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

Diagnosis: Hypertensive Emergency
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.

This is a male patient who was seen in the Emergency Department in early 2019 complaining of high blood pressure, as well as a headache, pain level 10/10. The patient stated that he had not had blood pressure medication in four days. The patient does have a known history of hypertension, as well as diabetes. He denied chest pain, dizziness and shortness of breath. An electrocardiogram (EKG) revealed normal sinus rhythm (NSR) with a prolonged QT interval and ST-T waves consistent with possible lateral wall ischemia. His vital signs revealed a pulse of 97 beats per minute (bpm) with a blood pressure of 206/130. Acute renal injury was noted by the elevated serum creatinine of 1.66 (baseline was 1.04). His urine analysis revealed findings of ethanol, cocaine, and marijuana. He gave a history of drinking a six pack of beer prior to arriving to the ED and cocaine and marijuana use the day before. His blood pressure was noted to be 206/130 and he was administered 20 mg of hydralazine intravenously (IV), as well as Tylenol and nitroglycerin. One hour later, the patient's pressure was 171/105 and he was still noted to have a headache and was not feeling well. It was recommended that the patient be admitted for further monitoring of his blood pressure and cardiac status. The patient continued with elevated blood pressure at 177/99. The documentation detailed that the patient's medication was reconciled. He continued with treatment and had no further significant adverse events and when then discharged with instructions to follow-up.  

According to current literature, a patient may be admitted when there is evidence of a hypertensive emergency indicated by systolic blood pressure greater than 180 or diastolic blood pressure greater than 120 with evidence of acute or worsening target organ damage as indicated by encephalopathy, cerebral infarction, intracranial hemorrhage, myocardial ischemia, heart failure, aortic dissection, increased creatinine with reduction of more than 50% in estimated glomerular filtration rate from baseline, papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, seizure, or other acute or worsening end-organ damage due to severe hypertension. This patient had a blood pressure of 206/130, with a severe headache and greater than 50% increase in his serum creatinine.

The carrier's denial of coverage for the inpatient hospital services at the acute level of care is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, chest pain and headache
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

Chest pain is a reasonably common complaint in the pediatric population. In terms of referral to pediatric cardiology, it ranks second only to heart murmurs. The most common cause is idiopathic, occurring in up to half of cases. Other causes include pulmonary, musculoskeletal, gastrointestinal, and psychological. Actual cardiac causes are present in less than five percent of cases. Most children have normal physical exam findings. Interventions depend upon etiology: bronchodilators for reactive airways disease, anti-reflux medications for gastroesophageal reflux, and non-steroidal anti-inflammatory medications for musculoskeletal pain. When cardiac cause is suspected, a reasonable evaluation would include comprehensive history and complete physical examination, selective laboratory studies including metabolic studies and indicators of cardiac stress, electrocardiogram, chest x-ray, and echocardiogram. In some cases, a period of cardiac monitoring may be indicated. Other patients may benefit from a Holter 24-hour monitor or an event monitor.

Acute abdominal pain is a very common complaint in children. The differential diagnosis is quite broad, including infectious causes, structural abnormalities, renal causes such as stones, constipation, behavioral/emotional issues, inflammatory diseases, and diseases associated with malabsorption. History, physical examination findings, lab evaluation, and radiographic studies provide additional clues to the etiology. Radiographic studies include plain x-rays, ultrasound, and computed tomography (CT) scan with and without contrast.
 
Constipation is not uncommon in childhood, and at times may be severe. It is typically functional. Functional constipation is a very common problem in childhood, with a worldwide prevalence of about three percent. In up to 40% of children, constipation begins in the first year of life. Constipation is typically associated with painful stooling, abdominal pain, stool incontinence, and infrequent stooling. Most children that present with this constellation of symptoms have no significant underlying medical etiology.

This boy presented to the ED with a constellation of complaints including chest pain, abdominal pain, headache, and weakness. He was diagnosed with dehydration and constipation, and admitted for monitoring. He was overall hemodynamically stable, with no respiratory distress, persistent vomiting/diarrhea, acute abdomen symptoms, or fevers. He did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Fever
Treatment:  Inpatient admission
Inpatient admission was not medically necessary.
The patient presented to the ED with same day history of fever refractory to Tylenol, one episode of vomiting, and poor intake. 

The patient's vital signs included temperature 103, heart rate 178, respiratory rate 22, and 95% oxygen saturation.  Examination was significant for no apparent distress, normal ears, clear lungs, benign abdomen, and non-focal neurologic exam.  Rapid RSV (respiratory syncytial virus) and influenza were negative.  Laboratory evaluation revealed normal WBC (white blood cell) count (4600) with left shift (80.3% neutrophils), and elevated lactate (2.7).  The remainder of the laboratory evaluation was to be completed upon admission to the pediatric floor.  Chest x-ray revealed prominent peribronchial markings suggestive of viral pneumonitis and/or reactive airway disease. 

