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

Appendicitis
Inpatient Hospital

The patient is a woman who presented to the ED with a history of progressively worsening abdominal pain. Her evaluation included physical exam, labs, and a computed tomography (CT) scan. She was without fever at the time of presentation. Her heart rate was 108 beats/minute. Lab data identified a white blood cell count (WBC) count of 13.8 K. The CT scan yielded the diagnosis of acute appendicitis. Treatment was initiated with IV fluid and antibiotics. Surgical consultation was obtained.
The patient underwent laparoscopic appendectomy on the following day. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. The operative note describes an acute, non-perforated, appendicitis. She was provided IV fluid and perioperative antibiotics. Her vital signs remained normal following surgery. She tolerated a diet and was discharged from the hospital the day of the surgery. The health plan denied the inpatient admission as not medically necessary. 

The health plan's determination is upheld. The inpatient admission was not medically necessary. The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient required urgent surgical intervention for acute appendicitis, however, 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. There was no documentation of hemodynamic instability, intra- or peri-operative complications, severe pain, or unstable comorbidities. The member tolerated oral hydration, diet and medication. Her pain was well controlled. The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care would have provided for presurgical assessment, operative treatment and postsurgical monitoring. This lower level of care would have also allowed for overnight monitoring.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a past medical history significant for diabetes mellitus type 2, hypertension, hyperlipidemia, morbid obesity, fatty liver, asthma, sleep apnea, neuropathy, bipolar depression, left knee pain and bilateral back pain.
The patient is requesting an increase of his personal care service hours from 26.25 hours per week to 35 hours a week.
Services were denied based upon lack of medical necessity.
The subject under review is the medical necessity of the 35 hours per week.

The patient is a male with multiple medical problems in the past, most notably diabetes mellitus with neuropathy, ambulatory dysfunction secondary to neuropathy and chronic pain. The patient's services were reassessed with a Uniform Assessment System (UAS) State of New York. Reassessment noted the patient required less service hours than the patient was currently receiving. It was recommended to decrease service hours to 26.25 hours per week.
Services were denied based upon the following rationale stating that the patient's medical condition has improved, and the patient did not need as much help with activities of daily living. It was noted the patient only needs "a little help." The patient needs help with stairs, transportation, bathing, taking medicine and getting meals ready. The patient currently lives with girlfriend and two children.
UAS State of New York was noted. The review noted that the patient was independent with personal hygiene, independent with bed mobility, independent with eating. The patient is able to ambulate using a cane.
There was a noted fall with no significant injury. The patient was attempting to get up from the couch and hit his elbow. No hospital or emergency room (ER) visits were noted. It was noted that the patient is able to walk between 150 and 299 feet without sitting.
It was noted that the patient needed limited assistance with dressing his lower body. The patient still needed assistance with bathing.
The number of hours of service that have been provided by the health plan are adequate to meet the patient's medical needs in the time noted. Additional services for "prevention of falls" for "monitoring" without services being provided are typically not covered. In order for services to be considered medically necessary, the aide must be performing a service such medically necessary ADL or IADL.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Swelling and abdominal pain.
Treatment:  Inpatient admission.

The proposed inpatient treatment was not medically necessary. 

The patient is a female who presented with chronic umbilical pain, getting worse with swelling, tenderness, and redness for two days.  The lump had been there for a reported three years, and the redness for three months.  There was no fever or vomiting.  Surgical evaluation documented a soft, non-tender, non-distended abdomen.  All labs including white blood cell (WBC) count and liver function tests (LFTs) were normal.  Diagnostic imaging revealed a mass.  The patient was admitted for intravenous (IV) antibiotics and biopsy.  On the first hospital day, while awaiting a magnetic resonance image (MRI), the patient was receiving as needed (PRN) pain medications and tolerating a diet, without nausea or vomiting.  All labs remained normal on follow up investigation. 

The patient presented with a chronic condition and acute surgical diagnosis was ruled out based on both subjective and objective criteria. 

This patient presented with exacerbation of a chronic condition that needed a diagnosis.  There were no signs or symptoms of systemic infection or sepsis.  The initial workup ruled out any emergency surgical issues, and the entire process could have been managed at a lower level of care. 

