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

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

The patient has no past medical history and presented to the emergency department with left leg lateral swelling after he was working and thinks he was bitten by something at the job.
On presentation, his temperature was 100.2 degrees Fahrenheit with a blood pressure of 134/82, heart rate 104, respiratory rate 18, and an oxygen saturation of 99% on room air. The exam otherwise noted an area of erythema that was tender on his lateral leg extending to the ankle measuring 15 centimeters (cm) by 15 cm with a small pustule and induration noted. Labs resulted with a white blood cell count (WBC) of 13.3, hemoglobin (HGB) 13.2, platelets 260, sodium 133, potassium 3.8, blood urea nitrogen (BUN) 11, creatinine 0.76, liver function test within normal limits, creatinine kinase 130, and international normalized ratio (INR) 1.0. The patient was given intravenous (IV) fluids, IV vancomycin and Unasyn, and blood cultures were sent. He was brought into the hospital with plans for ongoing IV antibiotics in addition to an ultrasound of his leg to rule out an abscess.
Overnight and the next day, the patient was noted to be improving. Repeat labs noted a WBC of 9.9, HGB 11.6, Platelets 225, basic metabolic panel (BMP) within normal limits. The ultrasound revealed a fluid collection that was 0.8 by 0.7 by 1.2 cm with surrounding hyperemia and edema. The plan was for ongoing IV antibiotics and vascular surgery consultation. Vascular surgery noted that no surgical intervention was needed. He was switched in the evening to oral antibiotics.
He continued to improve. The WBC was 12.7 with the rest of his lab results stable. He was subsequently discharged on oral antibiotics.
The issue under review is whether care at the inpatient level of care was medically necessary.

Inpatient level of care was not medically necessary. This is a patient without a significant medical history who presented with leg cellulitis with a small pustule. He was appropriate given the extent of his cellulitis in addition to fever and mild tachycardia on presentation to bring into the hospital for IV antibiotics, clinical monitoring, and further evaluation with ultrasound for abscess. It is notable, however, that he improved quickly with IV antibiotics and also did not have clinical risk factors increasing risk of poor response to IV antibiotics (immunocompromise, uncontrolled diabetes, failure of prior IV therapies, necrotizing fasciitis, etc.). Additionally, though he was mildly tachycardic and febrile on presentation, he also was not tachypneic or hypotensive, and did not have altered mental status, with quick Sequential Organ Failure Assessment (qSOFA) score predictive of sepsis notable zero. It is unclear why given his presentation and absence of clinical risk factors predisposing him to adverse serious outcomes why he could not have been safely cared for at a lower level of care than inpatient.
An inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was overturned.
This patient is a male with intermittent asthma and food allergies who presented to the emergency department (ED) with cough, chest tightness, and shortness of breath. His symptoms began 1 day prior to arrival. Additional symptoms included blood-tinged sputum and sore throat; there was no fever, vomiting, diarrhea, rash, swelling, or pain. Home treatment included over the counter (OTC) cough syrup. His last asthma exacerbation was 1 year prior.
His ED vitals were a temperature of 37.2 C, heart rate (HR) was 98, respiratory rate (RR) was 24, blood pressure (BP) was 123/76, oxygen (O2) saturation was 94% on room air.  The physical examination noted obesity and wheezing without respiratory distress. His labs showed a white blood cell count (WBC) at 13.3 with 78% segs and 13% lymphs, hematocrit (Hct) was 45, platelets (Plts) were 156; and electrolytes were within normal limits. A chest x-ray was unremarkable.
The patient was treated with Duo-nebulizers times (x) 3, 1 dose of oral prednisolone, and intravenous (IV) magnesium sulfate times (x) 2. An additional albuterol nebulizer was given 1 hour later. Post-treatment oxygen saturations were 93-95% on room air with continued inspiratory and expiratory wheezes and tachypnea noted.
Given the persistence of symptoms with tachypnea and hypoxemia, the patient was admitted to the hospital for further management. He was able to be weaned to room air and every 4-hour albuterol nebulizers. He was discharged home the next day.
At issue is the inpatient hospital admission for medical necessity.
The health plan's determination of medical necessity is overturned in whole.
Yes, the requested health service of the inpatient stay was medically necessary for this patient.
This obese male patient with asthma presented to the ED with difficulty breathing. He was found to have tachypnea and wheezing with O2 saturations in the high 80's to low 90's on room air. Despite appropriate treatment in the ED, tachypnea and hypoxemia continued requiring inpatient hospitalization. He showed vital sign abnormalities despite ED treatments for acute asthma exacerbation. Thus, the inpatient admission was medically necessary to continue treatment and vital sign monitoring.
Therefore, the requested inpatient hospital admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right axilla pain, redness and swelling. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a female whose Inpatient Hospital Admission is under review. The patient has a history of obesity and substance abuse. She presented with a several day history of right axilla pain, redness and swelling. She had fever at home. 

