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

Diagnosis: Back Pain
Treatment: Injections for Pain Management
The health plan denied the requested injections for pain management. The health plan's determination is overturned.

The patient is a female with moderate to severe low back pain which impacts functionality. Treatments tried include medication and physical therapy. Physical examination is significant for lumbar paraspinal muscle tenderness and pain with facet loading. A lumbar magnetic resonance imaging (MRI) by report describes degenerative changes including facet arthropathy. Lumbar facet joint injections are proposed. The procedure was initially denied because there are MRI reports of "bulging or herniated disc at the (lumbar-sacral) L5-S1 level" and the reviewer states "records must show that imaging studies have ruled out other sources of your back pain."
At issue is the medical necessity of the requested treatment. 

The health plan's determination of medical necessity is overturned, in whole.

Yes, the requested health service/treatment of injections for pain management is medically necessary for this patient. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain issued by the American Society of Interventional Pain Physicians state the medical necessity definition for spinal interventional techniques are as follows [1]:
1)	Suspected organic problem.
2)	Non-responsiveness to conservative modalities of treatment.
3)	Pain and disability of moderate-to-severe degree.
4)	No evidence of contraindications such as severe spinal stenosis resulting in intraspinal obstruction, infection, or predominantly psychogenic pain.
5)	Responsiveness to prior interventions with improvement in physical and functional status for repeat blocks or other interventions.
6)	Repeating interventions only upon return of pain and deterioration in functional status.

Comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain issued by the American Society of Interventional Pain Physicians state (in part) "Once the appropriate diagnosis is made, lumbar facet joint pain may be managed by either facet joint nerve blocks or neurolysis of facet joint nerves and intraarticular injections" [2].
Practice guidelines for chronic pain management issued by the American Society of Anesthesiologists (ASA) Task Force on Chronic Pain Management and the American Society of Regional Anesthesia (ASRA) and Pain Medicine state (in part) "Consultants, ASA members, and ASRA members agree that intraarticular facet joint injections should be used for symptomatic relief of facet-mediated pain" [3].
In this case, the patient is struggling with significant low back pain which failed to improve with conservative measures. The history, physical examination and imaging studies support a likely diagnosis of low back pain secondary to spondylosis (i.e., facet arthropathy). Based on the submitted clinical material, peer-reviewed medical literature and standard of care, the proposed procedure is considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal-Cholecystitis
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld the health plan determination in whole.

The patient presented to the hospital emergency department (ED) with right upper abdominal pain. The patient had a past medical history of obesity and gout and had been in the ED 2-days prior with similar abdominal complaints. The patient was tender in the right upper abdomen. At the time of presentation the patient was without fever and vital signs were normal. The white blood cell count was 9.77 thousand(K). The complete metabolic panel identified an elevated bilirubin of 2.6 with normal transaminases. Ultrasound showed gallstones, gallbladder wall thickening, and pericholecystic fluid. The surgical consultation note makes no mention of an umbilical hernia on examination.
He was initially treated with intravenous (IV) fluid and IV antibiotics. A magnetic resonance cholangiopancreatography (MRCP) was completed and did not identify common duct stones. The patient underwent cholecystectomy and umbilical hernia repair. The operative dictation describes an uncomplicated cholecystectomy procedure and the patient was started on a clear liquid diet, and when considered to be stable was discharged home.

An inpatient level of care was not medically necessary.
This patient presented to the hospital with symptomatic cholelithiasis/cholecystitis. The pre-surgical work up was completed on with labs, ultrasound and MRCP. The indications for cholecystectomy were established. The patient underwent an uncomplicated cholecystectomy. While the pre-surgical history and physical (H&P) makes no mention of the diagnosis of an umbilical hernia and the consent form does not include umbilical hernia repair, the surgeon reports finding an umbilical hernia at the time of surgery. This was repaired primarily with suture. The post-surgical course was uncomplicated. Diet was advanced. Vital signs remained normal. Pain was controlled with oral medication, and the patient was discharged home.
An inpatient designation was not consistent with Milliman Care Guidelines (MCG). In this case, the submitted documentation does not support that the patient had conversion to open surgery, severe systemic infection, care for active comorbidities, complications of the procedure, or failure to achieve discharge status criteria to warrant an inpatient level of care.
A lower level of care would have appropriately provided for the pre-surgical assessment, operative treatment, and post-surgical care and monitoring including overnight care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has upheld in whole the health plan's determination.

