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

This is a patient with a history of diabetes, polysubstance abuse, psychiatric illness and possible sleep apnea. He presented to the emergency department for an abnormal electrocardiogram (EKG). He was at a shelter for group therapy and a routine EKG was performed which reportedly demonstrated ST segment elevation in precordial leads. He denied chest pain, shortness of breath and fatigue. The review of systems was also negative for nausea, vomiting, syncope, headache, and numbness. He last used crack cocaine the prior evening. On physical examination, breath sounds were normal, heart was regular, abdomen was soft and nondistended. A chest x-ray was negative. The patient was admitted for an abnormal EKG and concern for acute coronary syndrome. The plan of care included cardiac enzymes, repeat EKG, intravenous (IV) fluids, echocardiogram, consideration of cardiac stress testing, monitoring kidney function, drug use counseling, and a cardiology consult. It was confirmed that the EKG abnormalities had been seen previously and were not new. Psychiatry saw the patient and initially stated that he was not psychiatrically cleared to leave the hospital. Urine toxicology was positive for marijuana and cocaine. Cardiac enzymes remained negative and the echocardiogram demonstrated a normal ejection fraction. He was later cleared by psychiatry for discharge. 

The health plan's determination is upheld. 

The patient had an abnormal EKG but the cardiac enzymes were negative. He had no typical signs or symptoms of cardiac ischemia beyond the EKG findings, such as chest pain or shortness of breath, and the EKG findings were seen on prior EKGs, as noted in the admission documentation. In addition, he was hemodynamically stable and had no other concurrent complications such as acute seizures or sepsis. His electrolytes were stable, there was no evidence of an infection, a chest x-ray was negative, and he was asymptomatic. He required further evaluation of the abnormal EKG but this could have been provided safely and effectively at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breakthrough seizure
 
Treatment: Inpatient admission

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

This patient is a female with a past medical history of asthma, diabetes mellitus, hypertension, and noncompliance with medication for seizure disorder.  The patient was brought to the Emergency Department by the Emergency Medical Services (EMS) with subjective complaints of severe headache, vomiting times approximately 1 hour, and the patient was noted to have left-sided facial droop on EMS arrival.  On arrival at the Emergency Department, the patient was awake and alert and continues to complain of a headache.  The patient stated she had urinated on herself and did not have neck pain or back pain.  The patient denied a fever.  The patient's blood pressure was 167/81 and her heart rate was 95.  The patient underwent imaging studies, which showed no acute pathology.  The patient had an active seizure in the Emergency Department and was treated with Ativan for the seizure.  She also received Keppra while in the Emergency Department.  A stroke was ruled out.  The patient was admitted to the general medical floor with a diagnosis of a breakthrough seizure.  The patient underwent a neurology consultation.  The patient was given a scheduled dose of Keppra and intravenous fluids, along with proton pump inhibitors and antiemetics.  The patient requested and was discharged in stable condition.

Based on MCG guidelines for Seizure, patient meets the criteria for observation care. Patient has an elevated lactate level of 2.3 and requires medication initiation.  Due to the patient's poor social condition (i.e. living in the shelter), medication should be monitored and adjusted with closing monitoring.  While the patient meets the criteria for observation status, patient does not meet the MCG guideline clinical criteria for inpatient admission.  The patient did not have hemodynamic instability or status epilepticus. Whether the patient's focal neurologic deficit (i.e. left facial droop) is new or not is questionable since the patient reported having residual left sided weakness from a stroke several years ago.  The patient's CT of the head and neck ruled out brain disorder or intracranial pathology. 

The patient was discharged within 24 hours of being started on scheduled doses of Keppra, which could have been done at the observation setting.  Thus, based on the medical records provided and MCG guideline review, inpatient admission was not medically necessary to treat this patient's medical condition. 

