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

Diagnosis: Shoulder pain
Issue under review: Shoulder surgery

Determination:
The Shoulder surgery was not medically necessary.

The patient is an adult with right shoulder pain. He was evaluated by his physician. He reported pains to the shoulder, specifically when throwing a baseball. His pain level at rest was 0. His pain level with being active was 9. He received an injection of cortisone and was referred for PT (physical therapy). 

The patient was found to have full motion, 4/5 strength and + Neer, Hawkins, Drop arm test. He was referred for MRI. 

The patient was diagnosed with a tear to the rotator cuff. He had completed six visits of PT as of three weeks after presentation. He was reported to have improved. 

Surgery was recommended approximately two weeks after presentation and completed approximately two months later. 

The patient reported a painful right shoulder. Surgery is recommended if there is consistency of subjective complaint, objective finding and failure of conservative treatment. The records show the patient has no pain at rest. He has limits to throwing a baseball. He was reported to have improvement with his treatments. He received six visits of PT. He did not receive a full course of conservative management. There was no documentation of six weeks of conservative management. 

The severity criteria require difficulty with performing at least two age-appropriate daily activities. These were not reported. 

Based upon criteria not being fulfilled, surgery would not have been indicated.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient Hospital

The patient is a female. She presented to the emergency room 2 days after ingesting a foreign body (silver marble). She reported abdominal pain on presentation. The initial X-ray showed the foreign body in the stomach with gastric distention. The patient was admitted with a plan for endoscopic foreign body retrieval the following morning. She received intravenous fluids and was ordered to receive nothing by mouth (NPO). The following day, a repeat X-ray showed that the foreign body had passed the stomach to the small bowel and the determination was to discharge the patient without an endoscopic retrieval, as the foreign body was likely to pass through the gastrointestinal tract spontaneously after passing the pylorus.

The health plan's determination is upheld.

The inpatient hospital stay was not medically necessary. The patient presented after ingesting a foreign body. She was symptomatic with abdominal pain and had evidence of intermittent gastric outlet obstruction on the X-ray (gastric distention). The standard of care in the management of symptomatic pediatric patients with foreign body in the stomach is endoscopic retrieval within 12-24 hours of presentation. Per the "Clinical Report of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) Endoscopy Committee: (1) "Gastric coins (and other blunt objects) can generally be managed expectantly, unless overt gastrointestinal (GI) symptoms are noted." Per Lee, Ji Hyuk "Long or large foreign bodies (FBs) in the stomach necessitate removal within 24 hours."
Therefore, admitting this patient to arrange for the urgent endoscopy was medically appropriate.
The standards practice are to obtain a repeat X-ray just before the endoscopy. This patient was lucky to have the foreign body pass spontaneously beyond the stomach. The endoscopy was no longer indicated at the point. The treating team had to admit the child and start the endoscopy arrangement because the progress of this situation was not predictable.
The care for this patient would not have been appropriate at outpatient level of care (emergency room or office). The patient was planned to have an urgent endoscopy in the morning and needed monitoring meanwhile. She also needed to remain fasting and on intravenous fluids. The care plan included a repeat  X-ray. Care at the emergency room is typically appropriate for stabilization and short term monitoring. In this case, prolonged (overnight) monitoring was required. Therefore, the emergency room (i.e. outpatient care) was not appropriate. 
However, the care provided was not medically necessary at an inpatient level. There was no complex treatments provided or invasive procedures that required an inpatient level. The patient could have been managed safely at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pyelonephritis; UTI refractory outpatient management

Treatment: inpatient admission

The insurer denied coverage for inpatient admission. The denial is reversed. 

This patient is a female with past medical history of recurrent urinary tract infection (UTI), gastroesophageal reflux disease (GERD), migraines, status post gastric banding ten years ago, status post gastrectomy (sleeve) several months prior and status post cholecystectomy who presented to the emergency department (ED) complaining of left flank pain radiating to her groin, low grade fever, nausea, and diminished oral intake. The patient was on Omnicef for a UTI diagnosed one week prior.  The patient was admitted for pyelonephritis and the management of UTI refractory to outpatient management.  Infectious Disease service was consulted.  The patient was started on vancomycin/ciprofloxacin, and was also given pain medication.  The patient's results of her urinalysis and urine culture collected on admission were unremarkable.  The patient had mild low blood pressures that were responsive to intravenous fluid administration.  The patient's symptoms improved, and the patient was discharged home.

