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

Diagnosis: Abdominal pain; Fecal Impaction 
 Treatment: Inpatient Admission 

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

This is a female patient with a history of orthostatic hypotension, ovarian cyst, colon polyps, abdominal laparotomy, and tachycardia. She presented to the Emergency Department with complaints of abdominal pain and constipation. A computed tomography (CT) scan of the abdomen was performed which was negative for an intestinal obstruction but positive for a fecal impaction. She received laxative and Golytely with positive results. The patient was discharged with instructions to follow up with the gastroenterologist. 

Based on the MCG Health 24th Edition clinical indications for admission for undiagnosed abdominal pain (M-05), inpatient admission is clinically indicated if the patient has a need for surgery that cannot be performed on an ambulatory basis and has peritoneal signs. However, this patient did not have these conditions. The patient neither had any hemodynamic instability, intestinal obstruction, bacteremia, nor severe electrolyte imbalance that would warrant inpatient level of care. This patient had constipation, and had developed a fecal impaction that was confirmed by CT scan that it was not causing intestinal obstruction. The patient's symptoms responded to laxative treatment that could have been taken on an outpatient basis. The patient did not meet the MCG clinical guideline and criteria for admission for undiagnosed abdominal pain. 

The healthcare 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

Diagnosis: Infection of abdomen 
Treatment: Inpatient stay 

The inpatient admission was not medically necessary.

Summary: The patient is a male. His medical and surgical histories were negative. He presented to an emergency room with a soft-tissue infection of his abdomen. 

The patient was admitted at an acute inpatient level of care. He underwent bedside incision-and-drainage without any complication. He was provided with intravenous antibiotics, wound-care, and analgesics. 

The patient was discharged home in good and stable condition with outpatient surgical followup; and prescriptions for dressings, antibiotics, and analgesics. 

Guidelines from the Infectious Diseases Society of America are clear -- for patients with abscesses, treatment includes: incision and drainage with associated wound care, abscess culture, and a short-course of antibiotics [Stevens et al.]. All of these interventions may be provided on an outpatient basis. In fact, according to the Infectious Diseases Society of America, "Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability." As this patient did not have SIRS, altered mental status, or hemodynamic instability, he did not require hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal
Inpatient Hospital

The patient is a girl who underwent resection of a soft tissue lesion of the right foot and ankle. She had previously undergone an attempt at surgical resection but the lesion had recurred. The lesion was described both as a giant cell tumor of the tendon sheath and as pigmented villonoduar synovitis. This was a radical resection of soft tissue, scar, and bone, necessary in order to excise the tumor in its entirety and prevent a second recurrence. The patient was initially on a patient controlled analgesia (PCA) pump, and received physical therapy to ensure that she could ambulate safely. At issue is the inpatient stay.

The health plan's determination is overturned. The inpatient stay was medically necessary. A radical resection of a soft tissue tumor is a major surgical procedure. Although the lesion was not malignant, it was locally aggressive and had already recurred once. Under these circumstances, the surgeon must carry out a very thorough and wide resection of soft tissue. In this case, it was also necessary to remove a portion of the calcaneal bone which had been invaded by the tumor. Such a procedure may be followed by substantial swelling and pain, and it may be difficult for a patient to resume ambulation with crutches. Monitoring of neurovascular status is also done. Because of the intensity of the services required, this patient required an inpatient hospital admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertensive Crisis
 
Treatment: Inpatient Admission

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

This patient presented to the Emergency Department (ED) with complaints of lightheadedness, blurred vision, and weakness. Upon arrival to the ED the patient's blood pressure was 239/107. Hypertensive emergency is defined as BP>180/120 with target organ damage. (1) In this patient, blurry vision and lightheadedness were concerning for central nervous system (CNS) target organ damage. The patient had a computed tomography (CT) scan of the head that was negative for a transient ischemic attack (TIA) and an acute stroke. Based on the patient's initial clinical presentation, admission to the hospital was medically necessary for aggressive blood pressure management and control. She had an electrocardiogram (EKG) that revealed sinus rhythm with possible anterior wall myocardial infarction. Cardiac enzymes were drawn with negative results. The patient was discharged with instructions to follow up with an outpatient cardiologist.

