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

Diagnosis: Swallowing a foreign body

Treatment: Inpatient admission 

The insurer is denied coverage for inpatient admission. 

The denial is upheld. 

The patient is a male with past medical history significant for fatty liver who was 
referred to the Emergency Department after swallowing a chicken bone several days prior and presented with chest discomfort on swallowing.  There was an incidental finding of a small abscess behind his left knee that was being treated with oral antibiotics. 

Vitals on presentation included: Temperature 99.5 F, Blood Pressure-141/81, Pulse-104, Respiratory Rate-19, and Oxygen (O2) saturation-98% on Room Air.  Laboratory results included the following: White blood cell (WBC) count-3.2, hemoglobin (HGB)-14.9, hematocrit (HCT)-44, creatinine-1.39, glucose-111, ALT-218, and AST-143.

The patient was admitted for evaluation of swallowing a foreign body (chicken bone).  CT scan of the neck showed no foreign body.  Chest x-ray was negative.  Gastroenterology was consulted.  Upper GI endoscopy was essentially normal.  He had an isolated fever episode.  Oral antibiotics (Bactrim and Kelfex) were discontinued due to possible adverse effects.  He remained afebrile and hemodynamically stable.  The patient was discharged to continue outpatient follow-up. 
 
According to documentation, the patient presented with throat and chest discomfort.  Otherwise, he was afebrile, hemodynamically stable.  Laboratory results reflected some chronic findings related to his underlying co-morbid conditions (fatty liver).  Imaging studies were negative for any foreign body.  The patient was able to tolerate oral intake, there was no evidence of shortness of breath or respiratory issues.  The patient did not meet criteria for acute inpatient hospitalization.  The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Pulmonary/Pneumonia
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer overturned the health plan determination in whole.

The requested health service/treatment of inpatient stay was medically necessary for this patient. This patient presented with 1 day of decreased activity, increased somnolence, abdominal pain and subjective fever. Despite only one day of symptoms patient had markedly elevated inflammatory markers along with CT scan evidence of a consolidative process in his right lung. Lung consolidation can be a sign of a resistant bacterial process. Without close monitoring and IV antibiotics this patient could be at risk for progression of  illness to bacteremia and possible sepsis. There was also concern for malignancy as patient had leukocytosis and hilar lymphadenopathy. Given that the clinical picture at presentation was not convincing for pneumonia, other differential diagnoses had to be considered. Patient had sustained tachycardia along with intermittent tachypnea in the absence of fever. Given the short duration of symptoms and critical lab values, resistant bacterial process with possible progression to bacteremia and sepsis is of great concern. Surveillance as an inpatient to monitor  response to IV antibiotics, including repeating  inflammatory markers and work up for alternate diagnoses would be acceptable and appropriate care for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Digestive System/Gastrointestinal
Surgical Services (All)

This is a female with a history of chronic sinusitis and gastroesophageal reflux disease. The patent was taken for an esophagogastroduodenoscopy (EGD) which revealed no evidence of erosive esophagitis. She was not found to have a hiatal hernia. She has had suboptimal response to proton pump inhibitor therapy. Lifestyle measures have not provided significant relief.
Under review is the Upper Gastrointestinal Endoscopy with Thermal Treatment (Stretta procedure) for the treatment of this patient's gastroesophageal reflux disease.

The health plan's determination is upheld. The proposed health service or treatment Upper Gastrointestinal Endoscopy with Thermal Treatment is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Given the information provided about this patient, it is unknown whether or not the patient has had adequate trials of high dose proton pump inhibitor therapy. The Stretta procedure has not been consistently shown to provide long term efficacy in comparison to a surgical fundoplication intervention. In addition, it does not appear that there have been head to head randomized controlled trials comparing use of high dose proton pump inhibitor and the Stretta procedure with assessment of side effects and adverse effects over the short and long term. For this reason, therapies such as the Stretta procedure must be individualized and the clinician must weigh the risks, benefits and utility of other therapeutic modalities against the role and utility of the Stretta procedure which has not been shown to consistently impact the care and outcome of patients receiving this treatment through evidence-based medicine at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

Digestive System/Gastrointestinal
Surgical Services (All)

The patient is a female with gastroesophageal reflux disease (GERD) and chronic sinusitis. She has had voice hoarseness, throat pain, frequent throat clearing, and heartburn for 10-15 years. She has failed Prevacid and Dexilant with H2 receptor antagonists. Esophagogastroduodenoscopy showed arytenoid erythema, edema, and intra-arytenoid mucosal thickening, a 1 centimeter (cm) hiatal hernia, and multiple gastric polyps; biopsies were consistent with fundic gland polyps. A pH study showed normal DeMeester score of 8.5, and symptom association probability of 93.4% for heartburn and 97.4% for chest pain. Under review is the Stretta procedure for the treatment of gastroesophageal reflux disease (GERD).