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

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

Diagnosis: Upper Right and Left Canines and Lower Right Permanent Second Molar Ectopically Erupting, Overjet
 
Treatment: Orthodontic Treatment and Orthodontic Treatment Visits

The insurer denied the Orthodontic Treatment and Orthodontic Treatment Visits. The denial was reversed.
This is a female patient who is seeking orthodontic treatment and treatment visits. She has an Ectopic Eruption Score of 9 and an HLD index score of 26. Medical and dental histories are unknown.  It is unknown if the patient has any genetic or other developmental issues.  The upper right and left permanent canines are seen to be ectopically erupting, as well as the lower right permanent second molar.  The patient has a significant overjet.

A review of the calculations from the health care plan's HLD form noted what appears to be a simple arithmetic discrepancy.  On the Ectopic Eruption line, "0" was selected in the second to last box but it appears that the number was actually 3 and was placed in the next box to the right.  Therefore, the Ectopic Eruption score is actually 9, which changes the score to 26, thereby qualifying the case for coverage.  The plan documentation states that the score must be at least 26 to qualify.  Orthodontic services are medically necessary.    

The carrier's denial of coverage for the orthodontic braces and periodic visits is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Middle East Respiratory Syndrome (MERS)
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.  

This is a male patient with a history of hypertension and diabetes mellitus.  He presented to the Emergency Department with complaints of a cough for 1 week and some chest pain. He had a non-productive cough, denied shortness of breath, hemoptysis, nausea, vomiting or diarrhea. He reported that he had recently traveled outside of the country and since returning he had developed a cough. On physical exam his lungs were noted to have bilateral wheezing. There was no respiratory distress noted, he was able to speak in full sentences. Oxygen 2 liters nasal cannula was administered; his oxygen saturation was 97%. An electrocardiogram (EKG) was performed with no ischemia noted. A computed tomography (CT) angiogram was performed that was negative for a pulmonary embolism; a 7mm right lower lobe nodule was noted. A respiratory virus panel was obtained with negative results. He received intravenous (IV) fluids, Reglan, and Pepcid. Albuterol was given as needed. The patient was treated with IV Fluids, Reglan, Pepcid, and received Albuterol PRN. The patient remained stable after admission, and subsequently discharged home the next day.

This patient did not need acute hospitalization. He could have been placed in Observation status while diagnostic testing and treatment initiated. Pulmonary embolism was rule out. The patient likely had a viral syndrome with some wheezing.  He remained stable after admission and could have been placed in Observation status briefly and subsequently discharged home on oral medications with close Follow-up in outpatient setting.

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 inpatient hospital services is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Substance Abuse/Addiction
Substance abuse/inpatient

The patient is a male who was admitted to inpatient level services for detoxification of opioid and cannabis class substance use disorders. His self-referral was prompted by the desire to receive treatment for substance use disorder and to address acute symptoms of withdrawal. He had a history of substance-related problems beginning in adolescence, and as many as 23 prior detoxification and/or substance-related treatments without sustained sobriety or meaningful involvement in rehabilitation/substance use disorder treatment. Following his last detoxification treatment episode, the patient had been referred for medication assisted treatment with methadone; however, the patient reported that he had not followed through with the referral despite having methadone present in his drug screen. At the time of presentation, the patient presented with withdrawal symptoms that were mild with a Clinical Opiate Withdrawal Scale (COWS) scale score of 8. He reported daily use of heroin with up to 5 bags with intravenous (IV) administration, and, up to $30 worth of cannabis/hashish per day with inhalation.

The health plan's determination is upheld. The Inpatient Substance Abuse Treatment is not medically necessary for this patient. The proposed inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The acute inpatient treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with opioids and cannabis. Moreover, the patient did not show evidence for suicidal or aggressive behavior, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. Again, there were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment recently, as noted in the clinical summary. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past history of multiple treatment episodes. Thus, admission for observation and detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Left Knee Arthroplasty 
 