In the ER (emergency room), the patient's vitals were as follows: T (temperature) - 38.0, P (pulse)  82, BP (blood pressure) - 138/92, RR (respiration rate)  18. On general examination, she was noted to be NAD (no acute distress). Examination of her chest, CVS (cardiovascular system), and abdomen were normal. Examination of her skin revealed right axilla induration, tenderness, erythema. 

The patient's labs were as follows: 
WBC (white blood count) - 13.9 (high), 
Hg (hemoglobin) - 13.5, 
Hct (hematocrit) - 42, 
Plt (platelets) - 361. 

The patient's blood culture revealed Staphylococcus capitis. Her abscess culture revealed MRSA (methicillin-resistant Staphylococcus aureus). 

In the ER (emergency room), the patient met sepsis criteria and was started on IV (intravenous) vancomycin and zosyn, as well as IV (intravenous) fluids. She was admitted, and IV (intravenous) vancomycin was continued. She underwent I&D (incision and drainage) and was discharged that same day. 

Yes, the Inpatient admission was medically necessary. 

The patient presented with cellulitis, with signs of systemic infection (elevated WBC [white blood count], and team concerned about sepsis). Systemic signs of infection are an indication for inpatient admission and IV (intravenous) therapy, according to the Infectious Disease Society of America (1). Failure to admit such a patient could lead to sepsis, loss of function, or death. Thus the admission was medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lumbar Stenosis, Back Pain
Treatment: CPT 22867 (insertion of interlaminar/interspinous process stabilization/ distraction device, without fusion, including image guidance when performed with open decompression, lumbar single level)
The insurer denied the CPT 22867 (insertion of interlaminar/interspinous process stabilization/ distraction device, without fusion, including image guidance when performed with open decompression, lumbar single level).
The denial is upheld. 

The patient is a male with pain and dysfunction in lumbar spine. The patient tried physical therapy and epidural injections. MRI (magnetic resonance image) lumbar spine reveals moderate facet arthopathy with bilateral facet joint fusion with mild posterior bulging and very mild spinal canal narrowing. The patient underwent lumbar decompression with coflex interlaminar stabilization.

No, the health plan should not cover the CPT 22867 (insertion of interlaminar/interspinous process stabilization/ distraction device, without fusion, including image guidance when performed with open decompression, lumbar single level).

This patient has reported lumbar dysfunction, but the clinical notes do not document symptoms of spinal stenosis and neurogenic claudication. The clinical notes provide a very limited history.

The patient should be more symptomatic with walking and get relief with sitting, which is classic for spinal stenosis.  The clinical notes state that the patient tried physical therapy, but the timing, duration and extent of patient involvement are not documented.  Also, the MRI (magnetic resonance image) does not reveal significant neural compression or stenosis to warrant surgery. Interlaminar stabilization is an adjunct to lumbar laminectomy (decompression) in an appropriately indicated patient, which this patient is not, based on the clinical documentation.

No, the CPT 22867 (insertion of interlaminar/interspinous process stabilization/ distraction device, without fusion, including image guidance when performed with open decompression, lumbar single level) is not likely to be more beneficial.

Coflex has been shown to be a safe and effective procedure for properly indicated patients with symptoms of neurogenic claudication. Based on the limited history provided in the clinical notes, it is not clear if this patient has neurogenic claudication.  Lumbar dysfunction is a rather vague term to describe the patient's symptoms.  Therefore other standard therapies such as physical therapy, facet injections, NSAIDs (nonsteroidal anti-inflammatory drugs), etc could be just as effective.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lumbar Stenosis, Back Pain
Treatment: CPT 22867 (insertion of interlaminar/interspinous process stabilization/ distraction device, without fusion, including image guidance when performed with open decompression, lumbar single level)
The insurer denied the CPT 22867 (insertion of interlaminar/interspinous process stabilization/ distraction device, without fusion, including image guidance when performed with open decompression, lumbar single level).
The denial is upheld. 

