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

Angina
Inpatient Hospital

The patient is a man with a history of hypertension and a family history of premature coronary artery disease. He presented to the hospital complaining of two days of constant, pleuritic, nonexertional, left-sided chest pain. His blood pressure was 147/94 mmHg with a heart rate of 66 beats/minute. On physical exam there was tenderness to palpation on the left anterior upper chest wall. The patient's pain could also be exacerbated by having him change posture. An electrocardiogram showed sinus rhythm with nonspecific T wave abnormalities. His troponin level was normal. He was treated with aspirin and morphine and admitted to the hospital. The next day, a stress echocardiogram was performed and showed no evidence of ischemia. The patient was discharged home. Coverage for an inpatient admission is at issue.

The health plan's determination is upheld. An inpatient level of care was not medically necessary. This man, with cardiac risk factors of hypertension and a family history of premature coronary artery disease, presented with atypical symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. On the other hand, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. There is no indication in the records provided that other potentially life-threatening diagnoses were considered likely. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal - Hernia
Inpatient Hospital

This patient is a male who presented to the emergency department (ED) with an incarcerated inguinoscrotal hernia. The hernia was able to be reduced in the ED. The patient was treated with right inguinal hernia repair. The submitted nursing, surgical, ED and anesthetic records document hemodynamic stability during the perioperative period.
The patient remained hemodynamically stable, post-surgical nausea was managed, his diet was advanced and pain medications were converted to oral medications. He was discharged from the hospital.
The appeal material indicates that inpatient care was required per Milliman Care Guidelines (MCG) because of signs of intestinal obstruction.
The subject under review is the medical necessity of the inpatient stay. 

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

No. This patient presented to the ED with an incarcerated right inguinal hernia. The hernia was able to be reduced in the ED. The patient underwent uncomplicated hernia repair and the period of monitoring was otherwise uncomplicated. The records support that inpatient care and treatment was not medically necessary. This patient required prompt evaluation and surgical treatment for a right inguinal hernia. However, the care and treatment provided could have reasonably been provided at a lower level of care setting with monitoring.
This patient did not require inpatient admission as provision of intravenous (IV) fluid, pain medications, antiemetics, and surgery could have been appropriately provided at a lower level of care setting. This level of care would have provided for regular clinical assessment, follow up monitoring, surgical repair of the inguinal hernia and provision of the prescribed IV medications and fluid. This lower level of care status would have also allowed for overnight monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain
Issue under review: Chiropractic treatments

Determination:
The Chiropractic treatments were not medically necessary.

The patient is an adult female. She has been receiving chiropractic care/treatment with her chiropractor for back and mid back complaints. Diagnoses rendered were noted to include pain in the thoracic spine, segmental dysfunction to the thoracic spine as well as sprain/strain to the thoracic spine. Treatment provided included modalities consisting of ultrasound therapy, mechanical traction as well as manual manipulative treatment.

Approximately 30 visits were supplied to the patient by the attending chiropractor. The patient underwent additional treatment.

Through to the point in question, the patient had received a sufficient amount of in-office conservative chiropractic care in both length and frequency. The clinical justification to continue ongoing chiropractic care has-not been supported through the documentation presented.

Documentation presented for this review fails to support the clinical necessity of ongoing chiropractic care/treatment. As explained previously, through to the point in question, the patient had been provided a sufficient course of in-office conservative chiropractic care/treatment in both length and frequency. Documentation presented by the attending chiropractic practitioners fail to reveal any significant objective clinical gains were being achieved with the treatment being provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult male. His medical history included asthma and marijuana use. His surgical history was negative. He presented to an emergency room with a three-day history of abdominal pain, nausea, and vomiting. 

The patient's vitals were blood pressure 98.7, pulse 92, blood pressure 121/76, respirations 17, oxygenation 99%. Physical examination demonstrated tenderness to palpation in the right lower quadrant and supra-pubis. Serum laboratories demonstrated leukocytosis to 16.1. Computed tomography demonstrated non-complicated appendicitis. 

The patient was admitted at an acute inpatient level of care with a diagnosis of acute appendicitis. Due to "delayed presentation, nonoperative management was attempted." He was made nil per os [NPO] (nothing by mouth), provided with intravenous fluids, antibiotics, and analgesics. 