The patient was treated with a normal saline bolus, ibuprofen, acetaminophen, and a dose of ceftriaxone prior to admission to the pediatric floor for observation and management of acute upper respiratory infection with pneumonia and dehydration.  Admission orders included IV fluids, ceftriaxone, and antipyretics.  Remaining lab work, including urinalysis, was unremarkable except for mild hyponatremia. 

During his hospital stay, the patient continued to have fevers (prompting an additional diagnosis of clinical sepsis), with maximum temperature 103.4.  Blood and urine cultures remained negative.  He was subsequently discharged home when he had been afebrile for 24 hours, with negative cultures, and resolution of symptoms, to complete a course of azithromycin. 

Despite the findings on chest x-ray, this child had no respiratory symptoms, no cough, no increased work of breathing.  He remained hemodynamically stable throughout his hospital stay with no oxygen requirement, no persistent vomiting, and no respiratory distress.  He did not require acute inpatient admission, and he could have been safely managed at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Acute Diverticulitis
 
Treatment:  Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was upheld. 

This is a female patient with a history of diverticulitis, osteoarthritis, obesity, and alcohol dependence who presented to the presented to the Emergency Room with left lower abdominal pain.  She was afebrile and the vital signs were stable.  There was no abdominal rebound or guarding.  A Computerized Tomography (CT) scan revealed diverticulitis, but no abscess or perforation.  Intravenous (IV) antibiotics were given.  She was able to tolerate a clear liquid diet.

Clinical indications for admission for acute diverticulitis (M-150) include peritoneal signs, hemodynamic instability, persistent bleeding, or a significant abnormality on imaging.  This imaging abnormality can be an abscess, fistula, obstruction, or free perforation.  The patient did not have any of these conditions.  She also did not have severe vomiting, severe dehydration, or an inability to tolerate liquids.

This patient had abdominal pain due to an uncomplicated diverticulitis.  This could have been treated with a course of oral antibiotics as an outpatient.  She did not meet MCG criteria for admission for diverticulitis.  

The carrier's denial of coverage for the inpatient hospital services at the inpatient level of care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of obesity, cardiomyopathy, hypertension (HTN), congestive heart failure (CHF), and hyperlipidemia.  The patient presented to the emergency department (ED) with epigastric pain and vomiting that started that morning.  The patient denied noticing any blood in his stool.  The patient has had multiple ED visits for abdominal pain in the past and was just discharged from a different hospital the day prior where he was for the same symptoms.

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  This patient was in the hospital for only one night for vomiting and abdominal pain.  A patient who comes in with symptoms without a true diagnosis and who is stable enough to be discharged home after only one night, does not qualify at an inpatient level of care.  An observation period is generally around 24 hours to determine if the patient will require ongoing care to stabilize his condition.  This patient did not require that extended period of time and was stable for discharge home within 24 hours. He could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Hip problem/pain
Physical Therapy

The patient began receiving physical therapy with complaints of right hip pain. It was noted the patient attended 31 sessions of therapy, and was then evaluated for complaints of low back pain in addition to the hip pain. The health plan's determination of medical necessity of requested PT services is upheld in whole. Records provided indicate that the patient has already completed a total of 35 visits of physical therapy for the hip and had completed 4 sessions of physical therapy for the low back. The patient had ongoing complaints of pain and there was no documentation of any significant functional benefit or progressive improvement. Symptoms remained largely unchanged since the start of PT with complaints of ongoing hip pain as well as low back pain. There was no documentation of any significant functional benefit or objective gains and no indication as to why the patient would not be able to transition into a fully independent home exercise program. The exercises performed were not complex and could have been completed independently at home following instruction from the initial therapy sessions. When a patient has reached maximum therapeutic benefit, additional physical therapy (PT) services are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: GERB, Hiatal hernia
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

This patient is a woman with a history of a GERD (gastroesophageal reflux disease) and hiatal hernia. She had comorbid health conditions of depression, asthma, anemia, neurogenic bladder, hyperlipidemia, bipolar disorder, gynecologic cancer, and lumbar stenosis.  The patient underwent a scheduled operative procedure that consisted of robotic repair of the hiatal hernia and fundoplication.  The operative dictation describes the laparoscopic repair of a three-cm hiatal defect and a partial (Toupet) fundoplication.  There was a lysis of adhesions required to obtain adequate operative exposure.  The anesthetic record indicates a stable perioperative course.  

