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

Diagnosis: Anemia

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was reversed. 

This is a male patient with a history of hypertension, dyslipidemia, coronary artery disease, and a recent cholecystectomy. He presented to the Emergency Department (ED) after being evaluated at primary care provider's office for complaints of dark-colored stools and weakness. The patient reported feeling weak since his recent surgery. It was noted that at the time of his discharge from the hospital he was having diarrhea and melanotic stool. His primary care provider reported that he had positive Hemoccult for melena and there was a drop in hemoglobin from 9.6 g/dL down to 6.6 g/dL over the course of several days. On physical exam it was reported that the patient did not have abdominal pain or tenderness. An electrocardiogram (EKG) was done with normal results. Gastroenterology was consulted.  The patient was initially transfused with 2 units of packed red blood cells. His post transfusion hemoglobin was 8.3; he received another blood transfusion the following day. The patient underwent colonoscopy that showed no active bleeding and esophagogastroduodenoscopy (EGD) that revealed evidence of gastritis, but no active bleeding. The patient continued to be monitored and experienced no adverse events.  The patient was medically stabilized with a hemoglobin level of 10.8 and was discharged home with outpatient follow up instructions. 

According to the Milliman Care Guidelines, the clinical indications for inpatient admission for upper gastrointestinal (GI) bleed include hemoglobin of less than 12 g/dL in a male patient, melena, and BUN greater than 18.2 mg/dL. In this case, the patient was sent from his primary care provider's office with positive melana. In the ED, the patient's labs showed hemoglobin of 6.6 g/dL and BUN level of 57 mg/dL. The patient required multiple blood transfusions, consultation, and diagnostic colonoscopy and EGD to rule out active bleeding and that the patient would be stable for safe discharge. During this patient's inpatient stay, the patient's blood levels were closely monitored; the patient's hemoglobin was improved to 10.8 g/dL and was stable for discharge. Based on this clinical presentation, the patient met the Milliman Care Guidelines criteria for inpatient admission. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission is reversed.  The medical necessity is substantiated.
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 male with a past medical history significant for HTN (hypertension), dyslipidemia, diabetes mellitus type II, poor compliance with medical therapy, tobacco abuse, strong family history of severe premature CAD (coronary artery disease) (father fatal MI [myocardial infarction], sister with fatal MI). He presented to the ER with complaints of new onset chest pain, radiating to the left arm, dizziness, near-syncope. 

The patient was hypertensive, with BP (blood pressure) 171/112, with stable rest of the vital signs. The initial cardiac troponin was negative. The ECG (electrocardiogram) revealed normal sinus rhythm with mild QRS widening and 0.5 mm ST depression in pre-cordial leads, chest X-ray was unremarkable. 

The patient was diagnosed with unstable angina and treated with anti-platelets, b-blocker and BP control. Cardiology consultation was obtained and the patient was referred for a cardiac catheterization due to high risk of obstructive CAD. The patient was found to have mid LAD (left anterior descending) severe myocardial bridging, which was felt to be responsible for his symptoms, and mild atherosclerotic disease, which was treated medically. 

The patient was started on medical therapy for his dyslipidemia, diabetes, CAD and 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, including diabetes, as well as a strong family history of severe premature coronary artery disease, including a fatal MI in two first degree relatives. The ECG was unrevealing for ACS (acute coronary syndrome), but was abnormal, with findings suggestive of ischemia. There was a high index of suspicion for an ACS, and a cardiac catheterization was performed. Given the presentation, uncontrolled hypertension, as well as clinical suspicion for an acute coronary syndrome/unstable angina, he would not be an appropriate candidate for an ED chest pain observation unit. 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

Diagnosis:  Transient Ischemic Attack

Treatment:  Inpatient Admission

The insurer denied the inpatient admission.  The denial was upheld.   

This is a female patient with a history of hypertension, hypothyroidism and hyperlipidemia.  The patient presented to the Emergency Department (ED) with complaints of intermittent left arm weakness, left side facial paresthesia, dizziness, unsteady gait, and pressure in her head.  Laboratory work up was performed that did not reveal significant abnormalities.  A computed tomography (CT) of the head was done with negative results.  The patient was admitted to the hospital for further work up.  She was started on aspirin.  A magnetic resonance imaging (MRI) of the brain was done with negative results for any acute process.  A carotid Doppler was performed with negative findings.  The patient was medically stabilized and discharged home with outpatient follow up instructions. 