Over the course of 48 hours, the patient improved. After he tolerated oral intake and his leukocytosis resolved, he was discharged home in good and stable condition with outpatient surgical follow-up and prescriptions for oral antibiotics and analgesics. 

For patients undergoing non-operative management for acute appendicitis, the median length of stay is 0.4 to 3 days. However, these patients can be managed at a lower level of care, precluding the need for admission at an acute inpatient level of care [Di Saverio et al; Findlay et al.]. Indeed, most patients improved to treatment in 24-48 hours [Talan et al.]. 

According to peer reviewed literature, patients can be treated safely and effectively at a lower level of care; they do not require admission at an acute inpatient level of care. The patient's computed tomography demonstrated non-complicated appendicitis. Therefore, the Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System
Inpatient Hospital

This is the case of a male with history of asthma who was brought to the emergency department (ED) with altered mental status. He was in his usual state of health until the day of presentation. He attended school without difficulty, but by the afternoon was tired, vomited, and appeared confused and was not responding appropriately. Recent symptoms include 3 days of cough.

ED vitals demonstrated a temperature (T) of 38.8 Celsius (C), heart rate (HR) of 140, with respiratory rate (RR) of 36, and oxygen (O2) saturation of 98% on room air. Examination was remarkable for confusion and aphasia. Chest x-ray was concerning for small right middle lobe (RML) infiltrate, electrocardiogram (EKG) showed sinus tachycardia. Head computed tomography (CT) was normal with incidental finding of left sided arachnoid cyst. Labs showed white blood cell (WBC) count=24.9 with 83% segs, hematocrit (Hct)=37.5, platelets (Plt)=302. Electrolytes, creatine kinase (CK), and troponin tests were normal, C-reactive protein (CRP)=0.6. Flu testing was negative.
The patient was given intravenous fluids (IVF), intravenous (IV) ceftriaxone and azithromycin, and Zofran. Baseline mental status returned to normal and the patient drank apple juice without vomiting.

At issue is whether the inpatient hospitalization was considered medically necessary.

The health plan's determination is overturned.

The requested inpatient admission was considered medically necessary. This is the case of a previously healthy male who presented to the ED with the acute onset of fever, vomiting, and altered mental status. He was notably very sleepy and febrile on arrival to the ED, had blood work done that showed leukocytosis, and had an IV placed for an IVF bolus. A chest x-ray demonstrated pneumonia. Given the concern for possible intracranial process, a head CT was performed. The patient continued to vomit while in the ED. Although his status improved with IVF and medications, this child's condition in the ED warranted inpatient hospitalization to monitor for possible sepsis or decline.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post motor vehicle accident; uterine contractions
Treatment: Inpatient admission

The inpatient admission was medically necessary.

The patient is a G1 female. At 34.3 weeks, she was involved in a low speed auto accident.  On presentation to the hospital, she was having uterine contractions observed to be 2/10 minutes on the tocodynamometer.  She denied feeling uterine contractions or bleeding.  However, variable decelerations were observed and the tracing was read as category II.  The cervix was one centimeter (cm) and no pooling was noted.  

The patient was admitted to the hospital and observed overnight on continuous EFM (electronic fetal monitoring) and given betamethasone.  The contractions and EFM abnormalities resolved and she was discharged home on hospital day #2.  

The studies of Pearlman et al regarding trauma in pregnancy demonstrate that an important prognostic factor in determining risk for immediate adverse outcomes is the frequency of uterine contractions occurring in the first four hours of observation in the hospital.  Patients demonstrating group IV contractions, contractions at a frequency of every two to five (q2-5) minutes, at any point in the first four hours of observation, are at risk for adverse outcomes and need prolonged observation.  This patient demonstrated contractions at this frequency.  During this observation period it may be necessary to perform emergent interventions, such as emergency Cesarean section for abruptio placentae or other life-threatening complications, and so this observation cannot be performed at an outpatient level of care.   

In addition, patients with abnormal fetal heart rate tracings such as this one cannot be discharged home until resolution of these abnormalities, and immediate Cesarean section must be available.  

