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

Diagnosis: Vertigo

Treatment: balance test (CPT [Current Procedural Terminology] code 92548)

The insurer denied coverage for balance test (CPT code 92548)

The denial is overturned.

The patient is a woman with a history of non- Hodgkin lymphoma. Her medical history of severe vertigo:

"Patient comes in for evaluation of severe vertigo.
Symptoms occurred with getting out of bed and lasted 2-3 hours.
She went back to bed and when she got up symptoms were entirely resolved.
She then had another episode of vertigo with getting out of her car. Symptoms were similar with severe vertigo. She had to tum off fan/lights. Symptoms lasted a few hours."

A comprehensive vestibular evaluation was obtained to rule out Meniere's syndrome. The per reviewed literature is consistent in recommending vestibular evaluation as an integral part of the evaluation of a patient for Meniere's syndrome1-3.
The vestibular findings were all within normal limits.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. She had symptoms which could be consistent with Meniere's syndrome and as per the peer reviewed literature required a vestibular assessment1-3. 

The balance test (CPT code 92548) is considered medically necessary for this patient as per the peer reviewed literature as she had symptoms of multiple severe episodes of vertigo1-3.  

The denial should be reversed as there was ample clinical evidence in the clinical records to mandate the need for vestibular testing. 

The insurer's denial of coverage for the balance test (CPT code 92548) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the hospital emergency department (ED) with a history of progressively worsening abdominal pain of 1-day duration. His evaluation included a physical exam, computed tomography (CT) scan, and labs. He was afebrile at the time of presentation. The heart rate was normal at 92/minute at presentation. The abdomen was tender in the right lower quadrant. Lab data identified a normal white blood cell count (WBC) of 8.9 thousand (K). The CT scan showed a periappendiceal fat stranding and inflammation of the terminal ileum and cecum. This was attributed to ileitis /colitis or appendicitis. Treatment was initiated with nothing by mouth (NPO) status, intravenous (IV) fluid and antibiotics. Surgical consultation was requested. He was admitted to the hospital.
The patient was without a fever and had normal vital signs. His pain was well controlled and he was started on a diet. He tolerated a diet, pain control was with oral medications and he had no abdominal tenderness . He was discharged home with continued antibiotics and consideration for outpatient colonoscopy and interval appendectomy.
At issue is the medical necessity of an inpatient stay.
Inpatient care was not medically necessary.
The patient presented to the emergency department (ED) and was evaluated with physical exam, labs and imaging that suggested the diagnosis of ileitis/colitis or appendicitis. He was treated initially with NPO status, IV fluid and IV antibiotics. He had a normal WBC count and was started on a diet. His clinical course was without adverse incident. The patient responded favorably to this treatment and the hospitalization was uncomplicated. The patient was previously healthy and the vital signs were consistently normal. The progress notes document clinical stability without complication during this period of monitoring.
The submitted clinical documentation does not support the need for inpatient admission for this patient. A lower level of care would have satisfactorily provided for the care and would have been consistent with the accepted standard of medical care.
Generally accepted medical standards indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications, treatment as provided in this case could be provided without an inpatient level of care. In this case, the patient tolerated oral hydration and a treatment plan was established with a plan for continued oral antibiotics, outpatient colonoscopy and possible interval appendectomy. A lower level of care would have appropriately provided for treatment and overnight monitoring. Inpatient care was not required or medically necessary in this case per generally accepted medical standards.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion and crowding
Treatment: Braces/monthly visits.
The insurer denied braces/monthly visits. 
The health plan's determination is overturned. 

The patient in question is a female with impacted tooth # (number) 11. This tooth is impacted in a mesioangular inclination and it is in close proximity to the root of tooth 10. Tooth 10 is also in crossbite with the primary left mandibular canine. She presents with a skeletal Class I malocclusion and crowding. She is treatment planned for Braces and Monthly Visits to address the malocclusion and impacted tooth. 