The Milliman Care Guidelines indicate that admission for transient ischemic attack (TIA) is appropriate for patients who have hemodynamic instability, focal neurological signs that recur, findings on brain imaging that require inpatient care, altered mental status, a cardiac arrhythmia of immediate concern, a clinically significant cardiac disorder that requires inpatient care, severe hypertension with a systolic blood pressure of greater than 180 mmHg or diastolic blood pressure of greater than 110 mmHg, when an urgent procedure is needed, or when parenteral anticoagulation is needed.  The records submitted for review indicated the patient had undergone a computed tomography (CT) scan of the head, which was normal and without any acute processes.  The laboratory studies did not reveal any significant abnormalities.  On exam, the patient was able to follow commands and was alert and oriented x3.  The patient's Carotid Doppler was also negative for concerns of stroke.  The patient did not have a cardiac arrhythmia of immediate concern or a clinically significant cardiac disorder that required inpatient care.  The patient did not have severe hypertension. Based on the review of the Milliman Care Guidelines on TIA, the patient would have been appropriately cared for at the Observation status.  Thus, acute admission was not necessary for this patient. 

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

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

Diagnosis: Abscess
Treatment: MRI
The proposed MRI was not medically necessary.

The patient is a female with a reported abscess to the left leg. Her physician recommended magnetic resonance image (MRI). The MRI demonstrated presence of possible septic arthritis/osteomyelitis to the left sacroiliac (SI) joint. 

An MRI is of benefit to aid in diagnosis and plan treatment. There should be consistency of medical records demonstrating a problem to require additional diagnostic testing. No such information was provided. It was unknown what types of treatment the patient had had. It was not known what her current complaint was. It was not known why the physician required this test.  

Based upon the above, there were no extenuating circumstances to substantiate the MRI at that time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath, cough, headache
Treatment: Inpatient admission

The inpatient admission was medically necessary.

The patient is a male whose inpatient admission is under review. The patient presented to the emergency room (ER) with headache, found to have dysuria and on antibiotic for a urinary tract infection (UTI) (Macrobid then Augmentin). Patient was positive for productive cough. There was no nausea, vomiting, fevers, chills, or dyspnea. The patient fell in the ER after standing.

Per the records:
Temperature (T) - 98.0   
Pulse (P) - 76   
Blood pressure (BP) - 105/55  
Respiratory rate (RR) - 16    
Oxygen saturation (O2 sat) - 96%
General - no acute distress (NAD)
Chest - normal
Cardiovascular system (CVS) - normal
Abdomen - normal
White blood cell (WBC) - 7.82
Hemoglobin (Hg) - 12.9
Hematocrit (Hct) - 40.2
Platelets (Plt) - 139
Sodium (Na) - 138
Potassium (K) - 4.3
Chloride (Cl) - 104
Carbon dioxide (CO2) - 25
Blood urea nitrogen (BUN) - 14
Creatinine (Cr) -  0.97

Urine analysis (UA) was read as turbid, occ epithelial, large leukocyte esterase (LE), greater than (>) 50 WBC.  Urine culture revealed Klebsiella pneumoniae.

Computed tomography (CT) of the chest showed patchy opacities in the right lower lobe (RLL) that may represent pneumonia.

The patient was thought to have a pneumonia and failure of UTI treatment. He was given intravenous (IV) ceftriaxone and azithromycin in the ER, and then admitted and placed on levofloxacin. He improved over the next few days and was then discharged home.

1) The patient failed outpatient therapy after taking two separate antibiotics for UTI. Standard of care and guidelines would require admission (1).

2) The patient had concurrent pneumonia and UTI; thus, this is not a standard, uncomplicated case, and there are no guidelines for this situation (1).  Standard of care would require admission.

3) The patient had a fall in the ED and it would not be safe to send him home.

Thus, this admission was warranted, supported by standard of care and Infectious Diseases Society of America (IDSA) guidelines. Failure to admit such as a patient can lead to loss of function, septic shock, respiratory failure, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin abscesses and cellulitis 
Treatment: Inpatient hospital admission 

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

The patient is a male with a past medical history significant for asthma, pilonidal cysts, and recurrent skin abscesses who presented to the Emergency Department with complaints of skin abscesses to the bilateral inner thighs. 

Vital signs on presentation included a temperature of 98.2F, a blood pressure of 132/62, a pulse of 140, a respiratory rate of 18, and oxygen saturations of 100% on room air. Laboratory results included a white blood cell (WBC) count of 8.5, hemoglobin of 10.1, a hematocrit of 32.7, a creatinine of 1.01, a glucose of 106, a lactic acid of 1.4, and a troponin of 0.08. 