American Heart Association guidelines recommend admission to the Intensive Care Unit (ICU) for management of hypertensive emergencies.(1) Following initial response to antihypertensive therapy, additional monitoring and treatment was necessary to achieve acceptable blood pressure control. Thus, inpatient hospital admission was medically necessary for this patient's case.

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

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

Diagnosis: Gynecological / Postpartum Endometritis
Treatment: Inpatient hospital admission

The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a female who presented to her doctor with new onset of lower abdominal pain four days after a vaginal delivery. The delivery was an uncomplicated vaginal delivery without fevers or lacerations. The patient reported being pain free on discharge from her delivery, and developing pain over the uterus the day after. She reported taking Motrin and Tylenol around the clock. Her evaluation included a leukocytosis of 18 and abdominal tenderness over the uterus. She was readmitted to the hospital and started on parenteral ampicillin, gentamicin, and clindamycin. 

The inpatient admission was medically necessary in this case. This was actually a dangerous presentation and warranted aggressive action by the clinicians involved. Postpartum sepsis is insidious and can be fatal. The patient's admission was necessary because her presentation required aggressive treatment. The putative treatment for postpartum endometritis is at least 48 hours of IV antibiotic therapy. Outpatient management of postpartum endometritis is possible only in select low risk cases where evidence of systemic infection is absent. References for these therapies recommend this generally in low resource settings where IV's are not available. The care during this admission met the definition of inpatient management because it was care not possible in an outpatient setting (i.e. IV antibiotics every 8 hours, serial blood pressure monitoring, and serial labs). 

The recent efforts against maternal mortality have involved calls for more aggressive action against maternal infection. This patient was diagnosed with endometritis based on pain and leukocytosis without other explanation, and then was treated with IV antibiotics along with serial lab and vital sign assessments. The treatment was at an inpatient level as it could not be delivered at a lower level of care. The inpatient level of care was medically necessary and appropriate for this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary/PE
Treatment: Inpatient hospital stay
The Health plan's determination is upheld in whole. The inpatient hospital stay was not medically necessary. 

This is a patient who presented with rib pain and was diagnosed with segmental and subsegmental pulmonary embolism with developing infarct. The patient did not have associated hypoxia, tachycardia, or hypotension, or right heart strain on imaging as manifest by elevated BNP or troponin or electrocardiogram changes, and hematology deemed the patient to have a low pulmonary embolism score of 73. Patient furthermore did not have any contraindications such as renal failure to being able to be placed on a novel anticoagulant, did not have a history of bleeding anticipated to complicate treatment, did not have intractable rib pain requiring repeated IV narcotics and management not amenable to lower level services, or other clear acute cardiopulmonary process complicating treatment (with it noted that patient received antibiotics prophylactically but had no imaging evidence of pneumonia). Given the extent of the pulmonary emboli (bilateral and with segmental in addition to subsegmental involvement), patient was appropriate to bring into the hospital for monitoring overnight for arrhythmias, initiation of anti-coagulation, and treatment of rib pain, but it is unclear why inpatient care was medically necessary. In the absence of hypoxia, arrhythmias, right heart strain, persistent rib pain requiring repeated doses of IV pain medications, contraindication to initiation of lovenox or a novel anticoagulant with need for several days of IV heparin infusion, concern for concomitant bleeding, other acute cardiopulmonary process requiring inpatient care, and in the setting of a low risk pulmonary embolism severity index, it is unclear why this patient could not have been safely cared for at a lower level of care to observe for arrhythmias.
Appeal type: Medical necessity
Decision: Upheld

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

The Inpatient admission was not medically necessary.

The patient is a female. She has a past medical history significant for Systemic Lupus Erythematosus (SLE), recurrent pericardial effusions and sickle cell trait. She presented to the ER with complaints of pleuritic chest pain of two to three days duration, with some improvement with Motrin, exacerbated by supine position. 

The patient's ECG (electrocardiogram) was unremarkable. Cardiac troponins were negative. Chest X-ray revealed patchy infiltrates and the patient was given empiric antibiotics. She was admitted with a diagnosis of atypical chest pain, pericarditis, SLE flare. 

The patient was treated with IV fluids. Her home medications were continued, and Motrin and Tylenol were given for pain. She was seen in consultation by cardiology, and her pain was felt to be pleuritic/pericarditic in nature. Echocardiogram revealed normal LV (left ventricle) function and no significant effusion. She was discharged home with a plan for outpatient follow-up.

