Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

The patient had a suspicious lesion on the thigh, evaluated with reflectance confocal microscopy and determined to be a benign mole. The use of the Reflectance Confocal Microscopy is under review. 

The health plan's determination is overturned. The Reflectance Confocal Microscopy is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Biopsy and histologic evaluation have been the gold standard to diagnose skin tumors. Reflectance confocal microcopy (RCM) is a noninvasive, innovative diagnostic technique that enables visualization of different skin layers at an almost histologic resolution. RCM has been proven beneficial in management of various cutaneous lesions. This prevents unnecessary biopsies. Current literature supports use of RCM.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The proposed inpatient admission was not medically necessary.
The treatment as provided was medically appropriate but not medically necessary at the level of care at which it was provided. 
The patient presented with the complaints of hematemesis and pain, but did not evidence anemia or further bleeding.  Risk stratification with an endoscopy should have been undertaken to determine the cause of the hematemesis.  As the patient did not undergo risk stratification with this modality and the patient continued to evidence clinical stability throughout the period of care and since the patient responded to the care provided, a full acute hospitalization was not indicated.  The entirety of the care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of obesity who presented to the emergency department (ED)  with a complaint of bilateral thigh pain for one day. The patient reported that she had a cough and fever 2 weeks prior and was prescribed Tamiflu and Prednisone taper. The patient stopped the steroids because she felt better then restarted them once the cough returned. She first felt left thigh pain followed by right thigh pain. She also reported sharp neck and back pains as well as the inability to ambulate without assistance. The health plan's determination of medical necessity is upheld. There were no acute findings or clinical criteria that required inpatient care in this case. The patient did not have any alarming signs or symptoms that required an inpatient admission. The generally accepted practice would be outpatient treatment and follow-up, given the lack of signs or symptoms of impending neurological or muscular compromise. This patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The proposed treatment -- admission an at inpatient level of care  -- was not medically necessary. 

According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), "patients undergoing uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged home on the day of surgery" [SAGES].  Indeed, insofar as the patient did not demonstrate significant co-morbidities or physiologic derangements, and insofar as surgery and recovery were uncomplicated, the patent could have been treated at a lower level of care, precluding the need for admission.
Based on the provided medical documentation and in accordance with national guidelines, for this patient, admission at an acute inpatient level of care was not necessary. The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anxiety, depression, and suicidal ideation

Treatment: Inpatient mental health treatment

The insurer denied for coverage Inpatient Psychiatric Service. The denial was reversed.

According to the patient's medical record, this is a male patient who was admitted to inpatient mental health treatment due to severe depressive symptoms including depressed mood, feelings of hopelessness, suicidal ideation and plan, isolation, withdrawn, severe psychomotor slowing, decreased motivation, energy, concentration, and anhedonia, and inability to care for his basic needs with poor ADL's. He had a reported diagnosis of Major Depressive Disorder. He had multiple medication changes and an active psychiatric treatment plan and still made minimal improvement until days prior to discharge. He reportedly tried Paxil, Bupsirone, Haldo, Abilify, Neurontin, Risperidone, Xanax, Lithium, and Remeron. He was discharged.

The insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary treatment. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorder reports that the least restrictive level of care for safe and effective treatment is appropriate. It also states that patients with suicidal intent or plan, or behaviors, or who present as an imminent danger to self or others are in need of hospital treatment. It also states that patients with inability to adequately care for their basic needs or severe psychomotor slowing may need hospitalization. 

This was the case with this patient. This patient had reports of severe depression including depressed mood, feelings of hopelessness, suicidal ideation and plan, isolation, withdrawn, severe psychomotor slowing, decreased motivation, energy, concentration, and anhedonia, and inability to care for his basic needs with poor ADL's. He had many medication changes with none to minimal improvement only, until recently. He continued to have severe depressive symptoms rendering him unable to care for his basic needs and he continued to require inpatient hospital treatment as a result. 