The patient has a past medical history significant for hypertension, diabetes mellitus, asthma, bipolar disorder, schizophrenia, and substance abuse who came to the emergency department with complaints of dizziness and weakness in the right side of the body that started one day before the presentation. The patient had one syncopal episode the day before the admission. The patient did not remember the details of this event. As a result of the fall, she injured her knee.  Since that time, the patient noticed a mild headache and numbness in the right hand and foot, also weakness on the right side of body. The patient was admitted to the hospital with a diagnosis of syncope, right-sided weakness, tobacco use disorder, diabetes mellitus, hypertension, and some other chronic medical conditions. In the hospital, the patient was seen by a cardiologist, endocrinologist, and neurologist. The patient underwent a magnetic resonance imaging (MRI) of the brain that revealed an infarct involving the lateral aspect of the left thalamus and adjacent posterior lane of the left internal capsule. This was evaluated by the neurologist who felt that the MRI findings suggestive of possible stroke had no clinical significance and likely represented chronic cerebrovascular accident (CVA) rather than an acute stroke. Patient was also seen by an orthopedic surgeon, physical and occupational therapy. 

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The review of the medical records clearly demonstrated that during the entire hospital stay the patient was hemodynamically stable. There was no evidence of severe or persistent altered mental status. Even though acute stroke was initially suspected as the reason for the possible syncopal episode, it was ruled out by the neurologist. The syncopal episode was not associated with acute congestive heart failure (CHF) exacerbation, or acute blood loss anemia. There was no evidence that the patient had acute cardiac ischemia. There was no need for prolonged cardiac monitoring. The patient's injury did not require any surgery or treatment with internal or external fixation. Taking into consideration all these facts, neither the severity of the patient's condition nor the complexity of the patient's condition rose to the acute inpatient level of care.
Admission to the hospital at a lower level of care was definitely justified, to rule out a possibly serious condition that contributed to the syncopal episode, to perform an evaluation of the knee injury, and to assess the patient's rehabilitation needs. The patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Revision of a cerclage
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a gravida two para zero (two pregnancies and no live births [G2P0]) female who presented to the hospital at for revision of a cerclage originally placed eight days prior to admission.  The prior cerclage had migrated to the posterior aspect of the cervix and the rectovaginal mucosa.  Past medical history was remarkable for two midtrimester losses at 15 and 20 weeks.  She was taken to the operating room for a revision of the cerclage stitch in which the prior McDonald cerclage was removed and Shirodkar cerclage placed without difficulty.  

In the recovery area, the patient had a fit of coughing and watery, bloody discharge was noted by the nurse.  She was evaluated for rupture of membranes; however, the watery discharge was fern negative and it was felt that the patient was not ruptured.  She was felt to be stable for discharge.  However, the patient refused to be discharged and subsequently she was admitted to the labor and delivery unit and observed for complications of the cerclage procedure and cervical shortening.  Her condition stabilized and she was discharged home on hospital day #1. 

The facility contends that the hospital admission was medically necessary to monitor for complications of cerclage, pain management, serial vital signs, and monitoring of fetal well-being and cites MCG 24th edition Ambulatory Surgery Exception Criteria, complicating features requiring inpatient care. The health plan contends that the admission was not medically necessary due to absence of hemodynamic, pulmonary, neurologic, or metabolic reasons for acute level of care, lack of positive tests.  

No, the proposed treatment was not medically necessary.  

Cervical cerclage is performed as an outpatient procedure unless there are significant anesthesia or surgical complications.  The afternoon of the procedure it is documented that the patient was ready for discharge.  Although there was a concern about possible rupture of membranes which if confirmed would merit admission for observation, it is clear from the notes following workup that the treating physician felt that the membranes were not ruptured and that she was ready for discharge.  No other evidence is presented that there was any other surgical, medical, or anesthesia complications that required admission to the hospital.  Therefore, admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Throat soreness. 
Treatment:  Inpatient stay. 

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

The patient is a man with a history of diabetes, right eye blindness, active smoking, and human immunodeficiency virus (HIV), who was admitted to the hospital.  He presented by ambulance because of rapid weight loss for the past few months, throat soreness with difficulty swallowing, weakness, and a fall.  He stated that he had difficulty taking his HIV medications because of difficulty swallowing.  He denied injury.  Review of systems was negative for fevers, chills, chest pain, and shortness of breath.  He reported a last CD4 count (T-cell test) of 141.  Vital signs showed blood pressure 107/74, heart rate 93, temperature 98.5 Fahrenheit, and respiratory rate 18.  On physical exam, heart was regular, breath sounds were normal with no wheezes, cranial nerves were intact, speech was normal, and there was no neurologic deficit.  Chest x-ray was negative for pneumonia.  Head computed tomography (CT) was negative for acute stroke.  Labs showed white blood cell (WBC) 10.6, hemoglobin 13.4, platelets 311, sodium 138, potassium 3.8, and creatinine 1.2.  The patient was admitted for multiple complaints. 