This patient is a male who presents with low back and radicular pain. The patient works as a Registered Nurse. The patient reported he sustained a traumatic fall a few years ago, and had experienced a degeneration of ability to be physically active. He reported discomfort that progressed to intermittent pain, started at the left buttock and radiated down to the left leg, then right buttock pain, heaviness and soreness in lower back, cycling was unbearable, hiking became untenable, pain and stiffness became severe. The patient is a former smoker.

Magnetic resonance image (MRI) of the lumbar spine showed mild degenerative changes L4-L5 (fourth lumbar spine vertebra - fifth lumbar spine vertebra) and L5 -S1 (fifth lumbar spine vertebra - first sacral vertebra) levels with mild malalignment abnormalities. There was mid spinal canal narrowing at L4-L5 (fourth lumbar spine vertebra - fifth lumbar spine vertebra), and bilateral foraminal narrowing at L4-L5 (fourth lumbar spine vertebra - fifth lumbar spine vertebra) greater on left than right. There was foraminal narrowing at L5 -S1 (fifth lumbar spine vertebra - first sacral vertebra) levels. There was no focal disc herniation. There was a nine millimeter cystic lesion in the right iliac bone adjacent to the sacroiliac (SI) joint, well-circumscribed and may represent a small subchondral cyst.

No, the health plan should not cover the CPT 22867 (insertion of interlaminar/interspinous process stabilization/ distraction device, without fusion, including image guidance when performed with open decompression, lumbar single level).

There is no clinical evidence of neurologic deficits correlating with MRI (magnetic resonance imaging) findings. In addition, there is no clinical evidence of documentation of outcome of a completed course of conservative therapy.

No, the CPT 22867 (insertion of interlaminar/interspinous process stabilization/ distraction device, without fusion, including image guidance when performed with open decompression, lumbar single level) is not likely to be more beneficial.

The patient has foraminal stenosis, stenosis at L4-5 (fourth lumbar spine vertebra  fifth lumbar spine vertebra). The patient has treatment options of lumbar laminotomy and foraminotomies at L4-5 (fourth lumbar spine vertebra  fifth lumbar spine vertebra).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lumbar Stenosis, Back Pain
Treatment: CPT 22867 (insertion of interlaminar/interspinous process stabilization/ distraction device, without fusion, including image guidance when performed with open decompression, lumbar single level)
The insurer denied the CPT 22867 (insertion of interlaminar/interspinous process stabilization/ distraction device, without fusion, including image guidance when performed with open decompression, lumbar single level).
The denial is upheld. 

The patient is a male with history of low back and leg pain.  MRI (magnetic resonance image) shows mild degenerative changes at L4-5 (fourth lumbar spine vertebra  fifth lumbar spine vertebra), and L5-S1 (fifth lumbar spine vertebra - first sacral vertebra) with mild narrowing at L4-5 (fourth lumbar spine vertebra  fifth lumbar spine vertebra), L5-S1 (fifth lumbar spine vertebra - first sacral vertebra) 2mm (millimeter) retrolisthesis.

No, the health plan should not cover the CPT 22867 (insertion of interlaminar/interspinous process stabilization/ distraction device, without fusion, including image guidance when performed with open decompression, lumbar single level).

The surgery performed, including an interspinous spacer at the L4-5 (fourth lumbar spine vertebra  fifth lumbar spine vertebra) level is not medically appropriate or standard of care. While the literature has shown with interspinious type devices that the outcomes are similar to gold standard surgery, which is a decompression of the nerves, there are higher rates of revision surgery and decreased long-term benefits. The long term outcomes have not been shown to be comparable with the gold standard procedure and they also have a higher rate of revision surgery. As such, the interspinous process spacer that was performed is not considered medically appropriate, and the health plan should not cover it.

No, the CPT 22867 (insertion of interlaminar/interspinous process stabilization/ distraction device, without fusion, including image guidance when performed with open decompression, lumbar single level) is not likely to be more beneficial.
The literature does not demonstrate that this is more beneficial than gold standard treatment.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male who was admitted to inpatient level services for treatment of cannabis use disorder; the patient had been using up to one ounce of marijuana per day in violation of his parole. The patient was referred for substance-related treatment in the context of risk for re-incarceration and violation of his probationary status. Thus, the referral to inpatient level substance use disorder treatment was mandated due to the probationary legal status (parole), and ongoing problems with maintaining abstinence from cannabis use. The patient was externally motivated to enter substance abuse rehabilitation treatment in order to comply with his parole officer's mandate and parole status and avoid serious legal consequences for his substance use.

