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

Diagnosis: Gastroesophageal reflux disease (GERD). 
Treatment: Transoral incisionless fundoplication. 

The insurer denied coverage for transoral incisionless fundoplication. 

The denial is overturned. 

The patient has a history of chronic gastroesophageal reflux disease (GERD). He has been on a proton pump inhibitor (PPI) for many years. His physician is now advising to do a transoral incisionless fundoplication as a better alternative than a surgical fundoplication. The physician reports that an extensive workup was done including endoscopy, Bravo study, esophagram, and esophageal motility. 

The American Society for Gastrointestinal Endoscopy (ASGE) has published a guideline on the role of endoscopy in the management of GERD. The paper states that the transoral incisionless fundoplication (TIF) procedure was approved by the Food and Drug Administration (FDA) in 2007. It reports that 15 studies and 550 procedures found improved GERD health related quality of life scores after the procedure. Three randomized trials with at least 6 months follow up found that TIF was more effective than high dose PPI therapy in eliminating troublesome regurgitation or extraesophageal symptoms of GERD. 

Surgical Endoscopy published an article in September 2016 titled "Transoral fundoplication offers durable symptom control for chronic GERD: 3 year report from the TEMPO randomized trial with a crossover arm." The conclusion was that the TIF procedure provides sustained symptomatic relief, healing of reflux esophagitis, and prolonged improvement in all esophageal pH parameters at 3 year follow-up. The results further confirm the safety, efficacy, and durability of TIF in symptomatic GERD patients on chronic PPI therapy. 

The scientific evidence supports the use of the TlF procedure in patients with chronic GERD. The procedure has FDA approval and has been shown to improve health outcomes. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a special endoscopic procedure is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The health plan denied inpatient admission. The denial is upheld.

This patient is an adult woman. She presented to the ED (emergency department) with the complaint of abdominal pain of one-day duration.

The patient's examination revealed abdominal tenderness in the right lower abdomen. Vital signs identified a normal temperature at the time of presentation. The heart rate was elevated at 122/minute, but normalized at the time pre-operative vitals were assessed on 01/19/2023. The WBC (white blood cell) count was elevated at 15.1 K (thousand). Abdominal CT (computed tomography) scan was completed, showing findings consistent with acute appendicitis. The patient was admitted to the hospital and started on IV (intravenous) antibiotics. Surgical consultation was obtained.

The patient underwent laparoscopic appendectomy. Operative findings included an acutely inflamed appendix. The operation was completed without complication. She was monitored following surgery and remained stable. The post-surgical note indicates that the patient was without new complaint. She had normal vital signs following surgery. She was started on a diet following surgery. She was discharged from the hospital the next day, following the initial surgical recovery with instructions for surgical follow.

Inpatient care was not medically necessary. This patient presented to the ED (emergency department) and was evaluated with physical exam, labs and imaging that supported the diagnosis of acute appendicitis. She was treated initially with NPO (nothing by mouth) status, IV (intravenous) fluid and IV (intravenous) antibiotics. The patient underwent laparoscopic appendectomy. Her clinical course was without adverse incident. The patient responded favorably to this treatment and the hospitalization was uncomplicated. The patient had no comorbid health conditions that mandated an inpatient level of care. The vital signs were consistently normal during the period of monitoring following ED (emergency department) presentation. The medical records 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 provided and would have been consistent with the accepted standard of medical care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headache; fever
Treatment: Inpatient admission
The health plan denied inpatient admission. The denial is overturned.

The patient is an adult pregnant patient G4P3 (4 pregnancies, 3 deliveries, currently pregnant) at 18 weeks 1 day of gestation who presented to the emergency room with a three day history of fevers and back pain.

The patient's temperature was 39 degrees Celsius, pulse 143, and costovertebral angle tenderness was elicited on her physical exam. Of note, she had been treated as an outpatient with antibiotics several days prior to presentation. The diagnosis of pyelonephritis and sepsis (met SIRS [Systemic Inflammatory Response Syndrome] criteria) was made and she was admitted to the hospital for intravenous broad spectrum antibiotics and monitoring. She improved with treatment and was discharged undelivered on hospital day #2.