The health plan's determination is upheld. The requested procedure is not likely to be more beneficial than any standard treatment or treatments for the treatment of gastroesophageal reflux disease (GERD).
A systematic review to evaluate all controlled trial evidence on the efficacy of Stretta for the management of gastroesophageal reflux did not show any benefit of Stretta over sham therapy . Specifically, data on the mean percentage of time that pH was less than 4 (over 24 hours) showed no significant benefit of Stretta over sham therapy. Data on the change in mean lower esophageal sphincter pressure showed no statistically significant advantage of Stretta over sham therapy. The pooled analysis showed no statistical advantage of Stretta over sham therapy for stopping proton pump inhibitor therapy. Finally, the pooled analysis did not show a statistically significant benefit of Stretta over sham therapy on improvement of quality of life scores from baseline. In addition to lack of efficacy, adverse events reported to the U.S. Food and Drug Administration include pneumonia, gastroparesis, esophageal perforation, cardiac arrest, and at least two deaths. Subsequent studies have not been controlled.
A 2019 review of evidence concluded that "high-quality randomized trials are warranted to address the controversy generated" by analysis of randomized trials of Stretta. The most recent American College of Gastroenterology guidelines for the treatment of GERD do not recommend Stretta.
Appeal type: Experimental/Investigational
Decision: Upheld

Digestive System/Gastrointestinal
Surgical Services (All)

The patient is a female under evaluation and management for gastroesophageal reflux disease (GERD). She has had symptoms for 10-15 years including heartburn and frequent throat clearing. An esophagogastroduodenoscopy (EGD) showed a 1 centimeter (cm) hiatal hernia. The patient underwent esophageal pH testing off therapy and was not found to have pathologic acid reflux overall but did have some reflux in the post-prandial and upright position (which overlap). Symptoms of heartburn and chest pain occurred during reflux events (high SAP).

The health plan's determination is upheld. The Upper Gastrointestinal Endoscopy with Thermal Treatment is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Small studies of inadequate design with long-term follow-up have found radiofrequency treatment to be effective. The durability of radiofrequency treatment was assessed in 26 patients who were followed for eight years. At eight years, 77 percent of patients were completely off PPIs. In a second study with 217 patients with refractory GERD who underwent RF treatment, normalization of GERD health-related quality of life (the primary outcome) was seen in 72 percent of patients at 10 years. A prospective third study evaluated the outcomes of 138 patients with refractory GERD who were followed for five years after RF treatment. At the end of the five-year follow-up, all symptom scores (heartburn, regurgitation, chest pain, cough, and asthma) had decreased.
At this time, there is insufficient evidence to support the use of this procedure in this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Crossbite  
Treatment:  Braces  

The braces are medically necessary.  

The patient has a crossbite of a lower anterior tooth (#27).  There is associated attachment (gum) loss.  This is an "automatic qualifier," per the handicapping index scale.  Orthodontic treatment is needed to correct this.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Musculoskeletal Pain

Treatment: 3 Visits of Physical Therapy

The insurer denied 3 visits of physical therapy.

The denial was upheld.

This is a female patient with complaints of musculoskeletal (MSK) pain; including but not limited to neck, back and ankles. The patient has a past history of in the neck, back and ankles surgery. The patient was treated with physical therapy in the past. Physical therapy was recommend and administered.

The minimal physical therapy treatment notes made available for review are hand-written, poorly legible and provide insufficient objective clinical information to support the medical necessity for the dates of service under review.  The clinical records do not establish the medical necessity of continuing a structured out-patient physical therapy treatment program.  The therapy notes merely document the date of service and type of therapy. There are no pain ratings, quantitative assessments or documented response to treatment.  The lack of documented quantitative functional improvement renders the treatment under review as not medically necessary.  

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 3 visits of physical therapy visits should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission 
The insurer is denied coverage for inpatient admission.
The denial is upheld. 
The patient was then a female with a past medical history of coronary artery disease with a prior myocardial infarction years ago, status post a coronary artery bypass graft and hypertension who presented to the Emergency Room (ER) with complaints of an acute onset of chest pain, dizziness and nausea. The patient took nitroglycerin at home which relieved the pain. The patient's electrocardiogram (EKG) demonstrated sinus bradycardia at 48 with Q-waves of the inferior leads. The patient was given additional aspirin in the ER. The patient's chest x-ray revealed low lung volumes. The patient's troponin level was less than 0.010. Cardiology was consulted and the patient was admitted to the hospital. The patient underwent a cardiac catheterization which indicated 2 of 3 occluded grafts; no revascularization was undertaken. Medical management was recommended. The patient was discharged with instructions to follow-up with cardiology as outpatient.

