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

Diagnosis: Elevated Troponin

Treatment: Inpatient Admission

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

This is a male patient with a medical history of anxiety, depression, diabetes mellitus, aortic coarctation, and chronic foot wounds. He presented to the Emergency department (ED) from a mental health clinic with complaints of hiccups and low blood pressure. His presenting blood pressure was 122/61, pulse 68, and respirations 18. A laboratory work up was performed revealing a troponin level of 0.04 and creatinine level of 1.37; repeat troponin level resulted 0.032. On physical examination it was reported that the patient had a stage lll ulcer on his right foot. He received intravenous (IV) fluids and antibiotics. He was consulted by cardiology. A computed tomography angiogram (CTA) of the chest was performed that was negative for a pulmonary embolism. A cardiac stress test was done with normal results.

Based on the review of the literature and the medical records provided, inpatient admission status was not necessary for this patient. The patient was normotensive with borderline troponin levels in the context of renal insufficiency. The patient had flat troponin levels without a rise and thus not consistent with acute coronary syndrome.  The patient remained asymptomatic.  The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing.  Further evaluation was warranted. However, the acute level of care for inpatient admission criteria was not met. The patient exhibited no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen, myocardial ischemia, or other medical conditions that warranted acute inpatient level of care.  

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

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gleason 3+3 adeno carcinoma
 
Treatment: Oncotype DX Prostate Cancer Assay

The insurer denied coverage for Oncotype DX Prostate Cancer Assay. The denial is upheld. 

This patient is a male with a prostate-specific antigen (PSA) of 2.5, who underwent a prostate biopsy for further evaluation. The patient was diagnosed with Gleason 3+3 adeno carcinoma in 1/12 biopsy cores, Gleason grade group 1. The patient then had on Oncotype Dx PCA test ordered for further risk stratification. The patient's genomic prostate score (GPS) score was 17, indicating very low risk prostate cancer. 
	
While the National Comprehensive Cancer Network (NCCN) guidelines state that men who have a NCCN low risk or favorable intermediate risk prostate cancer and at least a 10 year life expectancy should consider the usage of tissue based genomic biomarkers; they also note the absence of randomized prospective trials. The American Urological Association (AUA)  guidelines are not so positive on the usage of biomarker testing. The AUA states that the "tissue based genomic biomarker tests (such as Oncotype Dx PCA) have not shown a clear role in active surveillance for localized prostate cancer, and are not necessary for follow-up." Based on the review of the literature guidelines, the impact of tissue based gene expression tests, such as Oncotype Dx PCA, on clinical practice and long term patient outcomes remains to be empirically demonstrated. There is insufficient evidence to support that the prospective studies of these tests yield a true clinical benefit when implemented in clinical practice. It is not yet clear which patient population this test benefits and fits into the algorithm of the diagnosis and/or management of prostate cancer.

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

Based on the above, the medical necessity for the Oncotype DX Prostate Cancer Assay is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep impinging overbite and maxillary and mandibular crowding 

Treatment: Braces (code D8080) and monthly visits (D8670).

The insurer denied coverage for braces (code D8080) and monthly visits (D8670). The denial is upheld. 

This patient is a female who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to deep impinging overbite and maxillary and mandibular crowding.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage.  

Upon review of the submitted documentation, 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, 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 claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage.  This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet criteria to justify orthodontic care.  This reviewer concurs with the insurer attaining a score of 20 points on the HLD index (3 overjet, 6 overbite, 5 anterior crowding, 2 labiolingual spread, and 4 unilateral crossbite) which is below the threshold of 26 points to justify 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 the 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.  

Uphold denial as the clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

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

Braces (code D8080) and monthly visits (D8670) are not considered medically necessary for this patient.

The carrier's denial of coverage for braces (code D8080) and monthly visits (code D8670) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out pyelonephritis 

Treatment: Inpatient admission 

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

This patient is a female who presented at over 30 weeks gestation with complaints of feeling sick and a headache.  The patient's temperature was 100.7; and the patient's physical examination was normal.  The patient's fetal heart rate was normal; and there was no evidence of contractions.  The patient was admitted because of "weakness" and to rule out pyelonephritis. As per a specified progress note, the patient was afebrile and had no complaints. As per another progress note the patient was stable. The patient was discharged home.

According to the literature, the management of acute pyelonephritis in pregnant women includes hospital admission for parenteral antibiotics.  This is because pregnant women may become quite ill and are at risk for both medical and obstetrical complications from pyelonephritis.  It has been estimated that as many as 20 percent of women with severe pyelonephritis develop complications that include septic shock syndrome or its variants, such as acute respiratory distress syndrome. 

However, acute pyelonephritis is suggested by the presence of flank pain, nausea/vomiting, fever (>38oC or 100.4oF), and/or costovertebral angle tenderness, with or without the typical symptoms of cystitis, and is confirmed by the finding of bacteriuria in the setting of these symptoms. This patient presented with one episode of elevated temperature but did not have associative signs and symptoms to support the diagnosis of pyelonephritis, such as elevated neutrophil count, flank pain, costovertebral angle tenderness, or bacteriuria.