Therefore, given the above, the admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Preterm labor

Treatment:  Inpatient hospital admission

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

This patient is a pregnant female who presented at 32.2 weeks gestation with complaint of uterine contractions.  She has a history of a prior preterm delivery at 34 weeks gestation and was maintained on Makena during this pregnancy.  Fetal movements were present and the patient denied leakage of fluid or vaginal bleeding.  Vital signs were stable.  The fetal heart rate was reassuring.  The cervix was dilated 2 centimeters with 20% effacement.  She was admitted with the diagnosis of preterm labor and received Betamethasone.  Magnesium Sulfate was started but discontinued upon maternal fetal medicine recommendation.  The patient signed out against medical advice.  She was in good condition upon discharge.	

This patient was complaining of abdominal pain and has a history of a prior preterm delivery.  Preterm labor is an indication for admission and tocolysis .  Preterm labor is defined as uterine contractions with cervical changes.  Did this patient have preterm labor?  During this admission, there was no documentation of any cervical changes.  So the patient was not in preterm labor.  Ideally, this patient would have been observed in labor and delivery, received intravenous (IV) fluid and then reevaluated few hours later.  If upon reevaluation, no cervical changes occurred then she would be sent home.  If cervical changes did occur then she would be admitted for tocolysis and further management.  Please note that neither the patient nor the fetus were in any jeopardy.  There was no bleeding, and vital signs were stable.  Fetal heart rate was reassuring.  There was no evidence of ruptured membranes.  The management that this patient received during her admission could have been easily done in a less acute setting; once the provider ascertained that there was no evidence of preterm labor, (no change in cervical status after few hours of observation) the patient could have been sent home after being hydrated. 

Based on the above, since this patient was not in labor and was stable, admission to the hospital was not medically necessary.  This is in accordance with standard of care and Milliman guidelines.  The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.  The inpatient hospital admission is not considered medically necessary for this patient.  Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lower extremity cellulitis versus abscess

Treatment: Inpatient admission

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

This patient is a male with past medical history significant for pulmonary embolism, gout, and cellulitis who presented to the Emergency Department with complaints of pain and swelling of his right lower extremity. Vital signs on presentation included a temperature of 102.3F, a blood pressure of 145/83, a pulse of 115, a respiratory rate of 19, and an oxygen saturation of 94%. Laboratory values were notable for the following: a white blood cell (WBC) count of 12.8 (91.2% neutrophils), a hemoglobin of 13.6, a hematocrit of 39.2, a creatinine of 1.3, a glucose of 103, a lactic acid of 2.8, and a D-dimer of 1928.

The patient was admitted for possible lower extremity cellulitis and started empirically on intravenous antibiotics (vancomycin, ceftriaxone, clindamycin). A chest x-ray was negative. Doppler exam was negative for a deep vein thrombosis (DVT).  The patient developed a reaction to the vancomycin infusion. A magnetic resonance imaging (MRI) of the lower extremity was ordered, but not completed since patient opted to sign out of the hospital against medical advice. He was discharged on oral antibiotics (Augmentin).

According to the documentation, the patient was admitted with a lower extremity cellulitis versus abscess. He presented with a fever (temperature of 102.3F) and tachycardia (heart rate of 115). Laboratory results showed numerous abnormalities including leukocytosis (WBC count of 12.8 with a left shift), elevated creatinine (1.3), elevated D-dimer (1928) and increased lactic acid (2.8). 

Based on the above findings in a high-risk patient with a history of prior infections, as well as pulmonary embolism, the hospital admission was medically necessary for intravenous antibiotics and additional diagnostic testing.  

The prior determination of denial of inpatient admission has been reversed. The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest. Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
 
Treatment: Inpatient admission

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

This patient is a man with a past medical history notable for hyperlipidemia.  He presented to the ER with complaints of chest pain, associated with shortness of breath. EKG showed normal sinus rhythm. Troponin was negative initially and on repeat evaluation. He was evaluated by Cardiology. He underwent coronary CT angiography, which was negative for any significant stenosis. Echocardiogram showed ejection fraction 55-60%. He was discharged home after a period of medical stability.

The patient presented with chest pain.  The initial evaluation in the emergency room was unremarkable, including non-diagnostic EKG and negative cardiac biomarkers. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted; however inpatient admission criteria were not met.  There was no evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. 

The health care plan did act reasonably and with sound medical judgment and 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:  Marfan syndrome

Treatment:  Genetic testing

The insurer denied coverage for genetic testing.  The denial was upheld.