The patient was noted to adjust easily to the treatment program but indicated a preference for a treatment program at another location. In this regard, the treatment plan included working on coping skills and development of a relapse prevention plan with the identification of triggers including peer support to address the negative influence of the social environment. The patient was transferred to another substance use disorder rehabilitation treatment program the day after admission.

The health plan denied the inpatient stay as not medically necessary. The health plan's determination is upheld.

The inpatient substance abuse rehabilitation treatment, in this case scenario, was amenable to treatment at a lower level of care. The patient was externally motivated and able to effectively engage in rehabilitation services, and the patient did not need the structure or 24-hour monitoring of an inpatient setting in order to safely and effectively participate in rehabilitation substance abuse treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted inpatient level services and treatment.

The structure and intensity of services necessary for a successful rehabilitation/substance use disorder treatment could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression
Treatment: Inpatient mental health treatment
The Inpatient mental health treatment was medically necessary.

The patient is a female with a history of substance abuse and mental illness.
The patient has been diagnosed with mental illness including depression and anxiety.  There is a history of four prior psychiatric hospitalizations.  There is a history of alcohol abuse.  There is a history of lupus and asthma.  There is a history of therapy and psychopharmacology treatment.  She was taking Gabapentin 900mg PO (by mouth) BID (twice daily), Topamax 150mg daily, Bupropion 300mg daily, Sertraline 200mg daily, Naltrexone 50mg daily, Trazodone 150mg daily, and Buspirone 15mg BID.
The patient was sent to the emergency room by her outpatient psychiatrist with increasing depressive symptoms.  She was noted to be depressed with low energy, low motivation, and there was noted alcohol use.  She was evaluated for admission to the inpatient psychiatric unit and was admitted to Lenox Hill Hospital in NY.  She was treated by a multidisciplinary team including therapy, psychiatry, and nursing staff.  She received individual and group treatment.  
A nursing note stated that the patient was "depressed, reports no improvement in mood."  A note noted a "constrictive affect."  She received a psychopharmacology evaluation and Cymbalta was added and increased to 60mg daily.  Zoloft and Bupropion were discontinued.  The patient was noted to be stable and was discharged with a plan for outpatient psychiatric care.
The patient represented an acutely elevated risk of dangerous behaviors, and there was no less-restrictive treatment environment appropriate.  The acute risk factors of depression and medication changes with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were she to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.  
The patient represented an elevated risk of dangerous behaviors including self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained depressed.  The patient had multiple static risk factors for potentially dangerous behaviors, including substance abuse and diagnosis with a severe mental illness.  Therefore the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained depressed and with ongoing medication changes were acute risk factors for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient services. 
The denial is upheld in whole.

The patient is a male who underwent revisions of a left shoulder hemi-arthroplasty to a reverse total shoulder arthroplasty. The surgery was successful with no documented complications of the operation. The patient had an uneventful hospital stay and was deemed stable for discharge home the next day. At issue in this case is the medical necessity of the inpatient services.

The health plan's determination is upheld in whole. 

The requested health service/treatment of inpatient services was not medically necessary for this patient.
The rationale for this determination is based upon the provided medical records and the recommendations of the current, peer-reviewed literature. The provided records document that this patient underwent conversion of a left shoulder semi-arthroplasty to a reverse left total shoulder arthroplasty with no complications. The patient's lab values, and vital signs remained stable after the operation and he was deemed stable for discharge home the next day. Thus, the medical necessity of the inpatient hospital admission was not medically necessary because this episode of care could have been completed under a lower level of care status.
In addition, the current, peer-reviewed orthopedic literature has endorsed the safety and efficacy of reverse total shoulder arthroplasty surgery performed at a lower level of care status. A recent article published by Erickson and colleagues in the Journal of Shoulder and Elbow Surgery in 2020 concluded that reverse total shoulder arthroplasty performed in a lower level of care setting is a safe and reliable procedure. Thus, the inpatient hospital admission in this case was not medically necessary and not consistent with the recommendations of the current, peer-reviewed literature.