The inpatient hospital admission was medically necessary.  The patient presented with dysphagia and difficulty taking his HIV antiviral medication and achieving appropriate nutritional intake.  Because of the severity of the symptoms, and due to the risk of complications such as HIV antiviral resistance or injury from recurrent falling, it was appropriate to manage him at the inpatient level care.  He also needed more aggressive intervention including endoscopy and colonoscopy.  This intensity of care in a high risk patient would not typically be provided at the outpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Recurrent atrial fibrillation with rapid ventricular response

Treatment: Full hospital admission

The insurer denied coverage for the full hospital admission.

The denial is upheld. 

This is a female patient with a history of diabetes, atrial fibrillation, and laparoscopic hernia repair. She presented to the Emergency Department (ED) for palpitations, referred by her cardiologist. An electrocardiogram (EKG) revealed atrial fibrillation with rapid ventricular response and small R waves in V 3-6. Vital signs included blood pressure (BP) 114/39, heart rate 127, respiratory rate 21, and oxygen saturation 93%, with temperature 99.3 and oxygen saturation 95%. She was treated with intravenous Cardizem, followed by a Cardizem drip, with subsequent conversion to normal sinus rhythm.  Laboratory test results included white blood cell (WBC) count 23.23, hemoglobin 12.1, creatinine 0.847, troponin below 0.015 and D-dimer 1.54. Chest X-ray was normal and Computed Tomography (CT) angiography of the chest revealed a rounded hazy opacity in the right upper lobe. She was also treated with intravenous saline, vancomycin, and Zosyn and was evaluated by Pulmonology, who suggested transition to Ceftin at discharge. Echocardiography was normal with left ventricular ejection fraction above 55%. Blood cultures were also normal. She was discharged to home on her home medications plus Ceftin, for follow-up by her Cardiologist and other outpatient physicians.

There is no evidence that this patient required an acute inpatient level of care to evaluate or treat her recurrent atrial fibrillation with rapid ventricular response. This could have been completed in the ED or at an observation level of care, followed by outpatient management. The healthcare plan acted reasonably, with sound medical judgement, and in the best interest of the patient.

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

Diagnosis: Prostate cancer
Treatment: Oncotype Dx test for prostate cancer (denial code 775)

The insurer denied coverage for the Oncotype Dx test for prostate cancer (denial code 775).
The denial is upheld. 

This is a male patient who was diagnosed with prostate cancer. After discussing all treatment options with his urologist, the patient opted for active surveillance of his prostate cancer. An Oncotype Dx Genomic Prostate Score (GPS) test was performed. The insurer has denied coverage for this patient's test as not being medically necessary. They stated there is not enough medical proof indicating that this test provides a benefit for men with prostate cancer. 

While it is indeed true that the National Comprehensive Cancer Network (NCCN) Guidelines state that molecular testing, including Oncotype Dx Genomic Prostate Score (GPS) testing should be considered further with intermediate risk prostate cancer and a life expectancy of greater than 10 years, the American Urological Association (AUA) Guidelines are considerably less positive regarding the usage of this test. The AUA guidelines state "tissue based genomic biomarkers (such as Oncotype Dx GPS) have not shown a clear role in Active Surveillance for localized prostate cancer, and are not necessary for follow-up." The NCCN guidelines, in addition, also note the absence of randomized prospective trials. Essentially, the impact of tissue based genomic biomarker tests, such as Oncotype Dx GPS, on clinical practice, and long term patient outcomes remains to be empirically demonstrated. Prospective studies of these tests yielding a true clinical benefit when implemented in clinical practice are still lacking.

The Oncotype Dx GPS test for Prostate Cancer (denial code 775) is not considered medically necessary for this patient.

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

The carrier's denial of coverage for the Oncotype Dx test for prostate cancer (denial code 775) should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: GERD (Gastroesophageal reflux disease).
Treatment: Endoscopic Procedure(s) and Associated Codes [EGD - Esophagogastroduodenoscopy- Transoral Biopsy Single/Multiple] at the Outpatient Hospital Surgery Department.
The insurer denied the Endoscopic Procedure(s) and Associated Codes [EGD Transoral Biopsy Single/Multiple] at the Outpatient Hospital Surgery Department. The health plan's determination is overturned. 