Braces and Monthly Visits are medically necessary for this patient. 
If left untreated, the damage that will likely occur to the patient's teeth will be more time consuming and difficult to correct than the patient's existing orthodontic problem. Studies show that impacted canines with a mesioangular inclination have a less than 15% chance of spontaneous eruption. Complications of impacted canines include potential root resorption and devitalization of the adjacent lateral incisors. Given the position of tooth #10 and #11, I expect tooth #10 to be damaged if tooth #11 is not addressed. For this reason, braces are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Advanced Dementia
Treatment: Increase in Personal Care Services (PCS) to 24 hours/day, 7 days/week (split shift), for a total of 168 hours/week
The insurer denied the increase in PCS to 24 hours/day, 7 days/week (split shift), for a total of 168 hours/week.
The denial is overturned.

This patient has symptoms including advancing dementia, flaccid paraplegia, bed confinement, stage IV (4) sacral ulcer, diabetes, and hypertension. This is an appeal for denial of an increase in personal care services (PCS) to 24 hours/day, 7 days/week, split shift, for a total of 168 hours/week. The plan approved PCS 24 hours/day, 7 days/week, live-in, for a total of 91 hours/week. Uniform Assessment System (UAS) evaluation performed shows moderately impaired cognition, the member is bed bound, and assistance required with all ADLs (activities of daily living).

A letter from the provider notes the member is dependent for all ADLs. She notes the member has need for unscheduled toileting, diaper changes due to incontinence, frequent turning by caregiver, and reminders with eating.

Yes, the proposed treatment is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. The member has several chronic conditions including dementia, paraplegia, bedbound, and stage IV sacral ulcer. She is appealing denial of an increase in PCS to 24 hours/day, 7 days/week, split shift, for a total of 168 hours/week. The plan approved PCS 24 hours/day, 7 days/week, live-in, for a total of 91 hours/week. Per UAS evaluation, the member requires assistance with all ADLs. UAS evaluation performed shows moderately impaired cognition, the member is bed bound, and assistance required with all ADLs. She has incontinence. The appeal letter from her doctor notes that she is dependent with all ADLs. She requires incontinence care and frequent turning. This member has significant physical impairments due to paraplegia. She has a stage IV ulcer and needs frequent turning. The approved PCS live-in is inadequate to meet the member's needs for frequent turning and incontinence care. The proposed increase in PCS (split shift) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Leg pain with activity
Treatment: Duplex ultrasound, Physiological Testing
The insurer denied duplex ultrasound, physiological testing. 
The denial is overturned. 

The patient is a female who presented to her provider with leg pain with activity and improvement with rest. Arterial lower extremity ultrasound was requested by her primary care physician (or provider) (PCP).

At issue is the medical necessity of duplex ultrasound, physiological testing.

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

The requested health service/treatment of duplex ultrasound, physiological testing is medically necessary for this patient.

The patient's complaint of leg pain with activity and improvement with rest could be a sign or symptom of claudication and an arterial ultrasound looking for arterial disease is reasonable and medically necessary to evaluate the patient. In a patient who has leg pain due to activity, it can be caused by a circulation issue in either arterial blood flow or venous blood flow. Blood flow is easily and accurately studied by an ultrasound of those blood vessels in the legs. It is standard of care to begin evaluation of leg pain with activity with an ultrasound to confirm normal/abnormal blood flow.

Therefore, the requested health service/treatment of duplex ultrasound, physiological testing is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease.
Treatment: Humira CF Pen 40 mg/0.4 ml injection kit.
The insurer denied Humira CF Pen 40mg/0.4 ml injection kit. 
The denial is overturned.

The patient is a male who has severe fistulizing Crohn's disease and has had required prior incision and drainage (I&D) of an abscess. He also has ankylosing spondylitis. He has previously tried and failed certolizumab and secukinumab. He was started on Humira at standard dosing and initially responded but did not achieve remission. He required seton placement during which Humira was temporarily held for two weeks. He still did not achieve clinical remission. Therapeutic drug monitoring showed low adalimumab levels. He had elevated inflammatory markers (fecal calprotectin). Therefore, his attending gastroenterologist would like to escalate the dose of Humira to 40 milligrams (mg) every week to treat this patient's severe Crohn's disease.

