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

Diagnosis: CAD, renal disease, diabetes
Treatment: Inpatient admission

The proposed inpatient admission was not medically necessary; inpatient level of care was neither indicated nor provided.

The patient is a male on chronic dialysis who missed several treatments due to being "sick". He went to the emergency department (ED) for evaluation due to progressively worsening shortness of breath and chest tightness in the setting of recent nausea, vomiting, and diarrhea and non-adherence with outpatient dialysis.  He was admitted for purpose of hemodialysis (HD). At that time, he denied chest pain (CP), or shortness of breath (SOB), and was comfortable lying in bed. He has a history of coronary artery disease (CAD), hepatitis and diabetes. HD was performed without complications, then cramps. Hemodynamically stable and no significant or unexpected electrolyte imbalance, the patient was discharged per his normal routine. 

The patient had missed his dialysis for a week and came to hospital for the procedure. Per ED, he did not have chest pain or dyspnea. Nephrology arranged ultra-filtration, he did well and was discharged. There was neither hemodynamically instability nor critical electrolyte imbalance. He was discharged on his usual medications. 

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, his presentation was consistent with his missing HD sessions, but he did not have significant fluid overload or electrolyte imbalance or hemodynamic instability. Thus no criteria met for inpatient level of care. 

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only care provided was hemodialysis, usually performed in a lower level of care. The patient was admitted for monitoring and acute dialysis therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of active CAD. All tests showed absence of ischemia.  While there is always a potential for an adverse event, one did not happen and no actual treatment was added.

Milliman criteria requirements were not fulfilled as there was never any evidence of acute coronary syndrome (ACS) present. The ED notes did not suggest any active ischemia, nor was there hemodynamic instability, nor was the patient treated as angina. All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient admission

The Inpatient admission was not medically necessary.

This male presented to the ER for further evaluation/management of dizziness. Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. Examination was non focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities or neurologic deficits including focal weakness, altered mental status or paresthesias. Laboratory and ECG testing was also within normal limits with no significant abnormalities noted including no evidence of acute end organ damage. Head CT was negative for acute intracranial abnormalities and chest CT was negative for pulmonary embolus. 

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where he received supportive care with IV fluids and continued cardiac monitoring. He responded well to the prescribed therapies and was subsequently discharged in stable condition. 

There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting the patient's safety or outcome. For these reasons, the proposed treatment of Inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Otitis media

Treatment: inpatient hospital admission 

The insurer denied coverage for inpatient hospital admission. The denial was reversed.

This patient is a male child who presented to the Emergency Department (ED) with his parents.  The mother reported a rapid onset of swelling in the patient's fingers, mouth, feet and genitals.  The mother reported she had introduced the patient to a chicken-based food product and the swelling spontaneously appeared.  In the Emergency Room, the patient was treated with intravenous (IV) Benadryl and a laboratory work-up was performed.  There were abnormal lab values of potassium that was elevated at 5.8 and a reduced creatinine of 0.54.  The patient was subsequently admitted to the hospital as an inpatient.  During the night, the patient developed a fever of 102.7, and it was determined that he had left ear tympanic membrane erythema.  The patient was positive for otitis media, and he was treated with IV ceftriaxone and Tylenol.  The patient's inflammatory condition continued to be monitored for signs of swelling or any respiratory decompensation and the patient was discharged to home.

MCG states that pediatric general admission criteria includes hemodynamic instability, hypertension, cardiac arrhythmias of immediate concern, respiratory abnormalities, neurologic abnormalities, abdominal abnormalities, acute renal failure, severe electrolyte abnormalities, or high fever or other high-risk infection situations in a child.  In the clinical records submitted for review, there was documentation of anaphylaxis after ingesting a new food, chicken.  The patient quickly developed swelling of the fingers, mouth, feet and genitals.  The mother presented to the ED with the patient for treatment.  During the assessment, lab values indicated an elevated potassium level of 5.8 and a reduced creatinine of 0.54.  After the administration of IV Benadryl in the ED, it was determined that the patient should be admitted due to his swelling of the fingers, mouth, feet and genitals not subsiding as anticipated, as well as the abnormal lab values.  Therefore, the denial of coverage for the inpatient hospital admission is reversed. The medical necessity is substantiated.