The health plan contends that the admission was not medically necessary because the patient did not have abnormal vital signs, altered mental status, persistence or worsening of clinical finding, parenteral antibiotics needed, pregnancy of 24 weeks or beyond, immunocompromised, uropathy, ureteral obstruction, bladder emptying impaired, abscess, emphysematous pyelonephritis, pyonephrosis, acute renal failure, acute kidney injury, need for IV (intravenous) hydrations and cites MCG (Milliman Care Guidelines) guidelines. The facility contends that the admission was medically necessary due to the acuity of the patient's presenting symptoms, complexity of management required to treat acute pyelonephritis in the setting of early pregnancy, and need for specialist treatment.

Pyelonephritis in pregnancy is a medical emergency requiring inpatient treatment. Pregnant patients face considerably greater risks from pyelonephritis compared to non-pregnant patients, including sepsis (which this patient already had based on SIRS [Systemic Inflammatory Response Syndrome] criteria), septic shock, disseminated intravascular coagulation, hemolytic anemia, adult respiratory distress syndrome (ARDS), pulmonary edema, preterm labor and delivery, and death. This patient had also failed outpatient treatment with antibiotics. Therefore, the admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crowding; crossbite.
Treatment: D8080 Braces and D8670 Monthly Visit x12.
The health plan denied D8080 Braces and D8670 Monthly Visit x12. 
The denial has been overturned. 

The patient is an adolescent female. The request is for orthodontic benefits, including monthly follow up visits. The health plan's prior denial of coverage was due to handicapping index score of 10. The patient has Class II canines, mild upper and lower crowding, and a posterior crossbite on the right side.

The patient has an anterior tooth crossbite (tooth #27, lower right canine) with gingival attachment (gum) loss. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem, and the monthly visits are needed to follow up to make sure the treatment progresses properly.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Sickle cell crisis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is modified

The patient has the medical diagnosis of sickle cell anemia (SCA) and rheumatoid arthritis (RA). The patient's noted with sickle cell, history of (h/o) hip replacement, RA, and tested positive for Covid and was being treated with amoxicillin. The patient came to the emergency room (ER) with right (R) elbow, left (L) shoulder, and left (L) scapula, and chest pain. The patient vomited oxycodone and went on intravenous (IV) pain medication. In the emergency room (ER) she received 3 doses of intravenous (IV) Dilaudid and one dose of IV Toradol. The next day she received a total of 7 doses of IV Dilaudid. By four days later, the pain completely resolved. The treating provider is requesting plan approval for inpatient admission.

The patient's sickle cell pain is hard to evaluate, especially in a patient with resolving Covid-19 infection. As such, it is determined that for three days, an inpatient stay was reasonable and appropriate. The inpatient stay was needed especially once the patient could not tolerate oral oxycodone. The pain resolved by the fourth day and the patient could have been discharged on that day. 

The request is modified and partially approved. 

"Acute pain of SCD (sickle cell disease) is caused by vaso-occlusive crisis (VOC), impaired oxygen supply or infarction-reperfusion tissue injuries. In VOC, inflammatory cytokines include tryptase activate nociceptors and transient receptor potential vanilloid type 1. In tissue injury, the secondary inflammatory response is triggered and causes further tissue injuries. Tissue injury generates cytokines and pain mediators including bradykinin, and they activate nociceptive afferent nerves and trigger pain. The main causes of chronic pain are from extended hyperalgesia after a VOC and central sensitization. Neuropathic pain could be due to central or peripheral nerve injury, and protein kinase C might be associated with the pain. In central sensitization, neuroplasticity in the brain and the activation of glial cells may be related with the pain." (Takaoka, et al., 2021).

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The denial of the admission for three days is overturned. Uphold denial of the fourth hospital day.

The medical necessity of hospital admission for 3 days is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

 
This patient had a history of diverticulitis and presented with abdominal pain. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. A computed tomography (CT) scan showed diverticulitis but did not reveal an abscess or perforation. Antibiotics were given. There was a discussion about an elective colon resection in view of the recurrent nature of the diverticulitis. 