Occasionally, an endometrioma arises in the anterior abdominal wall, usually in the vicinity of a surgical incision, although these lesions can occur in women with no history of surgery or history of endometriosis.  Rarely, endometriosis has been reported in the breast, pancreas, liver, gallbladder, kidney, urethra, extremities, vertebrae, bone, peripheral nerves, spleen, diaphragm, central nervous system, hymen, and lung.  Most women have multiple areas of involvement.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End stage renal disease (ESRD)

Treatment: Inpatient admission

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

This patient is a man with end stage renal disease (ESRD) on dialysis. Patient was sent to the ED by the hemodialysis unit because patient missed a week (3 sessions) of dialysis. On triage vitals were blood pressure150/68, heart rate of 54/min, and respiratory rate of 16/min. The patient was afebrile, and had 99% oxygen saturation on room air. According to the ED physician note, the patient was clinically stable. He had no evidence of lung edema and though his potassium was elevated at 6.1, he was hemodynamically stable. The patient was admitted for uremia and hyperkalemia, and the plan was to obtain dialysis as inpatient. Patient's BUN was elevated at 124, and creatinine was elevated.

As per MCG Healthcare Guidelines, the clinical indications for admission to inpatient care are such: acute renal failure (i.e. serum creatinine greater than 4mg/dL with acute rise greater than 0.5 mg/dL) and renal failure that cannot be managed in outpatient or observation setting. While this patient's creatinine level of 8.49 supports for acute renal failure, there are no clinical complications that cannot qualify this patient for observation care. MD documentation indicates that this patient experienced mild dyspnea and CXR showed mild pulmonary edema, but was saturating 99% oxygen on room air (not requiring supplemental oxygenation). Though patient's blood pressure was slightly elevated at 150/68, it was not severe hypertension. The patient's hyperkalemia of 6.1 was not associated with severe EKG findings. Patient' EKG showed sinus bradycardia at 56bpm with questionable T-wave changes. Based on the review of the medical records, patient did not have any clinical signs or symptoms that were significant enough to warrant inpatient admission. Patient's condition resolved within 24 hours after receiving routine dialysis. Since patient's condition could have been treated safely under lower level of care, i.e. observation status, inpatient admission was not medically necessary for this patient. 

The patient's condition resolved within 24 hours after receiving routine dialysis.  There is no evidence-based literature indicating his condition could not be treated safely at a lower level of care. The health plan acted reasonably with sound medical judgment in the best interest of the patient. Admission was not medically necessary.

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

Diagnosis: Chest Pain
Treatment: Inpatient stay 

Summary:
The patient is a female with multiple complaints including anxiety, chest pain, palpitations, light headiness, dyspnea, ear pain, nausea, vomiting and diarrhea. Complaint was stomach pain after taking oxycodone. Patient also was lethargic after taking friend's opiate, requiring husband to throw water on her to wake her up. Exam unremarkable, WBC was 14k, troponin of 0.111. Her EKG was normal; chest x-ray negative, Echocardiogram, and CT of abdomen, chest, and pelvis were unremarkable. She was admitted to telemetry and observed. She was started on IVF, anti-nausea, and monitored in telemetry. She was seen by cardiology and discharged home.

This patient had multiple symptoms but no evidence of acute coronary syndrome. The troponin of 0.11, while outside the normal range, by itself is not evidence of acute ischemia. While it was appropriate to rule out ischemic heart disease, that work up does not require inpatient level of care. Level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome. Exam and cardiac findings were normal. EKG showed no evidence of acute ischemia. CXR was normal. Echocardiogram was ordered as a follow up. Physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for A.C.S. such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG.   

Letter of appeal was carefully considered but offered no evidence to support inpatient level of care. Only cardiac care provided was telemetry, frequently performed in a lower level of care. Patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD (coronary artery disease). In fact, all tests showed absence of ischemia.  While always a potential for an adverse event (and in this case a very low probability), one did not happen and no actual treatment was added.

Milliman criteria requirements were not fulfilled as there was never any evidence of ACS present.  All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was medically unnecessary.

The appeal statement that the management of this patient could not have occurred in a lower level of care is not consistent with guidelines or common community practice. 

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain
Treatment: Continued chiropractic services
The continued chiropractic care for was not medically necessary.