The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who had had two recent inpatient psychiatric admissions.  She was admitted for worsening of anxiety, dissociative symptoms and increase in school refusals. She was started on Prozac 10 milligrams (mg), which was titrated to 20 mg/day. She was then admitted againfor anxiety and dissociative symptoms and the Prozac was increased to 40 mg/day. Her parents had been having conflicts between them and the patient was discharged to the care of her mother with the plan to see her current provider more frequently until she was admitted to a dialectical behavior therapy (DBT) program. Two (2) days after discharge, the patient presented with suicidal ideation (SI) and a plan to jump out of the car.  She was then admitted to the current facility to inpatient psychiatry. During this admission, she was given a diagnosis of major depressive disorder, severe, recurrent. She was discharged with Prozac 40 mg/day and Risperidal 0.5 mg by mouth (PO) every AM (qam) and 1 mg PO q hour of sleep (hs). The health plan's determination is upheld. On the mental status exam (MSE), she was cooperative, had euthymic mood, normal speech and intact cognition. She was not suicidal or homicidal and denied psychotic symptoms. During her recent stay, she was compliant with medications and denied side effects. She denied SI/HI or psychotic symptoms during her entire inpatient stay, tolerated medications without side effects and participated in therapies and unit programs and activities. It was noted that the "patient would express SI in the context of increased anxiety and the need to escape these feelings."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Systemic Lupus Erythematosus (SLE)
 
Treatment:  Inpatient admission

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

The patient is a woman with a history of seronegative SLE (systemic lupus erythematosus), on methotrexate and Enbrel.  She presented to the ED after being evaluated in the ED the previous day for falls and traumatic event.  She reported having diffuse myalgias (especially of the right shoulder) consistent with a flare of SLE.  Exam revealed muscle tenderness and some bruising.  She had recently been having viral symptoms.  The impression was musculoskeletal flare of SLE versus viral syndrome in the setting of recent trauma.  There were no signs of other organ involvement from SLE. She was admitted to Observation and given prednisone, home medications and pain medication.  No clear signs of active SLE evolved. The source of the pain was not clear but was musculoskeletal in nature.  A localized reaction to non-steroidal anti-inflammatory drugs (NSAID) was treated.  The admission status was changed to acute inpatient the next day due to persistent pain.  She received IV and oral narcotics and was discharged home 1 day later.  

The pain being treated was of musculoskeletal origin, and the level of care was evaluated using MCG Musculoskeletal guidelines.  No other problems needed to be addressed during this 2-day stay.  She was given oral pain medication with IV prn dosing.  She was discharged the next day even after receiving several IV Dilaudid doses that day.  The potential consequences of the persistent pain and the intensity of the treatment given for pain did not require an inpatient level of care.  The insurer's determination that care could be at an Observation level is upheld. 

Based on the above, the medical necessity for the inpatient level of care admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Deep Vein Thrombosis
Inpatient Hospital

The patient who presented to the emergency room (ER) with pain in right leg for 5 days and was found to have an acute deep vein thrombosis (DVT). There were no clear provoking factors, and there was no significant family history of venous thromboembolism (VTE). The pulmonary embolism (PE) protocol computed tomography (CT) showed bilateral PEs. An electrocardiogram (EKG) showed diffuse ST changes consistent with (c/w) ischemia. Troponin I was negative. The patient had no symptoms of dyspnea, or chest pain. He was hemodynamically stable. Creatinine was slightly elevated at 1.2. The patient was started on intravenous (IV) Heparin and switched to Lovenox the next day. The transthoracic echocardiogram (TTE) was unremarkable. He was monitored with serial cardiac enzymes, serial EKG and telemetry.
The issue under review is the medical necessity of the inpatient admission.
The health plan's determination is overturned. The inpatient admission was medically necessarily for the patient. The patient had unprovoked symptomatic DVT and extensive, bilateral pulmonary emboli, complicated by evidence of cardiac ischemia on EKG. In addition, the patient had acute kidney injury. It was appropriate to start the patient on IV Heparin initially and monitor cardiac and renal function, then evaluate if patient can be safely transitioned to either Lovenox or one of the direct oral anticoagulants. In addition, given abnormal EKG, the patient required a TTE, as patients with right heart strain should not be managed as outpatients initially.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tremors
 
Treatment: Outpatient Ultrasound

The insurer denied the Outpatient Ultrasound. The denial was reversed.   