The patient could have been hydrated and observed; once the provider ascertained that there was no evidence of pyelonephritis, the patient could have been sent home on oral antibiotics. The inpatient admission to the hospital was not medically necessary.

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

The carrier's denial of coverage for the inpatient hospital services at the acute level of care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Respiratory System
Inpatient hospital

This is the case of a male with past medical history of chronic obstructive pulmonary disease (COPD), diabetes mellitus, morbid obesity, hypertension, coronary artery disease with prior myocardial infarction, and left nephrectomy, who presented to the emergency department with shortness of breath, productive cough, and chest pain. He was admitted to the hospital.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This is a patient who presented with shortness of breath and cough in addition to ground glass opacities on imaging. He was not hypoxic and was without persistent tachypnea. Though there was initial concern that his imaging could represent pneumonia, he had no clinical signs of pneumonia such as fever or leukocytosis, and infectious disease assessment was that he did not have pneumonia. He additionally had chest pain initially without EKG or troponin values suggestive of acute ischemia and with recent cardiac catheterization. In the absence of clear clinical evidence of pneumonia, hypoxia, persistent tachypnea, or chest pain thought to represent acute coronary syndrome, it is unclear why this patient could not have safely been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal - Shoulder Problem/Pain
Inpatient Hospital

The patient sustained a fall landing onto her right shoulder. She was subsequently seen and evaluated in the Emergency Department where x-rays confirmed a displaced right clavicle fracture. The patient underwent surgical intervention for this injury. She was discharged to home on hospital two days after admission. The health plan has denied the inpatient stay as not medically necessary.

The health plan's determination is upheld. Based upon the provided medical records in this case which do not justify inpatient hospital admission for this healthy patient. There were no complications from the surgery and the patient's pain was well controlled with oral medications after surgery. The care could have been completed at a lower level of care. Both outpatient and observation type admission for operative clavicle fractures are supported in the current, peer-reviewed orthopedic literature as documented by Herteleer and colleagues in the Journal of Shoulder and Elbow Surgery in 2018 and by Ahrens and associates in the Journal of Bone and Joint Surgery in 2017.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain 
 Treatment: Inpatient Admission 

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

This patient is a male child who initially presented to a medical facility with complaints of abdominal pain several hours with one episode of vomiting. The patients presenting vital signs were: blood pressure (BP) 92/57, heart rate (HR) 96, respiratory rate (RR) 22, Temperature 98.0. A laboratory blood work up was performed that revealed a white blood cell (WBC) count of 15.7.  He was transferred to another hospital due to concern for appendicitis. He had an ultrasound that revealed equivocal for findings of acute appendicitis. Pediatric Surgery consulted on the patient. On physical exam the patient's abdomen was soft, non-distended, and non-tender. A computed tomography was performed that showed the appendix was neither dilated nor inflamed but had wall enhancement. The patient remained afebrile and hemodynamically stable and discharged home. 

According to Milliman Care Guidelines General Recovery Care 22nd Edition Pediatric General Admission Criteria GRG: CG-PAC (ISC GRG), admission is indicated for 1 or more of the following: hemodynamic instability; hypertension in child requiring inpatient treatment; cardiac arrhythmia of immediate concern; severe heart failure in child; respiratory abnormalities in child; neurologic abnormalities; abdominal abnormalities; reduced urine output; acute renal failure; significant uremic complications; 29-day-old to 90-day-old child with temperature greater than 100.4 degrees F (38.0 degrees C) (rectal) and high-risk findings; high fever or other high-risk infection situation in child; severe electrolyte abnormalities; severe metabolic abnormality; acute blood loss causing significant abnormality; severe pain requiring acute inpatient management; severe malnutrition; severe behavioral health issues; suspected child abuse or neglect; inpatient monitoring needed ; treatment requiring inpatient care; and/or emergency procedures needed. 

Based upon these criteria, literature supports that this patient could have been treated with an observation admission and discharged home within 48 hours. This patient did not have any clinical indication that met the Milliman Care Guideline criteria for acute care admission. 

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

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems
Dental/Orthodontic Procedure

The patient is a female with a Class I occlusion and slightly high overjet and overbite. The maxillary and mandibular arches have some crowding. She is treatment planned for 24-30 months of orthodontics to correct her malocclusion. The provider notes that the patient has a traumatic deep bite with severe soft tissue damage. Full braces are being requested and is the subject of this review.