Following surgery, the patient required provision of IV fluid, parenteral analgesics, and antiemetic medications.  On the day of admission following surgery, vital signs were normal (heart rate 70, BP (blood pressure) 118/86, respiration rate 13), though the patient had transient desaturation to 87% O2 (oxygen) saturation.  She was treated with supplemental oxygen by nasal cannula. The post anesthesia evaluation was normal.  The records indicate that she was progressively advanced to a liquid diet.  

The next day the heart rate was 64-91/minute.  The patient was transitioned to oral analgesics and was tolerating a diet.  Room air oxygen saturation was 99%.  She was considered to be stable for discharge.

The health plan rationale for denial is that the patient underwent hiatal hernia repair and fundoplication and this procedure is usually done in the hospital setting with an observation level of care.  There was no hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care.

This patient underwent uncomplicated laparoscopic repair of a hiatal hernia and Toupet fundoplication.  Acute inpatient hospitalization was not medically necessary for this patient.  The medical records support that this patient could have been reasonably and safely monitored in the observational setting.  This level of care would have permitted overnight hospitalization, post-operative follow up, supplemental oxygen by nasal cannula, advancement of diet, and  provision of IV fluid, analgesics, and anti-emetics.

There is no clinical documentation to support need for inpatient admission.  The patient remained hemodynamically stable throughout the perioperative period, there was no fever or significant aberration of vital signs.  This patient's clinical needs could have been satisfied with an observational level of care.  The records support that the care provided was clinically appropriate.  It is the level of care (inpatient versus outpatient / observational) that is at issue in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck Mass
 
Treatment: Computed Tomography Scan of the neck 

The insurer denied coverage for Computed Tomography Scan of the neck. The denial is reversed. 

This patient is a male who presented to the physician's office with a right lateral neck mass that was noted five days prior to presentation.  The mass was large, hard to palpation, and non-tender without drainage.  There was no skin changes noted.  The patient denied fever, chills, and had no weight loss.  The patient reported chronic congestion for a few months.  The patient had nonallergic rhinitis and asthma.  The patient had no sinus pain or ear pain.  The physical examination revealed lymphadenopathy in the right lateral neck with a 1.5 cm hard, well-circumscribed, non-mobile mass.  The diagnosis was localized mass of the neck.  The treatment plan included computed tomography of the neck soft tissue with and without contrast. The insurer denied the computed tomography.

According to the clinical guideline referenced below "STATEMENT 6. IMAGING: Clinicians should order a neck computed tomography (CT; or magnetic resonance imaging [MRI]) with contrast for patients with a neck mass deemed at increased risk for malignancy.  Strong recommendation based on randomized controlled trials." In this case, this male with a history of fatigue and decreased libido for months who presented with a firm, large, non-tender mass in his neck.  This would be highly suspicious for malignancy, which would be a strong indication for a CT scan of the neck.  This reviewer approves this radiological study.

The health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient.  The Computed Tomography Scan of the neck performed is medically necessary for this patient.

The carrier's denial of coverage for the Computed Tomography Scan of the neck performed is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of hypertension and asthma who presented to the hospital with body aches, fever and nausea. The patient reported feeling extremely fatigued. The patient denied neck stiffness, rash, recent travel and diarrhea. The patient was admitted with urinary tract infection and suspected acute coronary syndrome (ACS). The plan of care included urine cultures, intravenous (IV) antibiotics, cardiac enzymes, EKG, chest computed tomography (CT), echocardiogram, and continue other home medications.

The health plan's determination is overturned. The inpatient stay was medically necessary. The patient had sepsis in the setting of urinary tract infection versus pyelonephritis and she had significant fevers and positive urine cultures. In addition, she did objectively meet sepsis criteria based on heart rate and white blood cell count along with positive cultures. She was at increased risk for an adverse outcome.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell crisis.
 
Treatment: Inpatient Hospitalization

The insurer denied the Inpatient Hospital. The denial was upheld.

This case involved a male who was seen in the Emergency Department (ED) in early 2019.  The patient had a past medical history of homozygous sickle cell anemia (Hb SS), hemochromatosis, pulmonary hypertension with tricuspid regurgitation, and functional asplenia.  The patient complained of pain to the bilateral shoulders, chest, lower back, and bilateral thighs.  The pain was noted to be 9/10 in intensity.
The patient was previously admitted for sickle cell crisis in mid-2018 and in late 2017.  The patient states that he drinks at least one gallon of water daily. He reported typically being compliant with home medications; however, he recently started a new job that requires him to wake up earlier, so this had caused him to miss taking his medication two times in the previous week.  The patient was given a normal saline bolus with morphine and Toradol via the intravenous (IV) route in the ED.  The patient was in mild distress.  There was mild conjunctival pallor.  The patient's history and presentation was consistent with acute sickle cell pain crisis, and the patient was admitted for pain management and hydration.  The patient had a blood pressure of 129/79 with a heart rate 83, respirations of 20, and an oxygen saturation of 100%. His white blood cell count was 11.58, the red blood cell count was 4.02, hemoglobin was 12, hematocrit was 36.5, and platelets were 186.  The patient had a sodium of 134, potassium of 3.9. a chloride of 100, and a carbon dioxide (CO2) level of 23. The glucose was 115, the blood urea nitrogen (BUN) was 20, the creatinine was 0.95, the calcium was 9.1, protein was 7.8, albumin was 5.16, bilirubin was 3, alkaline phosphatase was 74, alanine aminotransferase (ALT) was 12, aspartate aminotransferase (AST) was 25, and the reticulocyte percent was 8.81 with a count of 353.8.  The patient had a pH of 7.37, partial pressure of carbon dioxide (PCO2) of 44.8, partial pressure of oxygen (PO2) of 24.2, and a bicarbonate (HCO3) of 25.  A chest x-ray was normal.  The following day, the patient's pain improved and he was then discharged home.