Based on the review of the medical record and the literature, inpatient admission was not medically necessary for this patient. The patient presented with chest pain. The patient's initial evaluation in the Emergency Room (ER) was unremarkable, including non-diagnostic electrocardiogram (EKG) and cardiac biomarkers. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted; however, an inpatient admission criterion was not met. There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care.

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

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolisms

Treatment: Inpatient Admission

The insurer denied the inpatient admission.

The denial was upheld.

The is a morbidly obese female patient who presented to the Emergency Department (ED) with complaints of right leg and foot pain and difficulty ambulating after falling from steps a few months prior to presentation; swelling and erythema were noted around her ankle. The patient was alert and oriented x 3 and was able to speak in full sentences. She denied fever, cough, shortness of breath or chest pain. Vital signs at presentation were; temperature of 98.3F, a blood pressure of 177/100, a heart rate of 105, a respiratory rate of 20 and an oxygen saturation of 94% on room air; her lungs were clear. Cardiovascular system (CVS) heart sounds S1 S2 were normal.  Laboratory work up was performed that revealed white blood cell (WBC) count 12.5K with 65% Polys, hemoglobin was 14 and electrolytes were within normal limits with elevated D-Dimers.  A computed tomography angiogram (CTA) of the chest was performed that revealed bilateral pulmonary embolism (PE). No right ventricular strain was noted. The patient was admitted to the hospital for treatment for pulmonary embolisms. A deep vein thrombosis (DVT) study was done with negative results. A chest x-ray was performed that showed no acute pathology. An x-ray of the right foot was done that revealed a fracture of the distal fibula. Intravenous (IV) fluids, IV antibiotics, pain medications, and subcutaneous Lovenox were administered. The patient was discharged home after treatment after a period of medical stability.

This patient did not need acute hospitalization.  She could have been placed in Observation status while diagnostic testing and treatment were initiated. She was afebrile and hemodynamically stable throughout. The patient was seen by Hematology who recommended switching to oral anticoagulants at discharge and a follow-up in the outpatient setting. The patient was seen by Orthopedics who did not recommend any acute intervention. The patient was WBAT (weight bearing as tolerated). A stirrup brace or CAM boot was recommended at discharge with a follow-up in the outpatient setting.  The patient could have been treated with oral antibiotics if needed.  The patient was seen by Hematology and Orthopedics and cleared for discharge on oral medications.

The patient was stable to be discharged on oral medications after a period in observation. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

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

Diagnosis: Mood Disorder 
Treatment: Inpatient Psychiatric Admission 

The insurer denied inpatient psychiatric admission. The denial was modified. 

This is a male patient was admitted to the hospital for inpatient mental health treatment due to severe behavioral symptoms. These behaviors included aggressiveness, poor impulse control, severe agitation, restlessness, extreme anger, and medication noncompliance. He reported that he lived with his parents and he smoked 6-8 joints of cannabis per day; he had positive toxicology for cannabis. He had a past psychiatric history of Mood Disorder with past hospitalizations. It was reported that he had taken Zoloft and Risperidone. He was discharged home after a period of medical stability. 

The MCG Behavioral Health Inpatient Level of Care Adult criteria report that in order to meet criteria for inpatient behavioral level of care, a patient needs to present as an imminent danger to self, imminent danger to others, have severe psychiatric or behavioral symptoms, have severely dysfunctional living including inability to care for self, have an unwillingness to participate voluntarily, or a less restrictive level of care is not feasible. InterQual  Behavioral Health Adult  Psychiatry inpatient medical necessity criteria reports that  criteria for inpatient treatment is met if one has any of the following: assaultive behavior within 24 hours, catatonia, command hallucinations to harm self or others, destruction of property with poor impulse control within 24 hours, disorganized behavior, unstable eating disorder, fire setting, homicidal or suicidal attempt within 24 hours, suicidal or homicidal ideation with high risk for an attempt, mania, risk of harm to self or others, non-suicidal self-injury and continued danger to self, positive psychotic symptoms with risk of harm to self or others, post-traumatic stress disorder (PTSD) with risk of harm to self or others, psychomotor agitation and potential for violence, severe social withdrawal and refusing treatment, unavailable support or inability to provide needed care and supervision and there is acute deterioration in functioning. This patient had severe psychiatric and behavioral symptoms requiring 24-hour hospital treatment including aggressive behavior and property destruction. 

