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

Diagnosis: Cardiac/Syncope.
Treatment: Inpatient hospital stay.
The insurer denied the medical necessity of the inpatient stay. The determination is upheld in whole.

This patient has a past medical history of congenital hemiparesis who was admitted  with complaints of (c/o) three episodes of falling and syncope with a loss of consciousness (LOC) about 30 seconds. Vital signs were unremarkable. Physical exam notable for a right temple bump. Lab work notable for isolated erythrocytosis. Imaging studies, including a chest x-ray showed no acute disease, a computed tomography scan of the head showed no acute pathology, magnetic resonance imaging  scan showed no acute findings, transthoracic echocardiogram showed normal ejection fraction (EF). An electrocardiogram (EKG) showed normal sinus rhythm  without acute ischemia. The patient was diagnosed with syncope and treated with telemetry, MRI brain, carotid ultrasound (US), TTE and expert consultations. Cardiology evaluated the patient and diagnosed the patient with vasovagal syncope in the absence of structural heart disease. The patient was discharged the next day in stable condition.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with c/o LH and syncope with LOC about 30 seconds. The patient did not have structural heart disease, Hematocrit (HCT) < 30, shortness of breath (SOB), hypotension, or family history of sudden cardiac death, and was not considered high-risk via the San Francisco syncope role. EGSYS and OESIL scores were both zero, indicating unlikely cardiac syncope and low risk of mortality. Additionally, the patient did not have any history of dilated cardiomyopathy, aortic stenosis, hypertrophic cardiomyopathy (HCM), left ventricular outflow disease, pre-excitation syndrome, Brugada syndrome, QT interval abnormalities or conduction blocks. The patient did not have subarachnoid hemorrhage, pulmonary embolism, acute gastrointestinal (GI) bleed, malignant arrhythmia, sustained bradycardia, supraventricular tachycardia (SVT) or ventricular tachycardia (VT), confirmed acute coronary syndrome (ACS), evidence of heart failure, cerebrovascular accident (CVA), shock, coma major trauma or cardiac arrest, or exertional syncope. The patient was diagnosed by cardiology with vasovagal syncope and treated with telemetry, MRI brain, carotid US, TTE and expert consultations, all of which could have been safely and appropriately provided at a lower level of care, which is within standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Right upper quadrant pain.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a female.  She presented to her primary-care physician and an emergency department with a two-week history of right-upper-quadrant abdominal pain. 

The patient's vitals were as follows: temperature 98.4, pulse 80, blood pressure 109/86, respirations 20, oxygenation 98%.  Physical examination demonstrated tenderness to palpation of the right-upper-quadrant of the abdomen.  Serum laboratories demonstrated a normal white-blood-cell (WBC) count of 4.5, an elevated total bilirubin of 3.7, and elevated AST (aspartate aminotransferase) and ALT (alanine aminotransferase) of 994 and 308, respectively.  Computed tomography of the abdomen and pelvis demonstrated a common-bile-duct stone with intra- and extra-hepatic dilation of the bile ducts, porcelain gallbladder, and gallstones. 

No, the inpatient admission was not medically necessary. 

In accordance with peer-reviewed literature, in the absence of cholangitis, sepsis, or shock; significant co-morbidities; or significant physiologic derangements, this patient could have been managed at lower level of care.  She did not require admission at an acute inpatient level of care; indeed, "with a selective policy, an ERCP on an outpatient basis seems as safe as when performed on an inpatient basis" [Jeurnink et al.].  Treating the patient at a lower level of care would not have been reasonably expected to compromise her care or health, and would have been entirely within the standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Respiratory system/breathing problem. 
Treatment:  Inpatient hospital.
 
The insurer denied the inpatient hospital stay.  The denial is overturned in whole.

This is a female patient with history of albuterol use and recent admission for urinary tract infection (UTI), who presented to the emergency room (ER) with fever, upper respiratory infection (URI) symptoms and difficulty breathing.  This was also associated with decreased by mouth (PO) intake and decreased urine output.  