This is a male patient with a history of Parkinson's disease. The patient presented to a neurologist's office with complaints of increased tremors that were noted to be intractable a certain times of the day. The patient reported that the tremors increased as the medication was wearing off.  The neurologist recommended a magnetic resonance imaging (MRI) and a high-intensity focused ultrasound (HIFU). 
According to Bond, et al. (2017), "Focused ultrasound thalamotomy for patients with TDPD demonstrated improvements in medication-refractory tremor by CRST assessments, even in the setting of a placebo response."
  
Elias, et. al. (2016) stated, "MRI-guided focused ultrasound thalamotomy reduced hand tremor in patients with essential tremor.  Side effects included sensory and gait disturbances."

Chang, et. al. (2018) state, "Tremor suppression after Magnetic resonance guided focused ultrasound (MRgFUS) thalamotomy for essential tremor (ET) is stably maintained at 2 years."

The recent literature noted that the MRI guided focused ultrasound thalamotomy for essential tremor reduced the tremors and stability was maintained at two years.  Due to literature support, and the patient's frequency of travel, in this case, the use of the requested intervention would be appropriate and medically necessary.  As such, the healthcare plan did not act reasonably, and with sound medical judgment, and in the best interest of the patient.  

Based on the above, the medical necessity for outpatient ultrasound (MRI guided HIFU) is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia
Issue under review: Continued inpatient admission

Determination: 
The Continued inpatient admission was medically necessary.

The patient has been diagnosed with schizophrenia and has been hospitalized and treated with antipsychotics in the past.

The patient represented an acutely elevated risk of dangerous behaviors, and there was no less-restrictive treatment environment appropriate.  The acute risk factors of psychosis with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of aggressive or self-injurious behaviors (including but not limited to suicide) were she to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.  

The patient represented an elevated risk of dangerous behaviors, including aggressive behaviors, self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained psychotic.  The patient had multiple static risk factors for potentially dangerous behaviors, including prior hospitalizations and diagnosis with a severe mental illness.  Therefore, the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained psychotic and with ongoing medication changes were acute risk factors for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Large saddle pulmonary embolism

Treatment: Air medical transport

The insurer denied coverage for air medical transport. The denial was upheld.

This patient is a male who developed shortness of breath and was found to have a pulmonary embolus described as a "large saddle pulmonary embolism".

Intercurrent medical conditions included B-cell lymphoma, with central nervous system involvement.  The patient had a history of chemotherapy, radiation, and a known left lower extremity deep vein thrombosis treated with Eliquis. On a specified date he was transported by air ambulance. An alternate facility with appropriate capabilities was less than one hour's trip away by ground transport. Vital signs during transfer included modest tachycardia, blood pressure 111/76, and pulse oximetry 95% or greater on low level oxygen support (2 liters nasal cannula oxygen). 

Upon arrival at the receiving institution the patient remained stable and further aggressive interventional treatment was not recommended.

The health plan acted reasonably and with sound medical judgment and in the best interest of the patient. The patient had been stable for almost 24 hours and air transports was not medically necessary.

Although the findings of the CT scan legitimately caused concern, this patient was well-documented to have remained stable for 22 hours following the CT scan prior to the emergency air transport to another facility.  It is clear that the patient's condition was not deteriorating rapidly, he was not in extremis, and was in no imminent danger.  The patient's stability over this period of time belies any claims that emergency air transport was necessary on the following day. Transport was clearly not time critical, as the patient had been stable for almost 24 hours. Transport via ground based equipment to either of two hospitals in specified locations would have been entirely appropriate. 

As per CMS "Medical reasonableness is only established when the beneficiary's condition is such that the time needed to transport a beneficiary by ground, or the instability of transportation by ground, poses a threat to the beneficiary's survival or seriously endangers the beneficiary's health. Following is an advisory list of examples of cases for which air ambulance could be justified. The list is not inclusive of all situations that justify air transportation, nor is it intended to justify air transportation in all locales in the circumstances listed.


Furthermore,  guidelines state "Clinical situations for air transport in interfacility transfers are best summarized as being present when: 1) patients have diagnostic and/or therapeutic needs which cannot be met at the referring hospital, and 2) factors such as time, distance, and/or intratransport level of care requirements render ground transport nonfeasible."(2)

Transport was clearly not time critical, as the patient had been stable for almost 24 hours.