The patient is a female with hypertension (HTN), obesity and diabetes mellitus (DM) requiring insulin who underwent an upper endoscopy and colonoscopy. The colonoscopy was done for colon cancer screening. The endoscopy was performed for gastroesophageal reflux disease (GERD) that did not respond to proton pump inhibitor (PPI) therapy. On Pre-op assessment, the patient was felt to have a low risk for obstructive sleep apnea (OSA) and airway was a Mallapati II. Categorized as American Society of Anesthesiologists (ASA) 3. The procedures were done in a hospital rather than ambulatory setting. The procedure was denied on this basis as the patient had no significant co-morbidities which would warrant the procedures being completed in a hospital setting.

The Endoscopic Procedure(s) and Associated Codes [EGD Transoral Biopsy Single/Multiple] at the Outpatient Hospital Surgery Department was medically necessary for this patient.
The standard of care for patients who are ASA III and above is to perform the procedure in a hospital setting rather than an ambulatory surgical center (ASC). The reason for that recommendation is that ASC's do not have adequate capability to resuscitate patients who have underlying major organ dysfunction. Resuscitation may include endotracheal intubation with external ventilation for example - this is not available in an ASC. In this case, it was medically necessary to perform the procedure at a hospital setting. This meets the standard of care.
Appeal type: Formulary Exception
Decision: Overturned

Orthopedic/Musculoskeletal - Knee Problem/Pain
Pharmacy/Prescription Drugs 

The patient is a female with a history of chronic right knee pain, back pain from degenerative thoracic and lumbar disc disease, and iron deficiency. She is requesting coverage for Pennsaid (diclofenac topical), which is noted by her provider to be effective whereas the multiple other formulary drugs were not.

The health plan's determination is overturned.

In the documentation provided for review it was noted by the patient's provider that she has tried all of the formulary alternatives, and that they have been ineffective compared to the requested Pennsaid (diclofenac topical). The medical records reveal that the patient has been prescribed the Pennsaid (diclofenac topical) more than 3 years ago and that she has been taking it all along. In addition, it is reasonable to conclude that considering the patient's history of iron deficiency, the topical Pennsaid would be much less likely to cause serious side effects versus the oral agents. The formulary oral agents would likely have more adverse effects.
Appeal type: Medical necessity
Decision: Upheld

Chronic Kidney Failure 
Pharmacy /Prescription Drugs 

The patient with a history of chronic kidney disease and anemia of chronic disease. The request is for Procrit (Epoetin Alfa). It was unclear from the documentation submitted if Procrit was actually started or just ordered. The patient also has a history of congestive heart failure and hypertension. Chronic kidney disease is due to IgA nephropathy. 
Uphold, in whole the health plans determination. No. The requested Procrit is not medically necessary.
The patient has a history of advanced chronic kidney disease and resultant anemia of chronic disease. It is unclear in the records submitted if the patient  has started the Procrit, and the  last hemoglobin was 10.7. In addition, recent iron stores are not available for review. Per current literature and guidelines, the use of Procrit is considered medically necessary for treatment of anemia associated with chronic kidney disease to maintain hemoglobin levels in the range of 10-11 g/dL when the hemoglobin falls below 10 g/dL. Also, prior to starting an erythropoiesis-stimulating agent like Procrit, the member's iron stores should be evaluated, and blood ferritin should be at least 100 or saturation should be at least 20%, and ongoing erythropoiesis-stimulating agent therapy should not be administered unless iron stores are maintained.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertensive emergency.

Treatment: Full hospital admission.

The insurer denied coverage for the full hospital admission.

The denial is overturned.

This is a male patient who was admitted with hypertensive emergency which is indicated by a systolic blood pressure (SBP) greater than 180 or diastolic blood pressure (DBP) greater than 120 with evidence of acute or worsening target organ damage. The patient's blood pressure was 261/147, and he presented with signs of myocardial infarction including elevated troponin and electrocardiogram (EKG) changes. The patient also had acute kidney injury (AKI) noted with elevated creatinine from a baseline of 2.2 up to 4.7. The patient's condition required close cardiac monitoring in the Coronary Care Unit (CCU) and required intravenous (IV) Cardene drip and adjustment of multiple blood pressure medications to stabilize his condition and control his blood pressure.

Based on the review of the medical record and literature, the full hospital admission was medically necessary for this patient. The patient's medical condition required an extended stay after blood pressure control due to his worsening kidney function and possible need for renal replacement therapy. Thus, the inpatient admission was appropriate and consistent with the standard of care.

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

Based on the above, the medical necessity for the full hospital admission is substantiated. The insurer's denial should be overturned.