The patient is a female. Records presented for this review reveal that this patient presented for chiropractic care/treatment for complaints of mid back pain. The exact history is not documented through the records submitted for this review. It was noted that the patient was diagnosed by the attending chiropractor with pain in the thoracic spine, segmental dysfunction to the thoracic region as well as thoracic sprain/strain. The patient had also sustained low back complaints. Treatment was incorporated by the attending chiropractor, which consisted of modalities such as ultrasound therapy, traction as well as manual manipulation.

According to the documentation, it was revealed that the patient was treated under the guidance of the attending chiropractor up until the dates of service under review, consisting of approximately 11 visits within that time-frame. She then continued with chiropractic care/treatment for an additional six visits during the dates of service under review.

The documentation presented for this review fails to support any of the chiropractic care/treatment rendered to the patient, specifically for the dates of service under review. There is no objective evidence of the necessity of the chiropractic care/treatment in question from the attending chiropractor. This would consist of daily notes, examination findings, outcome measures, treatment plan as well as treatment goals.

The documentation presented by the attending chiropractor fails to support any and all of the chiropractic care/treatment in question. Again, as explained above, the documentation presented by the attending chiropractor fails to reveal that the patient was achieving any significant objective gains with the treatment dates under review.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Advanced breast cancer
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The patient is a female with an advanced breast cancer with 10/10 nodes positive with extracapsular extension.  She underwent a total mastectomy and axillary lymph node dissection.  

This patient underwent a total mastectomy and axillary lymph node dissection.  She had an advanced breast cancer with 10/10 nodes positive with extracapsular extension.  She had two drains placed.  Her partial pressure of oxygen (pO2) in the recovery room was marginal at 91%.  She was admitted overnight for close observation receiving supplemental oxygen.  The patient had to be monitored for 1) pain control, 2) post-operative bleed (especially with a lymph node dissection), 3) flap viability, and 4) in her case - respiratory status.  This type of close monitoring and care requires inpatient admission.

Admission after total mastectomy is standard of care.  Most patients go home the next day but 10% to 20% will stay longer.  

The patient did well and was discharged the next day.
Appeal type: Medical necessity
Decision: Upheld

Other
Inpatient Hospital

The patient is a female with pelvic pain who underwent a total laparoscopic hysterectomy. The procedure is reported to have been without complication, and the patient was discharged the following morning. An inpatient level of care is under review.

The health plan's determination is upheld. The inpatient hospital stay was not medically necessary. There is no documentation of any unexpected pain issues. The patient's vitals were normal the day of surgery, as well as the day after. The American Congress of Obstetricians and Gynecologists (ACOG) outlines criteria for discharge after outpatient procedures, and states vitals need to only be within 20% of baseline. The physician notes on postoperative day 1 suggest a routine postoperative course with plans for discharge. The management described in the record on the day after surgery included oral pain medication, spontaneous voiding, and tolerating oral diet - these are traditional targets for discharge that appear to have been reached. Again, there is no reference to an unanticipated event. There is nothing to suggest that an inpatient stay was medically necessary after the patient's laparoscopic procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Lung nodules
 
Treatment:  Chest computed tomography

The insurer denied coverage for chest computed tomography.  The denial upheld.

This patient is a female with history of mild emphysema.  She is a nonsmoker who had a CT Chest done for follow-up of lung nodules.  The patient was generally asymptomatic.  The patient has had multiple prior CT scans.  The first CT was done several years ago. That revealed some sub-centimeter lung nodules with no suspicious ground glass appearance or spiculations.  Repeat CT scan in mid-2018 revealed that the patient had few, 4 mm scattered nodules and a stable 3 mm nodule along the minor fissure.  The patient has had these sub-centimeter lung nodules since several years ago.  This CT was essentially unchanged.  She is a nonsmoker and low risk.  

The patient did not need repeat CT scan of the chest on the date in question.  Her lung nodules had been stable for over four years when repeat CT was done in mid-2018.  This patient's lung nodules were 4mm or less, and the patient was low risk for malignancy due to being a nonsmoker.  A repeat chest CT was not indicated and does not meet any guidelines.  The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

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

Diagnosis:  Cervical radiculopathy, thoracic segmental dysfunction
Treatment:  97035 (Application of a modality to one or more areas; ultrasound, each 15 minutes) x1 date of service (DOS) and all chiropractic services x3 DOS

The services under review were not medically necessary.
According to the documentation, it is noted that this male patient presented for chiropractic care/treatment previously in which the patient was diagnosed with cervical radiculopathy as well as thoracic segmental dysfunction.  According to the documentation, the patient underwent approximately nine visits up until the dates of service under review, at which point chiropractic care/treatment continued at the same facility for an additional eight visits.