Treatment: Continued Inpatient Admission 

The insurer denied the continued inpatient admission. The denial was modified.  
This is a female patient with a medical history of diabetes mellitus, morbid obesity, status post gastric bypass over a decade ago, meningioma, status post craniotomy, gastroesophageal reflux disease (GERD), epilepsy, allergic rhinitis, adjustment disorder, and osteoarthritis. She was status post a left knee arthroplasty (TKA). She was transferred to a subacute rehabilitation facility for ongoing rehabilitation. The patient was appropriately admitted to a subacute rehabilitation facility after undergoing a left TKA. The therapy notes document the patient's functional improvement. This physician agrees that the patient continued to require a level of assistance (minimal to stand by) for functional mobility according to a physical therapy progress note 2 days after admission thereby supporting continued subacute rehabilitation. However, the patient required only supervision to modified independence for bed mobility, transfer activities and ambulating with a walker approximately 250 feet several days prior to discharge. A similar level of (supervised) modified independence for activities of daily living was documented in the occupational therapy notes at the same time. Subsequent care could have been safely provided at a lower level (e.g., long term care or home with visiting therapy services).  In addition, there were no complex nursing issues or acute medical problems that required skilled nursing or physician services. 

The healthcare plan did not act reasonably or with sound medical judgment or in the best interest of the patient in their denial of the continued inpatient admission for the first 10 days of her admission. They did act reasonably with sound medical judgment and in the best interest of the patient in their denial of the continued inpatient admission for the last several days of her admission. 

Based on the above, the insurer's denial is modified.  Approve the first 10 days and deny the last several days.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mild Maxillary and Mandibular Crowding, Excessive Overjet, Overbite and Class II Malocclusion
 
Treatment: D8070 Comprehensive Orthodontic Treatment

The insurer denied the D8070 Comprehensive Orthodontic Treatment. The denial was upheld.   

This is a young female patient who consulted an orthodontist for orthodontic treatment. It was determined after a series of extraoral and intraoral clinical images were performed that she has mild maxillary and mandibular crowding, excessive overjet, overbite and Class II malocclusion. Comprehensive orthodontic treatment was recommended. 

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, a Handicapping Labiolingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criterion utilizing a point system if none of these initial qualifying conditions are met or selected is considered.  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 a Class II malocclusion and does not complete an HLD index. 

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 including. Each of these 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.  

In this case the specific issue is whether orthodontic services are covered.  There is no objective documentation provided, nor fully adequate information (i.e. cephalometric radiograph and cephalometric tracing) provided to support this assertion that orthodontic services are medically necessary.  Further, the treatment recommended does not meet the medical necessity requirements.

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

Based on the above, the medical necessity for the request for D8070 comprehensive orthodontic treatment is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain.
Treatment:  Inpatient admission.

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

The patient is a female with a past medical history significant for HTN (hypertension), anxiety disorder, NSTEMI (non-ST elevation myocardial infarction), cardiac catheterization revealed no significant coronary disease, and the patient was diagnosed with Prinzmetal Angina and treated with vasodilators.  She presented to the ER with complaints of chest pain for three days duration.  The patient was seen at an outside hospital for the same complaint about a week prior, and she was ruled out for ACS (acute coronary syndrome). 

The patient was hemodynamically stable.  ECG (electrocardiogram) revealed no acute ischemic changes.  Chest X-ray revealed no acute cardio-pulmonary disease.  Cardiac troponin was negative.  The patient was admitted to rule out chest pain.  Her oral medications were continued, and usual prophylaxis measures were provided. She was seen in consultation by cardiology and was diagnosed with atypical chest pain.  No stress test or cardiac catheterization was deemed necessary by the treating physicians.  She was discharged home with a plan for outpatient follow-up.

No, the Inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain.  The diagnosis of an acute MI was ruled out by cardiac enzymes, which were negative.  Prior cardiac catheterization was negative for significant coronary artery disease, and no further ischemic work-up was planned by the treating physicians.  There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability.  Therefore, 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: Upheld

Diagnosis:  Aortic stenosis; Diastolic heart failure.
Treatment:  Inpatient hospital admission.