The carrier's denial of coverage for the inpatient hospital services was upheld. The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #3:

The patient is a female with a left shin melanoma that was excised.  It has a depth of 1.1mm.  A DecisionDx-Melanoma is under review. The literature does not sufficiently support the test as improving health outcomes.  The DecisionDx-Melanoma has not had sufficient testing prospectively or a randomized controlled study to make it standard of care.  Therefore, the 81599 -Unlisted chemistry procedure-DecisionDx-Melanoma is not considered likely to be more beneficial for this patient's diagnosis than any standard treatment or procedures.

According to Weiss et al. (2015), "Recently, Castle Biosciences released the DecisionDx Melanoma gene panel which predicts the risk (high (69%) or low (3%)) of distant metastasis at 5 years for stage I-III patients [66, 113].  This panel may be used in clinical practice, however it is not currently recommended by any standard treatment guidelines, including the National Comprehensive Cancer Network (NCCN).  Definitive assessment of the sensitivity and specificity of this test should be conducted in prospective analyses of patients who are representative of the general primary melanoma patient population.  Moreover, guidance on interpretation of DecisionDx results is of critical importance.  Clinicians may suggest that patients predicted by this test to be at high risk for metastasis undergo more frequent clinical evaluations and surveillance imaging, particularly in patients who have negative sentinel lymph node biopsies. However, in settings in which adjuvant therapies are either contraindicated or not available, this categorization may increase patient anxiety without real benefit to the patient."

According to Boland & Gershenwald (2016), "The revisions to the American Joint Committee on Cancer (AJCC) melanoma staging system over time reflect changes in our understanding of the biology of the disease.  Since the 1st edition, where tumor thickness was defined anatomically by its relationship to the reticular or papillary dermis (Clark level) as well as tumor thickness (Breslow thickness), there have been significant strides in our use of clinicopathological variables to stratify low- versus high-risk patients"

The DecisionDx-Melanoma assay has not had sufficient testing prospectively or by a randomized controlled study to make it standard of care.  The lack of literature does not indicate that the patient is a good candidate for the requested testing. The DecisionDx-Melanoma is not regulated by any federal body.     
The 81599 Unlisted chemistry procedure-DecisionDx-Melanoma is not the best available treatment for this patient at this time and is not likely to be more beneficial for this patient's clinical scenario than standard procedures/treatments. 
    
The carrier's denial of coverage for 81599-Unlisted chemistry procedure-DecisionDx-Melanoma should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Congenital Elbow Anomaly

Treatment:  Prosthetic Arm with Active Grasping Capability

The insurer denied coverage for a Prosthetic Arm with Active Grasping Capability.  The denial was reversed.  

This is a young male patient who was born with a right below-the-elbow congenital anomaly who has been receiving occupational physical therapy.  It was reported by the mother that his current prosthesis no longer fits due to his increased growth, nor was he wearing it because of the pain it caused.  It was recommended by the treating physical and occupational therapist that he be fitted for a new prosthesis; a body powered prosthesis was recommended.

According to the current literature, prosthetic interventions are guided by developmental stages.  Components are chosen to anticipate growth and functional needs.  Devices should fit comfortably and utility and satisfaction is the main focus of prosthesis fitting.  Unwillingness to wear prosthesis often reflects poor fit, which seems to be the case for this patient who has outgrown his current device.  Myoelectric and body-powered devices are durable and are prescribed early on as young as 1-2 years old.  Prosthetic replacement for growth is indicated for children with amputations annually for the first 5 years of life, every 2 years from ages 5-12 years, and then every 5 years.  Based on this reviewer's clinical experience, current literature, and the clinical information provided, this prosthesis would be medically necessary. 

The carrier's denial of coverage for the prosthetic arm (pre-service) is reversed.  The medical necessity is substantiated.