Based on the review of the MCG Health (23rd Edition) guidelines on the management of urinary tract infection (UTI), this patient meets the clinical indications for admission to inpatient care. As per MCG criteria, inpatient admission is indicated if the patient presents with persistence or worsening of clinical findings (i.e. fever, pain) despite outpatient (course of antibiotics) and observation care treatment.  Prior to admission, the patient has trialed on outpatient antibiotic for her urinary tract infection but clinically worsened with symptoms including nausea and poor oral intake, and condition progressing to pyelonephritis. During inpatient stay, the patient required broad spectrum of intravenous antibiotics and intravenous fluid boluses to maintain the patient's blood pressure at her baseline. Based on this review of the literature and the medical records provided, this patient's inpatient admission is considered medically necessary.

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

The carrier's denial of coverage for the inpatient admission is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal
Surgical Services (all)

This is a female who has a bilateral breast pain from her breast implants. Her right implant was high riding. She has right breast Grade III/IV contracture and left breast Grade II contracture. Her surgeon performed bilateral implant removals and capsulectomies and mastopexies. Breast Repair/Reconstruction is under review.

The health plan's determination is upheld. The Breast Repair/Reconstruction was not medically necessary for this patient. The patient had a periprosthetic capsular contracture, which is a known complication of breast implants. A study by Dancey et al found a 26.9% incidence of capsular contracture following breast augmentation surgery. The original procedure was for cosmetic purposes. Capsular contractures typically cause discomfort and pressure in the breast, but have no long-term health risks if untreated. When implants are placed for reconstructive purposes, treatment of these complications is indicated. However, in this case, the initial procedure of breast augmentation was a strictly a cosmetic procedure.
Using the American Society of Plastic Surgeons (ASPS) position paper on reoperation for implants placed for cosmetic augmentation, the medically necessary conditions for reoperation are broken or failed implant, infection, implant extrusion, siliconoma or granuloma, interference with the diagnosis or treatment of breast cancer. The ASPS position paper goes on to say that insurance carriers "respond thoughtfully and with compassion on an individual basis" for several other conditions including "mastodynia (painful breasts) and medically significant capsular contracture (capsular contracture that produces pain, disfigurement and/or interferes with mammography)." Capsular contracture is a benign condition. Although contractures can be painful, they do not pose a health risk or danger. Surgery will make the patient more comfortable and will improve the appearance of her breasts, but it is not medically necessary to prevent a disease or illness or to treat a functional problem.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous system /Other 
Inpatient  Hospital

At the time of surgery, the patient with severe right arm pain from a cervical disc herniation who had failed conservative treatment. the past medical history (PMH) was significant only for gastroesophageal reflux disease (GERD) and obesity with a body mass index (BMI) of 30-30.9. The patient underwent an uncomplicated Cervical (C)5-6 ACDF (anterior cervical discectomy and fusion) on day #1. 
The patient was admitted as an inpatient to the hospital and did well. the patient  subsequently was discharged the next day after the Hemovac drain was removed.The health plans determination of medical necessity is upheld in whole . 
No, the requested service of inpatient stay was not medically necessary for this patient undergoing this ACDF procedure.
 There is no compelling clinical reason documented in the records provided that the patient could not have safely been classified at the lower level of care, rather than being admitted initially to an inpatient level of care. There were no comorbidities in his past medical history (PMH) that would reasonably have been expected to require an extended length of stay (LOS) in the hospital, his operative report documents an uncomplicated ACDF procedure, and the anesthesia and post-anesthesia care unit (PACU) records were unremarkable. It is very common to monitor patients undergoing an ACDF overnight, as the complications of respiratory distress from either tissue swelling or a postoperative hematoma usually occur the night of surgery and can require emergent attention (Tasiou et al and Arshi et al), but that would still fit into the lower level of care status. If ever any significant complications or vascular instability arises the patient can always be reclassified as an inpatient as needed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope and chest pain
 
Treatment: Inpatient hospital stay

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

This patient is a male who presented to the Emergency Department complaining of dizziness and fainting.  He also complained of headaches with shortness of breath and chest pain.  The patient does have a medical history which includes hypertension, as well as peptic ulcer disease, seizure disorder, stroke, diabetes, pulmonary embolism, and hyperlipidemia.  The patient has also had a prior myocardial infarction.  Physical examination revealed a heart rate of 95 beats per minute (bpm) with a blood pressure of 137/86.  The patient was alert and oriented.  The patient had a normal rate with regular rhythm on cardiac exam and there were no motor or sensory deficits.  The patient was recommended to undergo multiple laboratory diagnostic studies.  The patient's troponin level revealed a negative result.  The patient's prothrombin time was elevated at 21.4.  A chest x-ray revealed no focal or lobular lung consolidation.  There was mild persisting prominence of the central pulmonary vasculature which may reflect pulmonary hypertension. The re-evaluation detailed that the patient should be admitted to further evaluate syncope and chest pain. He underwent additional imaging to include an MRI of the brain with no acute pathology noted.  The patient did not have any further significant adverse events and he continued medication use while hospitalized.  He was discharged.