The requested health service/treatment of Humira CF (citrate-free) Pen 40 mg (milligrams)/0.4 ml (milliliters) injection kit for quantity increased to weekly dosing is medically necessary for this patient. Dose escalation in inflammatory bowel disease (IBD) is the standard of care in patients who are not responding to standard of the biological medication they are currently on. Dose escalation in biological therapy used to treat inflammatory bowel disease is a well-accepted practice and supported by literature in patients who are not responding to standard dosing of the medication. Dose escalation in biologic therapy used in inflammatory bowel disease can be done either based on clinical symptoms or laboratory markers or endoscopic or radiological features with or without therapeutic drug monitoring. Dose escalation is done either by increasing the dose of the medication or shortening the interval between doses or sometimes a combination of both. There are only a finite number of biological agents used to treat inflammatory bowel disease and the standard of care is to optimize dose of the current biological agent before switching to another agent. Humira dose escalation to weekly in this patient who is failing standard dosing of Humira is appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and dyspnea 
Treatment: Inpatient Hospital Stay 
The insurer denied inpatient hospital stay. 
The denial is upheld.

The patient is a female with a history of chronic obstructive pulmonary disease (COPD) and cigarette smoking presented to the emergency department (ED) complaining of chest pain and dyspnea. Her electrocardiogram (ECG) reportedly showed mild, "equivocal" ST segment (interval on an ECG) depression in leads V4-5 (chest leads on an ECG). Her serum troponin level was normal. She was admitted to the hospital and treated with nitrates, heparin and dual antiplatelet therapy. An echocardiogram showed normal left ventricular systolic function. She complained of worsening symptoms and was transferred to another facility for cardiac catheterization. This showed normal coronary arteries. The patient was discharged. Medical necessity for an inpatient hospital stay is the subject under review.

The health plan's determination is upheld.

Based on the documentation provided, an inpatient hospital stay was not medically necessary. This patient presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, monitoring until ACS could be ruled out by cardiac catheterization was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers. There were no diagnostic electrocardiographic changes. She did not require intensive monitoring or continuous infusion and titration of intravenous cardioactive medications. The care this patient received did not require an inpatient level of care and could have been provided under a lower level of care status. This approach has been shown to be safe and is in accordance with current guidelines, including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE)/American College of Chest Physicians (CHEST)/Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a female with a history of an enlarged fibroid uterus, heavy menses, iron deficiency anemia, and sickle cell trait. She presented to the ED (emergency department) with abdominal pain, nausea, vomiting, fatigue, weakness, and cold intolerance.

The patient was evaluated and found to be anemic with a hemoglobin of 6.5. Her baseline is 8. She had stable vital signs. She had a normal EKG (electrocardiogram) and normal chest x-ray. She was given IV (intravenous) fluids and 1 unit of PRBCs (packed red blood cells). Her potassium was low and she was given replacement. Her hemoglobin rose to 7.6 post transfusion.

The patient was admitted for further evaluation. She had a gynecology consult, and an endometrial biopsy and pap was obtained. The recommendation was for a hysterectomy in a few weeks. She was started on progestin and given another 2 units of PRBCs. Her vitals remained stable. She was discharged home with outpatient follow up and surgery booked. Her hemoglobin was 9.6.

No, the inpatient hospital admission was not medically necessary.

In review of the medical record, the patient presented with iron deficiency anemia. She was not actively bleeding and she was hemodynamically stable. She had a normal EKG. Although potassium was low, this was not in a range to cause heart irregularities. She was optimized in the ED with fluids and a blood transfusion. The remaining workup could have been performed in the outpatient setting. There is no evidence that she required an acute inpatient setting.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The plan denied coverage of the inpatient hospital stay based on lack of medical necessity. The care could have been achieved safely at a lower level. The patient was stable and did not require interventions that can only be performed in the acute inpatient setting. Therefore, the plan appropriately denied coverage of the inpatient hospital stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever, tachycardia, vomiting, diarrhea
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is a male with no significant history. He had a recent mild COVID (Coronavirus) infection. The patient was noted to have no symptoms of distress at that time. The patient presented to the ED (emergency department). The patient had a fever for four days, tachycardia, decreased appetite and PO (oral), with vomiting and diarrhea. There was a concern for dehydration and possible Kawasaki disease.

On evaluation of the patient's labs, dehydration was noted in urine specific gravity and CO2 (carbon dioxide). The ESR (erythrocyte sedimentation rate) was elevated as well. The patient required no oxygen support. No cardiac abnormalities were noted. The patient had vitals monitored and received IV (intravenous) fluids. When the patient was able to take good PO and no longer required IV fluids, he was discharged in good clinical condition.