Based on the above, the medical necessity for the inpatient psychiatric hospital services is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), as well as a history of poor adherence and also had a past medical history of esophageal candidiasis, pericarditis, asthma, anal condyloma, chlamydia, and syphilis. The patient presented with four days of non-bloody vomiting, and also reported watery diarrhea. The last CD4 count was 24. Patient denied any sick contacts and travel. Review of systems was negative for fevers. Patient also denied chest pain, palpitations, dizziness, and syncope.
Vital signs showed blood pressure 118/66, heart rate 96, respiratory rate 16, and temperature 98.9 Fahrenheit. In the emergency department (ED), patient was given Zofran, Bactrim, and fluconazole. On physical examination, there were numerous white plaques in the oropharyngeal region, heart was regular, breath sounds were normal, abdomen was soft and tender but later reported to be nontender. Labs showed sodium 139, potassium 3.5, white blood cell (WBC) count 6.6, hemoglobin 10.2, and platelets 305. Hepatitis B and hepatitis C testing were both negative. The patient was admitted with esophageal candidiasis and gastroenteritis. The plan of care included intravenous (IV) fluconazole, speech and swallow evaluation, IV fluids, stool studies, infectious disease consult, IV Bactrim, and azithromycin prophylaxis. During the hospital stay, the patient received an evaluation for frequent headaches and was seen by neurology and also underwent brain magnetic resonance imaging (MRI) which showed nonspecific hyperintensities but no acute lesions. The plan was to consider a lumbar puncture if headaches persisted. The infectious disease service saw the patient and recommended against anti-retroviral therapy because of history of non-adherence. Symptoms improved and the patient was discharged.
The health plan's determination is upheld.
The requested health service/treatment of Inpatient hospital admission for treatment dates requested was not medically necessary for this patient. The reason is that the patient was hemodynamically stable, and had no acute abnormalities requiring inpatient care. Patient did have significant risk factors for infection including untreated HIV. However,  improved rapidly from viral gastroenteritis, and had no other organ systems that were acutely affected by presenting symptoms.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history significant for coronary artery disease, hypertension, and hyperlipidemia and presented to the hospital with complaints of dizziness and unsteadiness. The patient had been in usual state of health until the morning of the day of admission. The patient woke up at 4 AM and started to feel dizzy.  The patient denied nausea, vomiting, headache, dyspnea, or syncopal episode.
The review of systems was positive for dizziness, the rest of the review of systems was negative.
On the physical exam the patient was afebrile, blood pressure was 158/77, pulse rate 56, and respiratory rate 20, with an oxygen saturation of 99% on room air. The patient was awake, alert and oriented 3, and was not in acute distress. The cardiac exam was unremarkable. The lungs were clear to auscultation bilaterally, the abdomen was benign, the 
neurological exam was non-focal.
Computed tomography (CT) scan of the head was performed in the emergency department and demonstrated no evidence of acute intracranial findings.
The patient was admitted to a telemetry floor. An acute coronary syndrome was ruled out. Echocardiogram was performed but did not show clinically significant abnormalities. The patient was seen by a neurologist and was recommended magnetic resonance imaging (MRI) of the brain which the, patient unfortunately, could not tolerate because of claustrophobia. Therefore, the patient was recommended to follow up with a neurologist as an outpatient. The patient felt significantly better,  symptoms essentially resolved, and no further acute inpatient management was indicated. The patient was deemed stable for discharge.
The health plan's determination is upheld. 

The requested treatment of inpatient stay was not medically necessary for this patient, who presented to the hospital with dizziness and unsteady gait. Although these symptoms might be present in cases of acute stroke, they are generally nonspecific. The patient was afebrile and hemodynamically stable, had unremarkable results of the physical exam including neurological exam, except for very questionable right upper extremity pronator drift. This patient had unremarkable results of laboratory studies and diagnostic tests. It was mentioned in the appeal letter from the hospital that the patient was out of the window for tissue plasminogen activator (TPA). Acute ischemic stroke was a consideration; therefore, the patient was appropriately admitted to a telemetry floor. The workup for possible acute stroke in the otherwise stable patient is usually performed at a lower level of care unless patient's condition requires interventions or diagnostic tests that can only be performed at the inpatient level of care.  Neither the severity of the patient's condition nor the complexity of the services provided justified the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma exacerbation

Treatment: Bronchodilators, IV steroids, IV antihistamines

The insurer has denied inpatient admission. That denial was upheld.

This is a female patient presented to the ER with shortness of breath and chest tightness. She has a past medical history of asthma and an allergy to red peppers. The patient reported accidental ingestion of red peppers, which triggered her asthma. EKG showed prolonged QTC and tachycardia. She was admitted to telemetry and given IV medications. She discharged.