The patient was started empirically on intravenous antibiotics (vancomycin and cefepime) for possible cellulitis of his lower extremity. A CT scan showed thick walled fluid collection in the left inner thigh region likely due to cellulitis and skin abscesses. Infectious Diseases consulted and their impression was hidradenitis suppurativa. They added clindamycin to vancomycin. Wound care was also provided. The patient remained afebrile and hemodynamically stable. He was discharged to continue oral antibiotics (doxycycline) as an outpatient. 

According to the documentation, the patient presented with bilateral thigh lesions consistent with hidradenitis suppurativa, a chronic skin condition that may span many years. Otherwise, he was afebrile and hemodynamically stable with unremarkable laboratory results including a normal WBC count. He did not have any evidence for a disseminated infection and no surgical intervention was required. Moreover, the patient was able to tolerate oral intake. Based on these findings, the patient did not meet criteria for inpatient level of care. Documentation does not support the need for acute inpatient hospitalization. 

The prior determination of denial of coverage for inpatient hospital services has been upheld. The insurer acted reasonably, with sound medical judgement, and in the patient's best interest. 

Based on the above, the medical necessity for inpatient hospital admission is not substantiated. Please note that the medical record indicates that the patient was admitted. The insurer's denial is upheld.
Appeal type: Experimental/Investigational
Decision: Overturned


Reviewer #3:

Diagnosis: Lupus; vision screening for Plaquenil toxicity 

Treatment: CPT code 92274 [Electroretinography (ERG), with interpretation and report; multifocal (mfERG)]

The insurer is denied coverage for CPT code 92274 [Electroretinography (ERG), with interpretation and report; multifocal (mfERG)]. 

The denial is upheld. 

This case involves a female with a history of lupus who had been taking Plaquenil to treat lupus. The patient underwent multifocal electroretinogram (mfERG). The examination revealed slight lower amplitude superior perifoveal regions however all within normal range. The recommendation was made for the patient to follow-up for a comprehensive examination. 

Peer reviewed literature supports the use of multifocal ERG in detecting plaquenil toxicity in patients with other macular comorbidities. Multifocal ERG has final approval from regulatory bodies for plaquenil toxicity screening (high risk medication). 

The patient was a good candidate for multifocal electroretinography, CPT code 92274. This patient had other macular comorbidities of Vitreomacular Adhesion (VMA), branch retinal vein occlusion, and had a visual field defect. The multifocal ERG can be used in the detection/monitoring of this patient's potential toxicity.

However, it is not the best available test for this patient. To detect chloroquine toxicity, the American Academy of Ophthalmology recommends performing fundus examinations, 10-2 automated visual fields, and at least one objective test: multifocal electroretinography (mfERG), fundus autofluorescence imaging, or spectral domain optical coherence tomography (SD-OCT). 

As per the AAO GUIDELINES, 10-2 visual fields are of value in the care of this patient. Only one other testing is recommended per above guidelines. The patient had mf ERG and microperimetry in the past. As per the provider notes in the "Other Discussion," the patient's microperimetry and visual field remained normal. Yet, the provider wanted to see the patient every 1 to 2 months during the coming year for Plaquenil testing and monitoring. These office visits and testing are overdone. Mutifocal ERG, even though approved in this case, is not warranted. Fundus autofluorescence imaging is recommended as an objective test along with mfERG and spectral domain optical coherence tomography as a primary test for plaquenil toxicity screening. mfERG is listed by the AAO as ".. mfERG is similar in sensitivity to visual fields and can provide objective confirmation of suspected field loss."(2) 

Thus, the multifocal electroretinography (mfERG), the requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of coverage for CPT code 92274 [Electroretinography (ERG), with interpretation and report; multifocal (mfERG)] performed should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #2

Diagnosis: Lupus; vision screening for Plaquenil toxicity

Treatment: CPT code 92274 [Electroretinography (ERG), with interpretation and report; multifocal (mfERG)]

The insurer is denied coverage for CPT code 92274 [Electroretinography (ERG), with interpretation and report; multifocal (mfERG)]. 

The denial is reversed. 

The patient is a female with a history of lupus treated with Plaquenil. The patient underwent multifocal electroretinogram (mfERG) due to long-term use of Plaquenil therapy. 