This patient is a male who was evaluated for Marfan syndrome.  The patient had a spontaneous pneumothorax x2 on the left.  There was no known cardiovascular disease, though he never had a formal evaluation.  The patient had myopia, but no other known ophthalmologic disease.  The patient exercised without symptoms of exertional chest pain, or dyspnea.  The patient felt occasional resting palpitations.  There was no known connective tissue disorder in the family history.  The patient's Marfan systemic score was 8.  The echocardiogram revealed that the aortic diameter was 3.1 cm with no dilation of other visualized segments of the thoracic aorta, no valve pathology, and normal left ventricular function and right ventricular size and function.  The ECG revealed normal sinus rhythm.  The patient was recommended for genetic testing including a Thoracic Aortic and Dissection (TAAD): 3-gene panel.

The testing that was performed was denied, as the services were not medically necessary.  The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The genetic testing is not considered medically necessary for this patient.  The main clinical findings to suspect a diagnosis of Marfan syndrome are aortic root enlargement, ectopia lenses and a systemic score of >7.  The patient has normal root dimensions, no evidence of ectopic lenses and the systemic score is reported as 8 but no details on the features used to calculate this score were provided.  Thus, the reported information does not support a diagnosis of Marfan syndrome or other TAAD syndromes.

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

Diagnosis: Non-obstructing renal stones 

Treatment: Inpatient admission

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

This patient is a man with a past medical history notable for; hypertension, hyperlipidemia, coronary artery disease, and diabetes mellitus. He presented to the ER with complaints of lower back pain and was found to have non-obstructing renal stones, but was also found to have atrial fibrillation with rapid ventricular response with rates up to the 150's. Diltiazem was given, which resulted in reduction in heart rates to the 80's. Cardiology was consulted, and the patient was admitted. He was referred for transesophageal echocardiography (TEE) with cardioversion, however he spontaneously converted to sinus rhythm and the procedure was cancelled. The patient was discharged home. He was given anticoagulation with instructions to follow-up with a cardiologist within a week.

The patient presented with atrial fibrillation. The remainder of the cardiac workup was unremarkable, including unremarkable cardiac troponin. The patient remained clinically and hemodynamically stable. Inpatient admission was not medically necessary for this patient. In the absence of evidence of myocardial ischemia, hypoxemia, hemodynamic instability, or other end-organ dysfunction, the patient's care could have been provided in the Observational level of care, allowing for additional cardiac testing. Inpatient admission criteria were not met. Although the patient had new onset symptoms, medical criteria were not met for any other additional extenuating circumstances.  

The health care plan acted reasonably and with sound medical judgment and 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: Overturned

Varicose Veins 
Surgical Services 

The patient presents with left leg symptomatic varicose veins. The  main symptoms included pain, fatigue, itching, burning and leg cramps. The symptoms are lifestyle limiting and interfere with the activities of daily living. The patient has worn graded compression stockings for greater than 3 months duration without symptomatic relief. The patient is noted to have significant reflux in the left duplicated great saphenous vein. The provider is requesting endovenous ablation of the left duplicated great saphenous vein for treatment of the condition. The health plans determination is overturned in whole. 
Yes, the procedure is medically necessary. 
Endovenous thermal ablation of the duplicated left great saphenous vein is medically necessary based on the peer reviewed literature. 
The patient presents with bilateral lower extremity symptomatic varicose veins which are refractory to conservative therapy. The patient has attempted conservative therapy with graded compression stockings for several months without symptomatic relief. Her main symptoms include aching, fatigue and swelling. The patient demonstrates bilateral great saphenous vein reflux. The current standard of care is to treat duplicated great saphenous the same way as non-duplicated saphenous veins. 
Endovenous ablation of the left refluxing duplicated great saphenous vein is the current standard of care treatment for patients with symptomatic varicose veins and saphenous vein reflux. The most recent consensus guidelines for the Society for Vascular Surgery and the American Venous Forum support endovenous thermal ablation for this patient based on her clinical presentation. Endovenous ablation is supported by the peer reviewed literature including level 1 randomized evidence. Several current peer reviewed papers support the use of endovenous thermal ablation for patients with symptomatic varicose veins with excellent results. Therefore, Endovenous thermal ablation of the duplicated left great saphenous vein is medically necessary.