The patient developed dizziness with a normal neurological examination and a negative CT and head MRI for stroke or acute pathology.  The literature details that a patient may be appropriate for an inpatient admission when there is evidence of acute motor, sensory or visual deficit that suggest an acute stroke. Additionally, when there are new focal neurological signs, acute stroke, hemodynamic or cardiovascular compromise or acute prolonged metabolic decompensation or seizure, a patient may be admitted.  The documentation does not detail the above.  As such, the patient condition could be managed in a different setting.

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 stay is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic pain
Issue under review: Inpatient rehabilitation

Determination:
The Inpatient rehabilitation is medically necessary.

The patient is a teen-aged female with history of fibromyalgia (M79.7) as well as generalized weakness, amplified pain syndrome, Raynaud's syndrome and Tietze syndrome. The patient has reported onset of pain and discomfort for a number of years. During the last six years, multiple physicians have been involved in her plan of care. The patient underwent diagnostic tests ordered by the qualified healthcare providers in rheumatology, cardiology, OB/GYN without evidence of pathology in multiple organs. 

The patient has failed outpatient therapy interventions. She has been undergoing outpatient physical therapy interventions at an outpatient physical therapy practice. Despite numerous interventions outlined in the medical records, the patient did not experience pain relief, therefore the decision was made to initiate a course of acute inpatient rehabilitation referral for four weeks duration.  

The chronic pain program offered by the specialized hospital is goal-oriented, and supporting documentation contains an outline of structured rehabilitation, pain management, cognitive goals that this child should achieve. Initial request for an inpatient admission to the hospital has been denied based on the lack of medical necessity.  An appeal by both patient and treating physician has been filed in response to the initial denial.

In this complex case, the patient has clear evidence of amplified pain syndrome signs and symptoms requiring utilization of structured patient-centered goal-oriented program in an acute inpatient rehabilitation setting. Clinical records convincingly demonstrated lack of response to the treatment in outpatient settings. In this case, there is a preponderance of evidence in support of utilization of the well-established "chronic pain program" at the rehabilitation facility. In fact, all of the referring providers are in support of the use of the acute inpatient rehabilitation capabilities. In addition, contemporary medical literature support use of acute inpatient rehab for complex cases of Amplified  Pain syndrome.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of carcinoid of the rectum status/post (s/p) resection. She has had a local recurrence that was also treated with surgery. She has had a persistently elevated chromagranin. A computed tomography (CT) with contrast was unremarkable for disease. An octreotide scan was requested and is under review for medical necessity.
The health plan's determination is upheld.
This patient has no CT evidence of disease and is without symptoms. It is unclear as to how Octreoscan would alter management as the patient is without symptoms and clearly has a low disease burden. Based on National Comprehensive Cancer Network (NCCN) Guideline recommendations, Octreoscans are not a preferred modality for imaging in this clinical scenario. Further, as the patient has no evidence of disease on conventional imaging, management as supported in the literature would either be observation or Octreotide/lanreotide. This decision would not generally be predicated on imaging findings as it is doubtful that somatostatin-receptor based imaging is going to result in evidence of a high disease burden. Given the lack of support in guidelines or the literature, medical necessity has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a male patient with a history of lumbar radiculopathy due to herniated discs. He had a magnetic resonance imaging (MRI) of the lumbar spine without contrast that showed shows extensive multilevel lumbar discogenic spondylosis. He had received 3 lumbar epidural steroid injections for pain management in the past year to treat his condition.

Clinical practice guidelines (1) and Medicare LCDs (2,3) support epidural steroid injections for lumbar Radiculopathy. The LCD supports 3 Epidural steroid injections (ESI) in a six month period and up to 6 in a 12 month period.

The patient has documented lumbar radiculopathy along with MRI documented pathology that matches his symptoms.  He has had 3 prior ESIs which have provided him with good effect. Clinical practice guidelines support the repeat of an epidural in this case and the NCD and LCDs support up to six injections in a 12 month period.