The requested health service/treatment of the inpatient hospital admission was medically necessary for this patient.  Based on the literature, the patient met two clinical criteria that are strong predictors of clinical deterioration and also possible need for major intervention.  The patient exhibited increased work of breathing with accessory muscle use.  Based on these clinical findings at presentation, which included significant distress requiring high flow nasal cannula for respiratory support, inpatient level of care was medically necessary.  The need for higher acuity of care once admitted was evidenced by need for respiratory support with high flow nasal cannula along with the need for close and frequent respiratory monitoring, as the patient was started on Albuterol nebulization every 2 hours.

This patient could not have safely and appropriately been transitioned to a lower care rather than admission to inpatient level of care because of the intensity of interventions the patient required for respiratory support.  This patient with RSV bronchiolitis presented with respiratory distress evidenced by tachypnea, retractions and wheezes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Pansinusitis
Treatment: Nasal/sinus endoscopy procedures with maxillary antrostomy and sphenoidotomy (endoscopic sinus surgery; EES)
The insurer denied coverage for nasal/sinus endoscopy procedures with maxillary antrostomy and sphenoidotomy (endoscopic sinus surgery; EES).
The denial is upheld.

This is a female patient with a medical history of persistent headaches as well as prior dental work, sinus surgery, and chronic pansinusitis. The patient was being seen for subsequent evaluation for sinus disease. The patient reported she had a sinus infection and she had just been treated with 2 courses of antibiotics. The patient does get frequent recurrent infections with classic sinus symptoms. A prior imaging study demonstrated moderate to severe disease. The physical examination revealed the external nose had no significant deformity. On anterior rhinoscopy the nasal mucosa was healthy in appearance, the anterior septum was midline and there was no visualized polyps, purulence, or masses. A nasal endoscopy indicated the middle meatus and sphenoethmoid recesses were clear bilaterally. The nasopharynx was normal; no infection present. She was given oral steroids and recommendation for repeat imaging was made. A computed tomography (CT) scan revealed mild to moderate nasal septal deviation, occluded ostiomeatal units due to anatomic narrowing and mucosal thickening and pansinus mucosal thickening, moderately severe left maxillary and bilateral ethmoid, moderate right maxillary and sphenoid and mild to moderate right and mild left frontal with significant interval progression and increased and moderate left maxillary sinus fluid consistent with acute sinusitis. The patient underwent surgical intervention to include a maxillary antrostomy and sphenoidotomy (endoscopic sinus surgery (ESS)) performed.

Nowhere in the provided paperwork from multiple visits is there any documentation of any prior medical treatment for the patient's chronic sinusitis. The patient was treated with antibiotics from her PCP prior visit and oral steroids starting. There is no documentation of current or past nasal saline irrigations or intra-nasal topical steroid sprays.

Based on the lack of optimal medical treatment the health plan acted reasonably with sound medical judgment in the best interest of the patient.

The medical necessity for the nasal/sinus endoscopy procedures with maxillary antrostomy and sphenoidotomy (endoscopic sinus surgery; EES) performed is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Digestive System/Gastrointestinal. 
Treatment:  Surgical Services. 

The insurer denied: Laparoscopic procedure code 47379 (wedge liver biopsy).  The denial was overturned in whole. 

The patient is an otherwise healthy male who presented to the hospital with epigastric abdominal pain.  At the time of presentation vital signs were normal.  Lab data identified elevated bilirubin and serum transaminases.  Pre-surgical ultrasound and magnetic resonance imaging (MRI) showed gallstones but no common bile duct stones.  The liver was normal on this exam.

Laparoscopic cholecystectomy was performed.  The operative dictation also states that there were nodules of the liver.  Consequently, the surgeon performed a wedge liver biopsy.  The pathology report identified fatty liver tissue with minimal inflammatory activity and mild fibrosis.  He tolerated this procedure well and remained hemodynamically stable post-surgery.

The patient was treated with post-surgical monitoring, intravenous (IV) fluid, IV analgesia, and antiemetics.  The immediate post-surgical recovery was uncomplicated. He was discharged from the hospital.

The subject under review is the medical necessity for the laparoscopic procedure 47379.

The health plan's determination of medical necessity is overturned, in whole. 

The laparoscopic procedure 47379 was medically necessary.  A liver biopsy may be considered when there is the intra-operative identification of a liver mass or lesion as in this case.  In this case the patient was undergoing cholecystectomy when the surgeon noted nodules of the liver.  The patient also had elevated serum bilirubin and transaminases.  Liver biopsy to be performed concomitantly with cholecystectomy was medically necessary, as this biopsy will definitively identify the nature and stage of the liver nodule.  When performed at the time of laparoscopic cholecystectomy (rather than percutaneously at a separate time) this procedure carries minimal risk and adds very little time to the operative procedure.