On presentation to the ED, the patient was in no acute distress. Vital signs included temperature (T) 98.4 F, heart rate (HR) 108, heart rate (BP) 123/79 mm Hg, respiratory rate (RR) 18 and oxygen (O2) saturations were 97 % on room air. No use of accessory muscles or stridor was noted. The patient had peak expiratory flow (PEF) 170-180 (baseline is approximately 220). Lungs were clear. The patient was alert and oriented x3. She had elevated D-dimers, so a CT was performed to rule out pulmonary embolism (PE). She did not need acute hospitalization. Her symptoms were mild. She was in no acute distress. She responded well to treatment in the ED. Her lungs were clear. She was not hypoxic on room air. The chest x-ray and chest CT did not reveal any pulmonary pathology. Pulmonary embolism (PE) was ruled out. She was ambulatory. This patient could have been placed on observation status while diagnostic testing and treatment was initiated. She remained afebrile and hemodynamically stable and could have been discharged on oral medications with close follow-up by the next day. 
Based on the above, the medical necessity for the inpatient hospital is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abnormal ECG
Issue under review: Inpatient admission

Determination:
The inpatient admission was medically necessary.

The patient presented for detox due to acute alcohol and substance abuse, and was found to have significant QT prolongation on the ECG, a finding which placed him at a high risk of malignant ventricular arrhythmias. The patient was closely monitored, provided with IV fluids and treatment for acute withdrawal. Given the acute withdrawal, need for IV Hydration and medication, it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of ischemic stroke and morbid obesity. She presented to the emergency department after an episode of syncope that was preceded by an occipital headache. She also reported a subjective increase in her baseline left-sided weakness. In the emergency department, her blood pressure was 116/76 millimeters of mercury (mmHg) with a heart rate of 81 beats/minute. The health plan's determination of medical necessity is upheld. This patient presented with syncope that occurred while standing. She was hemodynamically stable, with normal cardiac biomarkers. Her cardiac exam was normal; on neurologic exam she had mild left-sided weakness that was not a new finding. Her electrocardiogram was normal. There was no evidence of an acute stroke.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a male with a history of seizure disorder and bipolar disorder. He presented with decompensation in his pre-existing psychopathology. He was then reported to have a witnessed seizure at the nursing station.  He was given Ativan and valproic acid bolus. His valproic acid level was 99 at admission. His neurological examination was normal. 

The patient had a known history of seizure disorder and had a single event with return to his neurological baseline. He was already established on an outpatient anticonvulsant regimen, and his serum levels of this medication were therapeutic.  The diagnostic studies, clinical monitor and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient and her spouse are carriers of Tay-Sachs disease. They are requesting in-vitro fertilization with preimplanatation genetic testing to prevent having a child born with the disease. The health plan has denied the IVF as not medically necessary. The health plan's determination is overturned. IVF is medically necessary for this patient. If services are not provided, the couple have a 25% chance of having a child with a fatal childhood disease. With the testing the chances of having a child with Tay-Sachs are less than 1%. IVF with PGT-M is in accordance with accepted standards of medical practice for this patient's circumstances.
Appeal type: Medical necessity
Decision: Overturned

The patient with past medical and surgical history significant for Crohn's disease, rectal abscess, rectal stricture, and loop ileostomy status/post (s/p) reversal, presented to the emergency department with 1 week of worsening rectal pain. Of note, the patient also reported passing watery black diarrhea which was similar to prior episodes of clostridium difficile infection. The patient was unable to tolerate a rectal exam and computed tomography (CT) scan showed findings suspicious for perirectal abscess versus fistula with significant rectal thickening/inflammation and left greater than right inflammation and phlegmon in the ischiorectal fossa. White blood cell count was also elevated at 12.7. The patient was taken to the operating room the following day for examination under anesthesia and drainage of perirectal abscess. The left gluteal fold was noted to have significant erythema and induration and the abscess was successfully drained. On postoperative day #2 the patient's pain was much improved and it was felt the patient was stable for discharge. The health plan's determination is overturned.
Yes, inpatient level of care was medically necessary as the patient required reassessment of effectiveness of treatment with incision and drainage and intravenous antibiotics. The patient has a complex medical and surgical history and while the vast majority of perirectal abscesses can be successfully managed in the outpatient setting, the history of Crohn's disease, rectal stricture with significant inflammation on CT, incontinence soiling the wounds, and significant erythema/induration of the perirectal area warranted inpatient admission or urgent incision and drainage, local wound care, and intravenous antibiotics. If the patient did not clinically improve, then it is possible further surgical intervention with repeat incision and drainage versus fecal diversion would be required.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Contraction pain 
Treatment: Inpatient stay