This patient presented for evaluation of pleuritic chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac troponins, which were negative. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), pericardial tamponade, malignant arrhythmia or hemodynamic instability. There was no evidence of significant effusion on echocardiogram, and there was no need for pericardiocentesis. No ischemic work-up was planned. No surgical procedures were planned. The patient remained stable throughout the hospitalization. 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: Experimental/Investigational
Decision: Upheld

Lung Cancer
Lab Work

The patient had worsening cough and shortness of breath. Imaging was concerning for metastatic disease; bronchoscopy showed adenocarcinoma of the lung through cytology, but biopsy was inconclusive. The patient was not a candidate for radiation or surgery. Guardant 360 was sent due to the results from the biopsy being inconclusive and not enough specimen from cytology (also could not do testing for targetable mutations on cytology). Patient is a nonsmoker, making targetable mutation more likely. Patient started chemotherapy and immunotherapy due to no mutation being found on Guardant 360 testing. The health plan determination is overturned in whole. The patient had an invasive biopsy done that was inconclusive and only cytology confirmed diagnosis. Although there were some other areas of concern on imaging, the provider chose not to re-biopsy because it was thought that those areas could be infectious. Putting an elderly patient through an additional biopsy of something that could have been infectious could have put her at unnecessary risk. The National Comprehensive Cancer Network (NCCN) supports that when a patient is not fit for invasive tissue sampling (she just had an invasive test that was inconclusive, there is no reason to try again), or if there is insufficient tissue (in this case only cytology could confirm the diagnosis), then plasma deoxyribonucleic acid (DNA) testing is appropriate. NCCN does not include the brand names for this type of testing; rather it includes only the type of test (plasma testing). Thus, in this case it is medically reasonable and appropriate that a liquid biopsy/plasma test was done to look for targetable mutations in this nonsmoker. 

In addition, plasma testing has been shown to be effective and can even potentially show more targetable markers than tissue biopsy (2). Lastly, there have been over one hundred peer reviewed publications supporting Guardant 360 and covers all guideline recommended targetable genes (total of 73 genes that also include if the patient is a candidate for clinical trial).
Appeal type: Experimental/Investigational
Decision: Upheld

Lung Cancer
Lab Work

The patient was diagnosed with "suspicious adenocarcinoma" of the left lower lobe of the lung from a bronchial biopsy via bronchoscopy. The patient was given systemic therapy due to what was thought bilateral lung involvement and left adrenal gland as well. The therapy was carboplatin and alimta with the addition of Keytruda. This was followed by Tagrisso thereafter when an EGFR mutation in exon 19 was found in another biopsy. This was a biopsy of the LUL showing moderately differentiated adenocarcinoma, consistent with lung cancer. The health plan's determination is upheld in whole. According to National Comprehensive Cancer Network (NCCN) Guidelines, the choice of systemic therapy options are based on molecular markers obtained from tissue. Cell-free/circulating tumor DNA testing should not be used in lieu of a histologic tissue diagnosis. Studies have demonstrated cell-free tumor DNA testing to have significantly compromised sensitivity with up to a 30% false - negative rate. Standards for analytic performance characteristics of cell-free tumor DNA have not been established and no guidelines exist regarding the recommended performance characteristics of this type of testing. Such testing may identify alterations that are unrelated to the lesion of interest. The use of these types of assays can be used if a patient is medically unfit for invasive tissue sampling and if the initial diagnostic testing there is insufficient material for molecular analysis. 

Neither of these apply to this case as there was tissue biopsy/sampling. 
This patient underwent a second biopsy of the lung establishing the diagnosis. Therefore, a biopsy was not medically contraindicated. There was no documentation from the second biopsy as not having enough tissue for tissue-based molecular and biomarker analysis.
Appeal type: Experimental/Investigational
Decision: Upheld