Clinical indications for admission for Acute Diverticulitis (MCG (Milliman Care Guidelines) M-150) include hemodynamic instability, peritoneal signs, persistent gross bleeding, or a significant abnormality on imaging studies. This imaging abnormality can include a fistula, obstruction, or free perforation. The patient did not have these conditions. She also did not require an inpatient drainage procedure, have bacteremia, severe dehydration, or an inability to maintain oral hydration after observation care. 

This patient had recurrent episodes of diverticulitis but did not have a fluid collection, perforation, or obstruction. Antibiotics could have been given with observation care. She could have been referred to surgery clinic for further management of the diverticulitis after completing a course of oral antibiotics. She did not meet Milliman Care Guidelines (MCG) criteria for an admission for Acute Diverticulitis. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I skeletal malocclusion, impacted canine
Treatment: Braces and Monthly Visits
The insurer denied the braces and monthly visits.
The denial is overturned.

The request is for orthodontic benefits for this preteen female patient. She has a Class I skeletal malocclusion, moderate upper and lower crowding, a deep bite, and an impacted upper right permanent canine. The prior denial was due to a handicapping index score of 16.

The proposed treatment is medically necessary.

The patient has an impacted anterior upper right canine, where extraction is not indicated. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, gastroesophageal reflux disease (GERD), hyperlipidemia, migraines, osteoarthritis, and a gait abnormality

Treatment: Personal care assistance (PCA) services 40 hours per week

The insurer denied coverage for Personal care assistance (PCA) services 40 hours per week

The denial is overturned

 
This elderly patient needs assistance with daily activities due to functional decline associated with several medical conditions. The patient lives alone. The Uniform Assessment System (UAS) reports the patient has a son who lives out of state and visits monthly; sister visits weekly; no informal helpers are identified. The patient receives Personal Care Assistance (PCA) services to help with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). 

The most recent UAS provided was reviewed. The functional status report for IADLs indicates the patient needs maximal assistance for meal preparation, ordinary housework, shopping; extensive assistance for stairs, transportation; limited assistance for phone use, managing finances and medications. For ADLs, the patient needs extensive assistance for bathing, dressing lower body; limited assistance for personal hygiene, dressing upper body, walking, locomotion, transferring to the toilet, toilet use; independent setup help; bed mobility, and eating.

Regarding the patient's cognition, there are no medical records or physician letters available for review, so information is from the UAS (patient, her sister and PCA were present for UAS). As per the UAS the patient's decision making for daily tasks was noted as minimally impaired - in specific situations, decisions become poor/unsafe, cues/supervision are needed at those times (reported as modified independence in prior UAS). The patient was oriented x 3 with short term memory problem. She was self-directing. She could describe an emergency plan (call 911) and has personal emergency response system (PERS) in her home. Mini mental Status Exam (MMSE) was 24/30 (MMSE 27/30 in prior UAS). With decline in decision making, the MMSE score, and the patient reporting her memory is worse, it appears the patient had cognitive decline over the past year. 

The current PCA schedule is 4 days per week; the UAS indicates no informal helpers. The patient needs to move around her home at various times during the day so, she needs help with mobility every day. The current care plan does not appear to meet the patient's care needs for mobility.

Recommendation is given to approve Personal Care Assistance services 40 hours per week. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care assistance (PCA) services 40 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

The patient is an adult who has a history of hypertension, hyperlipidemia and asthma. She was sent to the emergency department (ED) by her primary medical doctor with an asthma exacerbation. As per vital signs initially recorded: Temperature 97.9 degrees F (Fahrenheit), Blood Pressure 168/85, Pulse 85, and oxygen saturations 97% on room air. The patient was noted to have some wheezing bilaterally. The patient was awake, alert, and in no acute distress with normal heart sounds and a neurologic exam that was unremarkable.

The white blood cell count was 7.5, Hemoglobin 13.2, and the Troponin was negative. The electrocardiogram (ECG) was normal sinus rhythm with no acute ST-T (intervals on an ECG) changes. The chest X-ray showed no acute infiltrates and no pneumothorax.

The patient was treated with an intravenous (IV) steroid, bronchodilators (BD) via nebulizer and magnesium. The patient improved rapidly after evaluation and treatment in the ED (emergency department). There was no wheezing noted on subsequent exams. Peak expiratory flow (PEF) was 280. The patient was discharged home the next day on oral (PO) steroids and bronchodilators.