As a result, modify the previous decision and approve coverage for inpatient mental health treatment in this hospital the initial day of admission, but deny coverage for inpatient mental health treatment in this hospital for the following two. The insurer acted reasonably and with sound medical judgment and in the best interests of the patient for the last two days of admission, but not on first one. 

The carrier's denial of coverage for the inpatient psychiatric admission from is modified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hypertension, Interstitial Pulmonary Disease, Osteopenia, Sickle Cell Trait, Thoracic Aortic Aneurysm, Hypothyroidism, Atrial Fibrillation and bilateral hearing loss.
Treatment:  Personal Care Assistance Service, 5 days/week, 7 hours/day; Total of 35 hours/week (Health plan approved 15 hours/week).

The insurer denied the Personal Care Assistance Service, 5 days/week, 7 hours/day; Total of 35 hours/week (Health plan approved 15 hours/week).  The denial is overturned. 

Yes, the proposed treatment of an increase in Personal Care Assistance Service, to 5 days/week, 7 hours/day; Total of 35 hours/week is deemed medically necessary. 

The patient is a female with a history of Hypertension, Interstitial Pulmonary Disease, Osteopenia, Sickle Cell Trait, Thoracic Aortic Aneurysm, Hypothyroidism, Atrial Fibrillation and bilateral hearing loss.  Due to impairments related to these conditions, she requires assistance with some of her activities of daily living (ADLs).  Appeal review requested for potential approval of an increase in Personal Care Assistance Service, to 5 days/week, 7 hours/day, totaling of 35 hours/week to offer increased ADL assistance. 

Recent documentation from the patient's Attending Physician indicates that the patient was recently hospitalized due to cardiac arrhythmias, requiring endotracheal intubation and mechanical ventilation for respiratory support.  Due to her recent hospitalization and progressive functional decline, she has been requiring increased levels of supplemental oxygen to treat her chronic dyspnea and has been demonstrating progressively worsening fatigue, weakness, gait ataxia and risk for fall injuries.  For these reasons, the currently approved plan of 15 hours/week Personal Care Assistance Services is insufficient to meet the patient's current needs.  Hence, the proposed treatment of an increase in Personal Care Assistance Service, to 5 days/week, 7 hours/day, totaling of 35 hours/week is deemed medically necessary to offer increased ADL assistance.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Arthrosclerotic Disease
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The denial was upheld.

This is a male patient with a medical history of hypertension, congestive heart failure, diabetes, peripheral arterial disease, and peripheral vascular disease status post coronary artery bypass graft with multiple stents to the right lower extremity. The patient presented to the Emergency Department (ED) with complaints of right calf pain and swelling. The patient's physical examination revealed normal range of motion with (2+) non-pitting edema to the right calf with pain in deep palpation. A computed tomography (CT) scan and an ultrasound were performed to evaluate the vascular supply. Laboratory studies were performed that revealed a BUN of 26 with anion gap of 12 and a PT of 17.3 with an INR of 1.5.  The CT scan revealed extensive arthrosclerotic disease with stenosis within the deep femoral artery, popliteal artery and tibioperoneal trunk. There was diminutive peroneal artery and likely occluded or severely stenotic anterior tibial artery; the posterior tibial artery was grossly patent with runoff into the foot.  The patient's ultrasound revealed a negative result for lower extremity acute, subacute or chronic thrombosis; there was a cystic to hypoechoic structure within internal flow from the right mid-calf in the area of interest.  A magnetic resonance imaging (MRI) was performed that revealed a tear of the fibular insertion of soleus tendon with focal edema and hematoma of the soleus muscle and subcutaneous soft tissue swelling.  The patient was admitted for a hematoma to the lower extremity and compartment checks due to the patient being on blood thinners. Cardiology, General Surgery and Orthopedics were consulted; no surgical intervention was required. The patient was medically stabilized and discharged with instruction to follow-up as outpatient.

Based on the review of the medical record and the literature, appropriate examination and diagnostic studies were ordered and interpreted.  Some of these studies such as the MRI were achieved in 48 hours, while others were more immediate.  Nonetheless, once the CT scan of the right leg and ultrasound and the MRI were complete, the various consultants felt no admission was required as the final diagnosis was a coleus muscle tear and focal hematoma and edema.  No surgery or invasive procedures were recommended. These series of diagnostic testing, and various consultations could have easily been achieved with an observation status instead of an inpatient admission.

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 acute inpatient stay should be upheld. The medical necessity is not substantiated.