There is scientific evidence for the use of multifocal electroretinogram (ERG) in the diagnosis of plaquenil toxicity. It is the only functional test of the three suggested by the American Academy of Ophthalmology for Plaquenil screening and to diagnose toxicity. Multifocal ERG is not a treatment. It is a test which helps determine the function of the retina, and via diagnosis helps improve health outcomes. Multifocal ERG is the only study which is able to determine if the macula (central portion of the retina) is functioning properly. It is the gold standard for determining the function of the retina. There is no need for approve from a regulatory body for multifocal ERG. It has been used in clinical practice for more than 20 years. 

Given the concern for Plaquenil toxicity, this patient was a good candidate for multifocal ERG testing. Thus, the multifocal electroretinography (mfERG), the requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of coverage for CPT code 92274 [Electroretinography (ERG), with interpretation and report; multifocal (mfERG)] performed should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #1

Diagnosis: Lupus; vision screening for Plaquenil toxicity

Treatment: CPT code 92274 [Electroretinography (ERG), with interpretation and report; multifocal (mfERG)]

The insurer is denied coverage for CPT code 92274 [Electroretinography (ERG), with interpretation and report; multifocal (mfERG)]

The denial is reversed. 

The patient was a female with lupus who was on Plaquenil.  The patient saw a doctor and a multifocal electroretinogram (mfERG) were performed. mfERG showed slightly lower amplitudes of the superior periforveal region in both eyes, within normal range. The doctor noted that the patient was on long-term Plaquenil therapy and that there was no changes indicated for Plaquenil.

The mfERG is the best available treatment for this patient at this time. Guidelines from the American Academy of Ophthalmology on screening for Plaquenil toxicity stated that newer objective tests, such as mfERG, can be more sensitive than visual fields. The guidelines recommended that along with 10-2 automated fields, mfEFG should be used for routine screening where available. The guidelines stated that, because mfERG testing is an objective test that evaluates function, it may be used in place of visual fields (Marmor, et al., 2011).

The American Academy of Ophthalmology guidelines also recommend the use of mfERG as a functional test that can provide objective corroboration for visual fields by documenting parafoveal or extramacular electroretinogram depression in early retinopathy from Plaquenil. The American Academy of Rheumatology also recommends mfERG be used as an objective test during the retinal exam (Marmor, et al., 2016).
The scientific evidence in peer-reviewed literature supports an improvement in health outcomes. Studies have shown that mfERG may have the ability to detect cases of retinal toxicity earlier than other modalities (Tsang 2015). In this case, the patient was a good candidate for mfERG because the patient was on long-term Plaquneil therapy and was at risk for development of retinopathy. The literature review supports that the mfERG is used as a primary screening tool for retinal toxicity in long-term Plaquenil users.

Thus, the multifocal electroretinography (mfERG), the requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for CPT code 92274 [Electroretinography (ERG), with interpretation and report; multifocal (mfERG)] performed should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease, diabetes mellitus, depression 

Issue under review: Personal care assistance, level II services to five hours/day, two days/week (Monday and Tuesday), four hours/day, three days/week (Wednesday, Thursday, Friday) and eight hours per day, two days/week (Saturday and Sunday), for a total of 38 hours/week

The insurer denied the Personal care assistance, level II services to five hours/day, two days/week (Monday and Tuesday), four hours/day, three days/week (Wednesday, Thursday, Friday) and eight hours per day, two days/week (Saturday and Sunday), for a total of 38 hours/week

The denial is upheld. 

No, the proposed treatment of an increase in personal care assistance, level II services to five hours/day, two days/week (Monday and Tuesday), four hours/day, three days/week (Wednesday, Thursday, Friday) and eight hours per day, two days/week (Saturday and Sunday), for a total of 38 hours/week is not deemed medically necessary. 

This is a female with a history of coronary artery disease, diabetes mellitus and depression. Due to impairments related to these conditions, she requires assistance for completion of many of her activities of daily living (ADLs). However, an in home assessment of the patient's overall functionality and ability to complete ADLs was performed and revealed that the currently approved plan of personal care assistance, level II services 22 hours/week is sufficient to meet the patient's current needs. There is no additional documentation noted since the date of this last assessment which demonstrates that the patient has sustained additional functional decline which would warrant an increase in PCA hours. For these reasons, the proposed treatment of an increase in personal care assistance, level II services to five hours/day, two days/week (Monday and Tuesday), four hours/day, three days/week (Wednesday, Thursday, Friday) and eight hours per day, two days/week (Saturday and Sunday), for a total of 38 hours/week is not deemed medically necessary.