Documentation presented from the attending chiropractic practitioner is insufficient to support the specific treatment under review.  According to the corresponding records, it was noted that this male underwent approximately nine visits under the guidance of the attending chiropractor previously, which treatment included passive modalities including ultrasound therapy within that time-frame.  The clinical justification to continue such passive modalities is not supported through the documentation presented.

As explained through the answer above, documentation presented by the attending chiropractor fails to objectively support the specific passive modality in question, ultrasound therapy specifically, for the dates of service under review. 

Documentation presented fails to contain treatment plan, treatment goals, and timeframe to achieve such goals.  Moreover, the continued passive treatment has not been supported through the records submitted concerning this case.  The importance of progressing a treatment regimen away from passive treatment and modalities to more active care is considered best practices in the chiropractic and physical medicine fields.

This would be especially true regarding this case and this patient's age.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient is an adult female. She has a past medical history significant for HTN (hypertension), dyslipidemia, CHF (congestive heart failure), and CAD (coronary artery disease), s/p (status post) prior PCI (percutaneous coronary intervention) of mid LAD (left anterior descending). She presented to the ER with complaints of new onset chest pain at rest, dyspnea and diaphoresis. 

The patient was hemodynamically stable. Her cardiac enzymes were elevated, consistent with myocardial injury. Laboratory data was also significant for renal insufficiency with serum creatinine level of 3.0, anemia with Hg (hemoglobin) of 9.1, and hypokalemia with K (potassium) of 2.9. Troponin was 0.188. 

The patient was admitted for unstable angina/NSTEMI (non-ST elevation myocardial infarction). The cardiac troponins continued to rise, increasing to 0.21, and her renal function gradually improved. The patient underwent a cardiac catheterization, revealing patent stent in the LAD, and non-obstructive disease in RCA (right coronary artery) and LCX (left circumflex). The patient was treated with medical therapy for ACS (acute coronary syndrome). Her condition improved and she was discharged home with a plan for outpatient follow-up.

The patient presented with new onset chest pain, suggestive of unstable angina. The patient had multiple risk factors for CAD, as well as a known history of coronary artery disease, requiring prior revascularization in the past. Her ECG was unrevealing, however the cardiac troponins were abnormal on serial measurements, suggestive of acute myocardial ischemia, NSTEMI, and thus the patient was referred for cardiac catheterization. The course was also complicated by acute renal insufficiency. Given this presentation, suspicion for an acute coronary syndrome, as well as risk factors and known CAD, it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

PD:Dental/Orthodontic Procedure
PT:Dental/Orthodontic Procedure
ST:Dental/Orthodontic Procedure

The patient has a Class I occlusion with appropriate overjet and a slightly deep bite. The maxillary and mandibular arches have some minor crowding. No treatment plan was provided. The patient has some mild crowding but a solid Class I occlusal relationship. His bite is slightly deep but there is no indication of damage to the incisors or the palate in the photographs, and his cephalometric radiograph show the lower incisors are contacting the maxillary teeth in occlusion, not the palate.There is no medical reason to correct his mild crowding with braces. There are many ways to correct patients with a deep bite and retroclined incisors, and there is strong evidence that one treatment is not better than another.  Futhermore, deep bites may be corrected in adulthood. The health plan's denial of medical necessity is upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a male with a history of Crohn's ileocolitis who has had symptoms of abdominal pain and bloody diarrhea.  His disease has been refractory to therapy with prednisone, Pentasa, Remicade, Humira, and most recently has been treated with Stelara 90 milligrams (mg) every 8 weeks.  The provider seeks approval of increasing frequency of Stelara to 90 mg every 4 weeks, which is the subject of review.

The health plan's determination is upheld.  Stelara 90 mg/mL (milligrams per milliliter) Syringe every four (4) weeks is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.  The requested dosing of Stelara has not been proven to be safe and effective for treatment of the patient's medical condition, as supported by well-designed randomized controlled trials; therefore, such dosing is not FDA or compendia supported.  The data available in the medical literature is retrospective observational studies, which does not prove the safety and efficacy of the requested therapy.