomy and stent implantation were performed for lesions on the mid LAD and first diagonal artery. 

Based on the documentation provided, an inpatient hospital admission was not medically necessary.
This patient presented for elective percutaneous coronary intervention. He was stable upon presentation, without acute symptoms or ischemic electrocardiographic changes. Atherectomy (2 vessels) and stent implantation (3 vessels) were performed without complications. While some period of observation immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document From the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications.
This patient met none of these criteria. Per the 2018 update to this document, with the exception of patients with ST segment elevation myocardial infarction, most stable patients can be discharged post- percutaneous coronary intervention (PCI) on the day of the procedure provided they are at their baseline functional and mental status and all of their comorbidities are stable. Certain patients may remain in the hospital on observation status following PCI for a number of medical and procedural reasons, including atherectomy. In this instance, given that the patient underwent two atherectomies, admission for overnight observation post-procedure was appropriate. However, it did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Pneumonia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient with a past medical history (PMH) of human immunodeficiency virus (HIV), prostate cancer, diabetes mellitus type 2 (DM2), hypertension (HTN), mastoiditis, and hyperlipidemia (HL) who was admitted with complaints of (c/o) a one-week history of subjective fevers, chills, productive cough, and mild shortness of breath (SOB).  Imaging studies, a chest x-ray (CXR) showed left lower lobe (LLL) pneumonia, a computed tomography (CT) scan of the chest showed LLL pneumonia. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with community acquired pneumonia (CAP) and treated with intravenous (IV) antibiotics. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was medically necessary at an acute inpatient level of care. This immuno-compromised patient presented to the emergency department (ED) with complaints of (c/o) a one-week history of subjective fevers, chills, productive cough, and mild shortness of breath (SOB). This patient with multiple co-morbidities, including HIV and diabetes, was considered pulmonary severity index class IV, and considered high risk with mortality rates of 9.3 percent (%). In addition, the patient's clinical status was further complicated by hyponatremia, new onset hypoxia, elevated creatinine, elevated lactic acid, and sepsis with tachypnea and leukocytosis. Overall, this patient's illness severity and risk for complications indicates that an inpatient level of care was medically necessary for the patient's close monitoring and treatment.