Summary:
Inpatient admission is not medically necessary.  
The American College of Obstetricians and Gynecologists recommends that preterm labor treatment be limited to patients who demonstrate cervical change by digital exam in response to preterm uterine activity.  The vast majority of patients who present with preterm uterine activity will go on to deliver at term, so treatment is only indicated if labor, as defined by progressive effacement and dilation of the cervix, is demonstrated.  In some cases exceptions can be made if the cervix is exceptionally short, i.e. less than 2 cm, or if fetal fibronectin is detected in the vaginal fluid.  None of these criteria was met in this case.  Therefore, in the absence of the diagnosis of preterm labor the admission is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned


This case involves a patient who presented for a confocal diagnostic evaluation of a concerning lesion on the right neck.  The lesion was 6 x 4 mm.  The lesion had been there for years and may have gotten a little bit bigger.  There was a personal history of melanoma.  The confocal image showed a honeycomb or cobblestone pattern with a ringed (edged) and nested/clod patterns.  There were dermatomal nests.  The diagnosis was melanocytic nevus-compound.

Babar K. Rao, et al. (2019) state "Noninvasive techniques, including reflectance confocal microscopy (RCM), optical coherence tomography, and Raman spectroscopy, have enabled dermatologists to manage skin lesions in real time without the need for biopsy ....  In conclusion, RCM is a noninvasive real-time tool with the potential to diagnose skin lesions with high accuracy and without biopsy".

The RCM was needed to determine if a biopsy of the lesion was appropriate.  Peer-reviewed literature does support a result of improvement in health outcome with the use of reflectance confocal microscopy.  

The RCM has final approval from the appropriate regulatory bodies.  The patient was a good candidate, and it was the best available treatment at that time.  The requested service is likely to be more beneficial than any other standard treatment/procedure for the patient.
Appeal type: Experimental/Investigational
Decision: Overturned

The treating physician noticed an atypical appearing nevus on the patient's right neck.  It was decided that this would be evaluated by confocal microscopy.  The confocal microscopy determined that this was a compound melanocytic nevus with no atypia or dysplasia and no biopsies or other therapeutic measures were necessary.  The provider is requesting plan approval for coverage of the confocal microscopy procedure.

The patient is a good candidate for Reflectance Confocal Microscopy (RCM); it is the best available treatment for this patient.  The advantage of confocal microscopy, especially in this patient, is that this it is a noninvasive procedure that in essence histologically evaluates the epidermis and superficial dermis.  Therefore, there is a diagnostic histologic interpretation.  This can determine if the lesion being evaluated is benign or malignant.  The advantage of this procedure is that it is noninvasive and surgery is not necessary, unless there is a malignant potential or an obvious malignancy. The medical literature is replete with references as well as books documenting the efficacy and accuracy of confocal microscopy in experienced hands. 

RCM is likely to be more beneficial than any other standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Skin lesion
 
Treatment: Reflectance Confocal Microscopy

The insurer denied the Reflectance Confocal Microscopy.  The denial was reversed.  A panel of 2 out of 3 reviewers determined the treatment was more beneficial than other standard options.

This is a female patient who had a suspicious lesion on right neck, for whom the provider requests Reflectance Confocal Microscopy (RCM).

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.  This is not the best available treatment.  There is insufficient evidence to draw conclusions about the effect of computer-based optical devices on patient management or health outcomes.  No studies were identified that addressed the use of computer-based optical imaging for serial assessment of lesions or for defining peripheral margins of lesions prior to surgery dermatoscopy and computer-based optical diagnostic devices are considered unproven for evaluating pigmented skin lesions suspected of malignancy.     

The carrier's denial of coverage for Reflectance Confocal Microscopy should be upheld, as this testing is not likely to be more beneficial than any other standard treatments.