This patient did not need acute inpatient hospitalization. She could have been placed on Observation status while diagnostic testing and treatment were initiated. Observation could be for up to 48 hours. This patient improved rapidly after evaluation and treatment in the ED and could have been placed in observation status and subsequently discharged home on PO Meds after a period in Observation.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld. 

The patient had a previous cholecystectomy and presented with Right Upper Quadrant (RUQ) abdominal pain and vomiting. The patient was afebrile, and the vital signs were stable. The abdominal exam was benign. There was no leukocytosis. The liver enzymes were elevated. An ultrasound showed mild dilatation of the Common Bile Duct (CBD). An abdominal Computed Tomography scan was negative for acute disease. A Magnetic Resonance Cholangiopancreatography (MRCP) was negative. 

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Obstruction (Milliman Care Guidelines (MCG) M-555) include having acute cholangitis. This needs to be manifested by systemic signs of infection and evidence of common bile duct disease. In this case, there were no systemic signs of inflammation and the MRCP did not show a common bile duct stone or abnormality. 

The hospital has cited MCG guideline for Gastroenterology MG-GAS. Clinical indications for admission include having a suspected acute intra-abdominal process as indicated by hemodynamic instability, peritoneal signs, ischemic colitis, and free air. The patient did not have these conditions. 

There was a concern that this patient had a CBD stone and imaging studies were required. This could have been done on an outpatient basis. There was no evidence of acute cholangitis or a severe systemic infection. Intravenous (IV) hydration and analgesics could have been given in the Emergency Room (ER) as an outpatient. The patient did not meet MCG criteria for admission for either Gallbladder or Bile Duct Inflammation or Obstruction or Gastroenterology. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. The denial is upheld.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient Admission
The insurer denied coverage for inpatient admission.
The denial is upheld.
 
The patient presented to the emergency room (ER) with complaints of a 6-week history of vaginal bleeding and dizziness. Her hemoglobin/hematocrit were 5.4/19.4. Pelvic examination showed no active bleeding. Vital signs were stable. She was admitted, transfused with 2 units packed red blood cells (PRBCs) and received IV (intravenous) tranexamic acid. She was discharged.

This patient has symptomatic anemia. She fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8 grams per deciliter (g/dl). Transfusion was necessary.

Transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home). The need for transfusion is not a reason for admission. The patient could have been transfused as an outpatient. Note that the patient was not actively bleeding.

Milliman Care Guidelines (MCG) lists the clinical indication for inpatient care for patients with anemia. These include: active massive hemorrhage, active hemolysis, cognitive impairment, heart failure, chest pain, and syncope.

This patient was stable and did not have any of the above. The patient could have been transfused with the 2 units PRBCs and discharged home ensuring that the patient was stable.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dysphagia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld 

This case involves an adult patient under review for a prior hospital stay. The emergency department note reported the patient had complaints of difficulty swallowing. The patient had recent neck surgery. The patient also reported chest pain with swallowing. A Computed Tomography (CT) scan showed a prevertebral hematoma from C2-C6 (Cervical) compressing the esophagus. It was noted the incision was intact with no visible hematoma from the level of the skin. The patient was without airway compromise and vitals were stable. The patient was recommended for consultations with possible hematoma evacuation. The progress note reported the patient was improving. The plan was for discharge. A determination letter reported the previous hospitalization was denied as the patient could have been managed at a lower level of care. An appeal letter reported the patient presented to the emergency department with a 2-day history of an inability to swallow as well as chest pain with swallowing. The patient had recent neck surgery and a CT scan showed a hematoma with mass effect. The patient was treated with intravenous (IV) medications including steroids. The patient gradually improved, and surgery was not necessary. The facility was appealing the prior decision.

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

The inpatient admission is not considered medically necessary for this patient. In this case, the patient returned to the emergency department with a 2-day history of difficulty swallowing status post a recent cervical fusion procedure. Imaging noted a hematoma compressing the esophagus. However, the airway was intact and vital signs were stable. The documentation did not note airway restriction/obstruction or ongoing symptoms beyond observational care to support inpatient admission. Therefore, the prior denial is upheld.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.