If a laparoscopic biopsy of the liver is performed at the same time as another laparoscopic procedure, use of the unlisted code 47379 is most appropriate, as there is no CPT code for a laparoscopic liver biopsy.

Performance of liver biopsy at the time of other abdominal procedure is the standard of care that is regularly and routinely performed in this clinical circumstance.  For patients with hepatitis of various etiologies or liver masses, liver biopsy is used not only to establish the cause of the disorder, but also to assess the degree of inflammatory activity (grading) and the extent of fibrosis (staging).

Liver biopsy is an appropriate and standard of care intervention in the setting of imaging abnormality that identifies hepatic steatosis or liver mass.  Liver biopsy is also appropriate when these conditions are identified at the time of surgery.  Lab abnormalities, such as elevated serum transaminases are an indication for liver biopsy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Cerebral Ischemic Attack
Issue under review: Physical therapy services
The insurer denied the physical therapy services. 
The denial is upheld.

The patient is a male who sustained a neurological event, reported to be a transient ischemic attack (TIA).  He remained in the hospital for two days.  He saw his physician, who referred him to physical therapy.

The patient presented to a physical therapy practice.  He was having difficulty with balancing when standing and walking.  He underwent a therapy program that included therapeutic exercises, neuromuscular reeducation, gait training, electrical stimulation and manual therapy.

He had difficulties with balance at night, balance with eyes closed, and difficulty with uneven surfaces.  Active range of motion in the lower limbs was within functional limits.  Strength was in the 4-/5 to 4/5 range.  Berg balance score was 48/56.

The patient had undergone some therapy visits.  He was reporting improvement in walking.

No, the treatment in question was not medically necessary.

The patient had a neurological event that was described to be a transient ischemic attack.  The nature of this condition is that its effects are transient and resolve fully.  The patient had undergone extensive rehabilitation.  He continued to have various symptoms with respect to his mobility.  He did not, however, have impairments that would have precluded an independent exercise program to address his symptoms.  While the patient had persistent symptoms, no marginal difference in clinical course and outcomes would have been expected with an ongoing formal therapy program over an independent program based on the available clinical data.  The passive interventions he was receiving such as electrical stimulation and manual therapy have no proven role in the setting of a transient ischemic attack.  The services in question were not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal
Inpatient Hospital

Diagnosis: Back pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a girl with a history of acute myelogenous leukemia who presented to the emergency department with back pain.
She had been in remission from her leukemia, and also had cardiomyopathy secondary to her chemotherapy. She was seen  for right-sided chest pain and shoulder pain that was thought to be musculoskeletal. She was subsequently in her usual state of health until the day prior to presentation when she developed severe, generalized pain that was worse on her back. She described it as burning from her neck all the way down her back. It was worsened by ambulation. She was unable to walk on the day of admission, which prompted the emergency department visit. 

The the inpatient hospitalization was medical necessary for this patient.
This is a young girl with a very complex medical history, including a history of leukemia and cardiomyopathy, who presented with severe pain. At the time of presentation, she described her pain as 9 out of 10 in intensity, and she was unable to ambulate. She was febrile and her erythrocyte sedimentation rate was significantly elevated, raising concern for inflammation or infection. She required prompt initiation of pain management along with evaluation for the etiology of her pain. In the emergency department setting, she required several doses of narcotic medication and Toradol, as well as intravenous fluids. Hospitalization was appropriate for ongoing pain management, intravenous fluids with additional parenteral therapies as needed, and continued evaluation for infectious or rheumatologic causes of her pain.
The decision making at the time of admission for this patient was consistent with her young age, the presence of a significant and complex medical history, severe pain of unclear etiology, and the need for careful evaluation and prompt management with parenteral therapies and consultation as needed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and trouble breathing
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male with a past medical history significant for morbid obesity, chronic lower back pain, obstructive sleep apnea on CPAP, conversion disorder, who presented to the ER for evaluation of chest pain and back pain. The patient was hemodynamically stable. ECG revealed no acute ischemic changes. Cardiac enzymes were negative. The patient was admitted to telemetry to rule out ACS (acute coronary syndrome). Repeat troponins were negative. An echocardiogram was obtained, which was of poor quality due to body habitus. Stress test or other ischemic evaluation was not done due to morbid obesity. The patient was treated with pain management for his back pain. The plan was for transfer to sub-acute rehab; however the patient signed out against medical advice.