Lung Cancer
Lab Work

This is a patient with metastatic adenocarcinoma of the lung. The patient has progressed on carboplatin+pemetrexed. The Guardant360 assay was obtained. The health plan's determination is upheld in whole. The use of next generation sequencing gene panels to guide the treatment of patients with lung cancer has not been demonstrated to be of benefit. The assay in question is not Food and Drug Administration (FDA) approved. This approach remains the subject of multiple clinical trials including, but not limited to, NCT03477474, NCT03615443 and NCT03576937. To date, the SHIVA trial is the only large randomized trial to off-label use of molecularly targeted agents on the basis of identified molecular alterations for which results have been published in the peer-reviewed literature. The conclusion of the authors was "The use of molecularly targeted agents outside their indications does not improve progression-free survival compared with treatment at physician's choice in heavily pretreated patients with cancer. Off-label use of molecularly targeted agents should be discouraged, but enrollment in clinical trials should be encouraged to assess predictive biomarkers of efficacy". Further complicating the role of liquid biopsies if that their results are limited in sensitivity to between 60 and 80 percent. The limited sensitivity of liquid biopsies is thought to reflect the biology that some cancers do not shed DNA into the bloodstream rather than a feature of any given assay. Based on the paucity of supporting data, neither the National Comprehensive Cancer Network (NCCN) nor the authors of UpToDate recommend the use of the Guardant360 assay in this clinical scenario. Treatment based on published literature and guideline recommendations has been encouraged.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:   Depression
Treatment:  Inpatient Mental Health 

The insurer denied the inpatient stay.  The health plan's determination is overturned. 

The patient is a woman with diagnoses of Major Depressive Disorder (MDD), severe, recurrent, without psychotic features, post-traumatic stress disorder (PTSD), and post-concussive syndrome (PCS).  Under review is her inpatient hospital admission. 

The inpatient hospital admission through discharge was medically necessary for the reasons above.  Poor social attachment is associated with increased suicide risk.  This patient is isolative with poor social attachment.  Migraine and depressive disorders both relate to a high stress level.  This patient's migraines are part of her post-concussive syndrome and cause much pain and light intolerance.  Remeron and Effexor may increase suicidal ideation.  This patient did not tolerate Effexor, which increased her rage of feeling of being out of control.

Discharge prior would have a high likelihood for readmission or harm to self or mother.  On the proposed day of discharge by health plan, the patient would not have been able to care for herself in an adequate manner as an outpatient.  This patient's illness was severe, chronic, with interactive comorbidities of MDD, PTSD, and PCS.  Several medications in hospital were tried and found to be ineffective or worsened the patient's symptoms; therefore, a longer time was necessary for treatment as an inpatient.
Appeal type: Medical necessity
Decision: Overturned

Dx: Dental Problems
Tx: Dental/Orthodontic Procedure
Denied: Orthodontic treatment
Denial OVERTURNED in whole

The patient is a male with a Class I malocclusion and anterior crossbite of #7, 10, and 11. Tooth #23 and 27 are already showing some recession. He is treatment planned for orthodontics to correct the malocclusion.
The subject under review is the medical necessity for the planned orthodontic treatment.

The plan's determination of medical necessity is overturned, in whole.
The requested treatment of braces (comprehensive orthodontic treatment and periodic orthodontic treatment is medically necessary for this patient.

The patient has significant maxillary anterior crowding with three anterior teeth in crossbite. These teeth have a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult.4   Teeth 23 and 27 already have slight recession, and further movement of these teeth will likely lead to the need for future for periodontal grafting on this tooth. The patient's periodontist also submitted documentation echoing these concerns. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures. For these reasons orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Dental Disorder
Dental/Orthodontic Procedure

Diagnosis: Dental Disorder
Treatment: Braces (Comprehensive Orthodontic Treatment). The insurer denied the Braces (Comprehensive Orthodontic Treatment). 
The denial was overturned.

This is a patient with a Class I malocclusion and anterior crossbite of number (#) 10. Tooth #22 is already showing some recession. His treatment plan is for orthodontics to correct the malocclusion. His health plan denied the services as not medically necessary. At issue is the medical necessity of braces (comprehensive orthodontic treatment).

The patient presented with an anterior crossbite and significant crowding. 
The patient has significant maxillary anterior crowding with tooth #10 in crossbite. This tooth has a high risk for restorative problems in the future due to the traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time (4), which will make treating this occlusion at a later time more difficult. Tooth #22 already has slight recession, and further movement of #22 will likely lead to the need for future for periodontal grafting on this tooth. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures. For these reasons, the requested orthodontic treatment is medically necessary.