Based on the above, the medical necessity for the air medical transport performed is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Ankylosis; proposed dental extraction 
Treatment:  Surgical removal of tooth #8 with bone augmentation and replacement with an implant under anesthesia

The proposed treatment is medically necessary.

This is a male who had tooth #8 avulsed.  This was re-implanted and now has ankylosis and internal resorption.  As this is tooth is now non-restorable, the provider plans to remove this, bone graft the area and place an implant. 

The removal of #8 is necessary, as it is non-restorable.  The placement of an implant in the #8 area is appropriate for the symptoms and treatment of the condition and provided for the diagnosis and direct treatment of the condition.  The treatment is within the standards of good medical practice and not primarily for the convenience of the patient or provider, and this is the most appropriate procedure which can safely be provided.  The evidence shows that benefits from implants are clinically significant and produce a greater benefit without risk of harm for the patient than the alternatives.  The options in this case to restore function are an implant or a bridge.  An implant is the best option.  A bridge is considered radical treatment as adjacent tooth structure must be drastically reduced in this process.  The bridge has been regarded as the standard of care for some time in the replacement of single and multiple missing teeth.  However, to obtain optimal functional and aesthetic results for full-veneer bridges, a significant reduction in the amount of tooth structure is necessary occasionally predisposing to endodontic, periodontal, and structural complications.  The abutment teeth often become carious and have an increased rate of needing a root canal procedure.  If one of the abutment teeth are lost, a longer span bridge would be required.  The implant procedure is more conservative and has a better prognosis.  Implants have a high rate of success, do not require procedures on adjacent teeth and are not susceptible to caries.  The bone graft is needed to provide the necessary bone for implant placement.  Adequate buccal plate thickness at the time of implant placement is a key component of successful and esthetic implant therapy.  During implant placement a thickness of facial bone of at least 1.8 millimeters (mm) after the final osteotomy is drilled resulted in significantly less bone resorption than facial plates that were less than 1.8 mm.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bipolar Disorder and Histrionic Personality Traits

Treatment: Inpatient psychiatric treatment

The insurer denied coverage inpatient psychiatric treatment. The denial was upheld.

This patient is a female admitted for acute inpatient psychiatric treatment. She was diagnosed with Bipolar Disorder and Histrionic Personality Traits. She was discharged.

The insurer has denied coverage for inpatient psychiatric treatment for specified dates.

The medical record indicates she was admitted to the hospital following multiple emergency room (ER) presentations. She reported depression and a suicide attempt by pill overdose. She indicated she was experiencing stressful events. She had a long history of a chaotic lifestyle that included homelessness, outpatient psychiatric treatment with multiple missed appointments, and medication compliance issues. She had a history of multiple psychiatric admissions and previous suicide attempts by pill overdose. She reports being on multiple medication treatments without benefit. Following admission she was placed on sertraline and quetiapine. She had no reports of suicidal ideation or intent but ongoing complaints of depression. 

She had discharge dates set over the first week of treatment but for unstated reasons the disposition was not carried out. She was noted with mood lability that appeared chronic; but she also reported sleeping well, and in the opinion of her provider she did not require use of psychotropic medications. She continued to show no acute signs of psychosis, severe depression, suicidality, or severely disorganized behavior in the remaining time she was hospitalized. She was discharged with the diagnosis of Borderline Personality Disorder.

Based upon the information available this patient did not medically require acute inpatient psychiatric treatment. The insurer's denial is upheld. She was no longer severely depressed. She had no psychosis. She had no acute suicidal ideation or intent and she was not assessed as being at imminent risk of harm to herself or others. She was assessed as not being a candidate for psychotropic medications. As such she could have received ongoing treatment at a lower level of care.  

This finding is consistent with the general standards of psychiatric care, the APA Guidelines for the Treatment of Patients with Schizophrenia/Bipolar Disorder, the APA Guidelines for the Treatment of Patients with Borderline Personality Disorder, and InterQual Behavioral Health Criteria 2018 Adult and Geriatric Psychiatry, Hospitalization, Psychiatric, Adult, Mental. The health plan acted reasonably and with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient services is not substantiated.  The insurer's denial is upheld.