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

The male patient had a past medical history notable for hypertension, hyperlipidemia and coronary artery disease with multiple stents placed two years prior.  He presented to the emergency department with complaints of fatigue and an abnormal lab value.  The patient reported he was sent by his primary medical doctor for low hemoglobin of 8.6 and by his Cardiologist for aortic stenosis.  He reported feeling weak and having dyspnea on exertion (DOE) when going up several steps.  The patient was admitted for further evaluation of aortic stenosis.  He underwent echocardiogram, which revealed ejection fraction 61-66% with mild left ventricular diastolic dysfunction noted.  The patient underwent computed tomography angiography (CTA), which revealed heavily calcified coronary arteries and stents.  He was evaluated and followed by the cardiology transcatheter aortic valve replacement (TAVR) team.  The patient underwent esophagogastroduodenoscopy and colonoscopy.  His symptoms improved, and after a period of medical stability, the patient was discharged with instructions to follow up with cardiology and gastroenterology.

The patient was admitted with symptoms of dyspnea consistent with diastolic congestive heart failure.  Echocardiography demonstrated aortic stenosis and diastolic heart failure.  However, his care could have been rendered under observational status.  There was clinical congestive heart failure with symptomatic anemia supporting necessity of observational care, but inpatient admission status was not met, due to lack of severity of disease or comorbidities.  There was no myocardial ischemia, hemodynamic instability, no electrolyte abnormalities, hypoxemia, or other indications for acute inpatient admission status during the stay.  In essence, this patient underwent evaluation for his aortic stenosis and anemia, neither of which presented an acute issue and thus could have been evaluated as an outpatient. 

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 inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive System/Gastrointestinal issue.
Treatment: Inpatient Hospital.
The insurer denied the Inpatient stay.  The denial is upheld in whole.

The patient is a female with medical history of hypertension, diabetes mellitus type II.  She presented to the emergency department with a week of watery, non-bloody diarrhea, and transient cramping lower abdominal pain.  She had failed outpatient anti-diarrheal medication.  Physical examination was notable for generalized abdominal tenderness.  Labs were notable for leukocytosis with white blood cell count of 14.2 thousand per microliters (K/uL), low hemoglobin of 11.6 grams per deciliter (g/dL), low potassium of 3.3 millimoles per liter (mmol/L), elevated creatinine of 1.4 milligrams per deciliter (mg/dL), and elevated alkaline phosphatase of 129 units per liter (U/L).
Blood cultures ultimately grew coagulase-negative Staphylococcus, which was considered a contaminant.  Computed tomography scan of the abdomen and pelvis showed no acute intra-abdominal pathology and left adrenal adenomas.  She was treated with ciprofloxacin and metronidazole, famotidine, Zofran, and morphine.  The next day she had ongoing diarrhea and abdominal pain, which improved after bowel movements; she had a low appetite but was attempting oral intake.  Labs showed higher white blood cell count of 15.6 K/uL, low hemoglobin of 10.6 g/dL, and lower creatinine of 1.36 mg/dL.  The following day she had no further diarrhea and less abdominal pain; she was able to tolerate only fluid intake.  Physical examination was notable for right-sided abdominal tenderness.  Labs showed lower white blood cell count of 12.1 g/dL.  On the day of discharge, labs showed white blood cell count of 13.6 K/uL.  She was discharged on MiraLAX, pantoprazole, ciprofloxacin, and metronidazole.  

At issue is the medical necessity for the inpatient stay. 

The health plan's determination is upheld, in whole.

The patient had nausea, diarrhea, and abdominal pain consistent with acute gastroenteritis.  The standard of care for the treatment of gastroenteritis and the evaluation of diarrhea was appropriately performed, including intravenous fluids, empiric antibiotics, and supportive care, and her symptoms improved [1-4].
 
Computed tomography scan of the abdomen and pelvis did not show any acute changes, and there was no suspected or established complication such as gastrointestinal perforation, pancreatitis, intra-abdominal abscess, toxic megacolon, gastrointestinal bleeding, bowel obstruction, peritonitis, sepsis, or other complications, which would warrant the inpatient level of care [3-5].  She also had uncomplicated acute kidney injury, which was appropriately addressed  per the standard of care with intravenous fluids, and improved [6].  
The standard of care which was undertaken, including observation, monitoring, labs, antibiotic administration, and intravenous fluid administration, could have been performed without the inpatient level of care.