The health plan's determination is upheld. Braces are not medically necessary. There is no medical reason to correct her malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. There are many ways to correct patients with a deep bite, and there is strong evidence that one treatment is not better than another. Furthermore, deep bites may be corrected in adulthood, so it is not as if she will lose the ability to correct her malocclusion should she choose to do so as an adult.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient hospital

The patient is a male was seen in the emergency room (ER) for 2 days of abdominal pain. The patient had been seen 4 days earlier in the ER for similar complaints. He was thought to have a viral syndrome on the first visit. At the present ER visit, the patient was denying associated nausea or vomiting. No symptoms of gastrointestinal (GI) bleeding were noted. He has asthma and previously had an appendectomy. On exam, he appeared uncomfortable, frequently holding his abdomen and grimacing. No fever was noted. The abdomen had some tenderness and guarding. Labs showed the urine drug screen was negative. All other labs were normal and the abdominal X ray and ultrasound were both negative. The patient was given famotidine and Toradol in the ER. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient warranted observation as he was in significant subjective pain and there was guarding on physical exam. It was not clear concerning the etiology of the pain which was a recurrence from a previous recent admit. Due to this diagnostic uncertainty and the condition of the patient, observation was appropriate. However, this could have been done at a lower level of care. The patient did not require an acute inpatient stay.
Appeal type: Medical necessity
Decision: Upheld

The patient lost more than 120 pounds following bariatric surgery. The weight gain was due to hypothalamic obesity syndrome. The patient now complains of hanging abdominal skin with related skin infections. Topical medications have not provided relief. On examination there are no hernias. There was no mention of visible intertrigo at any of the office visits. A medication list does not include any medication for a skin condition related to a hanging abdominal pannus. Undated photos show an infraumbilical pannus that hangs over the pubis whose fold extends laterally to the anterior axillary line. There are no views of the under surface of the pannus. The surgeon is proposing panniculectomy surgery. The health plan's determination is upheld. 

Panniculectomy (CPT 15830) only involves removal of the lower abdominal skin without muscle tightening or supraumbilical skin tightening. It would be medically necessary if the removed skin has a history of recurrent infections, is necrotic, interferes with range of motion, blocks a body orifice etc. The mere presence of a pannus and/or its psychological or physical burden on the patient does not automatically make its removal medically necessary. 

In this case, while there are photos that illustrate that the patient has a panniculus that hangs below the level of the pubis, there is no documentation of any of the above conditions that would warrant panniculectomy. There is no evidence in the reviewed materials that would support the medical necessity of a panniculectomy in this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer/Lung Cancer
Treatment: Inpatient hospital stay

This patient has a history of lymphoma and a left lung nodule status/post (s/p) video-assisted thoracoscopic surgery (VATS) wedge resection. Patient presented to the hospital for a scheduled right VATS wedge resection of a right lung nodule. The surgical procedure was uneventful, and subsequently the patient was transferred to the post-anesthesia care unit. Chest tube was discontinued on postoperative day (POD) #0. In the evening, the patient became tachycardic with a heart rate in the 140's, and soon thereafter developed chest pain/pressure and shortness of breath. An electrocardiogram was performed that demonstrated supraventricular tachycardia (SVT) with ST changes, and troponin was < 0.02. SVT did not resolve after two doses of intravenous (IV) metoprolol. Patient was given IV fentanyl and a normal saline IV bolus, but heart remained in SVT. Ultimately, the Intensive Care Unit (ICU) team was consulted and carotid massage was performed which broke the SVT, and heart converted to a normal sinus rhythm. Following these events, the patient was maintained on telemetry until  discharged to home on POD #3. The health plan's determination of medical necessity is overturned in whole. This patient received appropriate attention and care, including studies to rule out myocardial infarction, pharmaceutical intervention and finally carotid massage for definitive treatment of arrhythmia after it was determined to be SVT. Following this episode, the patient experienced an uneventful recovery. However, due to the events of the first postoperative day, this patient required an inpatient level of care.
While the patient underwent an uncomplicated VATS right upper lung lobe wedge resection, postoperatively the patient developed tachycardia, chest pain and shortness of breath that required work-up and intervention at an inpatient level of care. Further, the patient required 3-midnights in the hospital, whereas a lower level, such as observation level of care, is intended for patients who are expected to stay < 2 midnights(1) and do not require the inpatient attention and care that this patient received.
Appeal type: Medical necessity
Decision: Upheld

Digestive system /Gastrointestinal Abdominal /stomach pain 
Inpatient hospital 

Patient with a history of Crohn's Disease versus ulcerative colitis. The patient was admitted to the hospital for abdominal pain for 2 weeks associated with bloody diarrhea. The pain was located in the  left lower quadrant (LLQ) and sharp in quality. The health plans determination of medical necessity is  upheld in whole.

No, the inpatient stay is not medically necessary for this patient.
In general, the criteria used by IBD providers is as follows: Inpatient hospitalization is required for patients with Crohn's disease who are acutely ill due to a complication such as partial small bowel obstruction, peritonitis, or a disease flare that is not responding to outpatient therapy. Management may include intravenous fluid and electrolyte replacement, intravenous broad-spectrum antibiotics, nutritional assessment, and consultation with a gastrointestinal surgeon. Some patients may also require treatment with intravenous glucocorticoids or biologic therapy. Based on the presenting data including the totality of the patient's symptoms in conjunction with the physical examination findings, laboratory results, and the computed tomography (CT) report, the patient did not meet this criteria for inpatient admission.
This patient presented similar to a presentation of mild-moderate uncomplicated acute diverticulitis. The standard of care for acute diverticulitis consists of evaluation and po antibiotics, and for mild-moderate uncomplicated acute diverticulitis the patients do not require inpatient admission to the hospital and can be treated at a lower level of care.