Yes, the inpatient hospital admission was medically necessary.

Considering the patient's clinical presentation and recent medical history, the patient had multiple concerning symptoms such as fever, decreased PO and urine output with continued high fevers for 4 days. The patient had elevated inflammatory markers, signs of dehydration as well as concerns for a possible Kawasaki disease diagnosis. This required clinical monitoring for tachycardia, signs of dehydration on electrolyte assessment and urine work up and elevated inflammatory markers. When reviewing the ER (emergency room) note, the patient's vitals were remarkably noted for signs of dehydration with the elevated heart rate. The patient was admitted and appropriately monitored and treated until the patient was clinically well for discharge.

Due to the patient's age, there was a concern for possible Kawasaki disease and dehydration. As such, an inpatient hospital admission was medically appropriate to thoroughly evaluate and monitor and care for this child until a proper diagnosis and treatment plan could be made.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

An inpatient hospital admission with the patient's clinical course was medically sound in judgment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission.
The denial is upheld.

This is the case of a female with a history of Barrett's esophagus, GERD (gastro-esophageal reflux disease), HPL (hyperlipidemia), and obesity. She presented to the ED (emergency department) with complaints of abdominal pain. As per the ED provider note, the patient presented with sudden severe RUQ (right upper quadrant) pain and tenderness with nausea without vomiting. She denied fevers or chills. The abdomen was soft with RUQ tenderness and no guarding. The pain radiated to her back. Exam revealed stable vital signs and the patient was afebrile. Her BMI (body mass index) was 37.76. Her abdomen was soft, tender to palpation with positive Murphy's sign. The plan was labs and a GI (gastroenterology) consultation. The suspicion was cholecystitis versus choledocholithiasis. 

Based upon the records the inpatient hospital admission was not justified, as this patient could have been managed as noted by the insurer in an ambulatory/observation setting as she had an uneventful lap cholecystectomy. Furthermore, the patient had acalculous cholecystitis and did not have choledocholithiasis as there was no indication of elevated bilirubin or dilated CBD (common bile duct). In fact, on the following morning the WBC (white blood cell count) was totally normal. There was also no fever and an MRCP (magnetic resonance cholangiopancreatography) that did not show a dilated common bile duct. She had mild transaminitis but was also morbidly obese, which could explain some of the elevated liver enzymes. I therefore believe she did not need an acute inpatient hospital admission, as noted by the insurer. According to the guidelines of MCG (Milliman Care Guidelines) Health Inpatient and Surgical Care - 26th edition Gall bladder or bile duct inflammation or stone ORG: M-555 (ISC), patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. 

Finally, MCG General recovery care 26th edition Ambulatory surgery exception criteria GRG:CG-AEC (ISC GRG) notes that potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: inpatient care needed for clinically significant preoperative disease or condition, complex surgical approach or situation anticipated, procedure is not low risk and patient at high anesthetic risk, presence of drug-related risk, inadequate outpatient care situation, postoperative event, condition, or finding that warrants inpatient stay. Given the above the patient did not warrant inpatient status, but ambulatory for this procedure as she did not warrant inpatient care as she did not have a significant preoperative disease or condition that warranted inpatient hospital admission.

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

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

Diagnosis: back pain
Treatment: facet joint injections
The insurer denied facet joint injections.
The health plan's determination is overturned. 

This patient is a male who has a long-standing history of low back pain for several years. His pain is localized in the left side lower back with no radicular symptoms. He had tried physical therapy (PT), non-steroidal anti-inflammatory drugs (NSAIDs), and over the counter pain medications, however, none of which provided him with adequate pain relief. His pain is severe enough to interfere with activities of daily living. He had excellent pain relief from lumbar medial branch blocks (MBB) with over five months of pain relief. Physical exam (PE) revealed tenderness to palpation (TTP) over L (lumbar) 3 to S (sacral) 1 facet joints with positive facet loading tests.

The requested Facet Joint Injections are medically necessary for this patient.
This patient has a long-standing history of low back pain for several years. He had tried PT, NSAIDs, and over the counter pain medications without adequate pain relief. His pain is severe enough to interfere with activities of daily living. Further treatment is medically necessary to improve his pain and function. He had excellent pain relief for over 5 months from lumbar medial branch blocks. Given this clinical scenario, the requested treatment is medically necessary.