No, the proposed Inpatient admission is not "medically necessary".

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. ECG was unremarkable.  No stress test or angiogram was planned due to body habitus limitations. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. The clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Overturned

Pregnancy/Childbirth
Inpatient hospital

Diagnosis: postpartum preeclampsia
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned.

The patient is a female status/post (s/p) cesarean section with vacuum - assisted delivery of the neonate. Her pregnancy was complicated by severe preeclampsia. The patient received magnesium sulfate, was started on Procardia 90 mg XL and was discharged.
The patient presented on PPD (post-partum day) # 6 with complaints of headaches, lower extremity edema, worsening of hypertension.

The Inpatient Hospital Admission was medically necessary for this patient. Based on provided clinical information, the patient's delivery was complicated by severe preeclampsia. She was discharged home  with residual hypertension, on Procardia 90 mg XL. When the patient presented again, her BP was in severe range (163 / 97), she was symptomatic (headache) and her transaminases were abnormal (ALT was 53). Based on the constellation of these findings, she was correctly diagnosed with recurrence of severe preeclampsia in postpartum period. 25% of patients develop preeclampsia or its recurrence in the 6 weeks postpartum period. Of note, the presence of blood pressure in severe range (greater that 160 / 110 for systolic or diastolic measurements) is considered a medically necessary indication for admission as per the Milliman Care Guidelines (MCG) criteria. To prevent progression to eclampsia, the patient was started on magnesium sulfate.
Due to toxicity of this medication and its narrow therapeutic range, administration should be performed only at acute inpatient unit with cardiac monitoring and cannot be achieved on any other level of management (outpatient or observational). This practice is supported by literature and generally accepted standards of practice.
Therefore, based on the above discussion, the acute inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute cholecystitis 
Treatment: Inpatient admission for acute level of care 

The insurer is denied coverage for inpatient admission for acute level of care. The denial is overturned. 
 
This case involves a female who had been previously diagnosed with a ventral hernia as well as acute cholecystitis and a history of cholelithiasis who presented to the emergency department with complaints of abdominal pain. The documentation indicated she experiences chills when she has the pain and has "attacks" from her gallbladder. The patient on physical examination was in no apparent distress. The patient was positive for guarding with a reducible large ventral hernia present. The patient had tenderness to the right upper quadrant, and it was recommended she undergo laboratory and diagnostic studies. The laboratory studies revealed the specimen was moderately hemolyzed. The patient's white blood cell count was 15.54 and an abdominal ultrasound revealed gallstones without sonographic evidence of acute cholecystitis. The physician indicated the patient has known gallbladder disease and it was recommended the patient be admitted under surgical services to be assessed for pancreatitis as well as cholecystitis and biliary colic. The documentation detailed she was treated with medications and IV fluids. The documentation does indicate she did undergo a laparoscopic cholecystectomy and was transferred to Post Anesthesia Care Unit (PACU) in stable condition. The patient did not have any significant abnormalities. She was discharged the following day with instruction to follow-up. 

This patient had acute and chronic cholecystitis as demonstrated by the final pathology report. While the initial ultrasound did not demonstrate this, the literature has consistently demonstrated that ultrasound only has a sensitivity of 86% and a specificity of 71% (Jain et al., 2017). The patient's initial physical examination and history with a known history of gallbladder pathology warranted admission. Another study by Borzellino, et al. (2016) found that when using ultrasound findings alone to determine gallbladder pathology, 53% of cases with pathologically-proven cholecystitis had only 1 finding on ultrasound of gallbladder disease, demonstrating that ultrasound alone is not adequate to diagnose cholecystitis. The history and physical, the exam, lab values, and final pathological exam of the gallbladder all play a role. Therefore, the denial of coverage for inpatient care should be overturned. 

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

The carrier's denial of coverage for the continued inpatient admission for acute level of care is overturned. The medical necessity is substantiated.