This procedure is likely to be more beneficial that a surgical intervention.

The carrier's denial of the epidural steroid injections (Current Procedural Terminology (CPT) code 62323 and Healthcare Common Procedure Coding System (HCPCS) code J3301) should be reversed.
Appeal type: Experimental/Investigational
Decision: Upheld

This patient has requested epidural steroid injections for his lumbar spine. His magnetic resonance imaging (MRI) demonstrates mild bilateral lateral recess stenosis at L4-5 and right lateral recess stenosis at L3-4.

Scientific evidence in peer-reviewed literature does support a result of improvement in health outcome with epidural steroid injections (CPT code 62323 and HCPCS code J3301), but only short term.

Epidurals have demonstrated efficacy for short term relief of inflammatory and radicular pain due to nerve root compression. This has been shown to improve function, reduce pain, and medication use. However for this patient's diagnosis further ESI would not be more beneficial.

"Lumbar radiculopathy is a common diagnosis for patients who present with low-back pain and leg pain, typically along a particular dermatome. This pain is commonly associated with a lumbar disc herniation. The prognosis is usually favorable, and the symptoms can resolve spontaneously over time. In patients in whom leg and back symptoms are severe, lumbar epidural (cortico)steroid injections are good options for the short to medium-term management of pain." (Pena, et al. 2016).
The patient is not a good candidate for epidural steroid injections (CPT code 62323 and HCPCS code J3301). Based upon the medical records provided there is no evidence to support epidural steroid injection in this patient.    Epidural steroid injections (CPT code 62323 and HCPCS code J3301) is not the best available treatment for this patient at this time. There is no documentation of degree of functional benefit or duration and percentage of pain relief from prior injections.

"Approximately 14% of patients with lumbosacral radiculopathy will eventually require surgery for severe pain that may or may not be associated with neurological deficit.[8] However, in many cases, radicular pain secondary to intervertebral disc herniation improves with medical and rehabilitative treatment. Steroid injection into the epidural space is used to achieve inflammation reduction, pain relief, and limit the need for medications or surgery." (Hassan, et al. 2019).                                                    

The carrier's denial of the epidural steroid injections (Current Procedural Terminology (CPT) code 62323 and Healthcare Common Procedure Coding System (HCPCS) code J3301) should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lumbar Radiculopathy

Treatment: Epidural Steroid Injection (CPT code 62323 and HCPCS code J3301)

The insurer denied the Epidural Steroid Injection (CPT code 62323 and HCPCS code J3301). The denial was upheld.   

This is a male patient with a diagnosis of lumbar radiculopathy. He had a lumbar magnetic resonance imaging (MRI) without contrast that revealed extensive multi-level discogenic spondylosis.  At L4-L5, there was a broad central and left-sided disc herniation with facet and ligament hypertrophy resulting in a mild degree of canal stenosis, bilateral recess narrowing, and compression upon the exiting left L4 nerve root.  It was reported that the patient had several past epidural injections along with a home exercise program and non-steroidal anti-inflammatory drugs allowing him to maintain functional status a year prior to this request for treatment. 

The current standards of care support lumbar epidural steroid injections for suspected radicular pain based on radiation of pain along the dermatome of the nerve or for neurogenic claudication and low back pain of moderate to severe intensity associated with significant impairment of activities of daily living in combination with substantial imaging abnormalities such as a central disc herniation or severe degenerative disc disease or central spinal stenosis. 

The FDA has not approved corticosteroids for injection into the epidural space; however, physicians are using them "off label" for this purpose. Repeat injections may be medically necessary when there is documentation of at least 50% or more cumulative pain relief obtained for a minimum of 6 weeks to be considered a positive and effective response. 

The cited literature notes that no more than 4 injections should be performed per 12 months. Although the patient may be a candidate for epidural steroid injections, further documentation is needed regarding the previous levels injected, and the response to those injections including percentage and duration of pain relief. The patient underwent a L5-1 ILESI. An MRI did not demonstrate significant disc herniation, central canal or neuroforaminal stenosis at this level. Therefore, a L5-1 ILESI would not represent the best available treatment in the absence of exceptional factors.  It cannot be said that the requested service would likely be more beneficial than standard treatments in the absence of corroborating imaging findings at the L5-1 level.

The carrier's denial of the epidural steroid injections (Current Procedural Terminology (CPT) code 62323 and Healthcare Common Procedure Coding System (HCPCS) code J3301) should be upheld.