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

Diagnosis: Syncope
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission. 
The denial is upheld.

The insurer has denied coverage for an inpatient admission. In their Final Adverse Determination letter, they write that the patient felt dizzy and passed out, but they were not unstable. The patient did not have unstable vital signs, dangerous beating of the heart, severe or persistent confusion, a heart attack, a stroke or bleeding in the brain. The inpatient admission was not medically necessary according to MCG (Milliman Care Guidelines) 26th Edition, Syncope, Pediatric. 

In an appeal letter it is noted that the patient history of recurrent syncope with possible seizure activity warranted admission to an inpatient level of care for expeditious evaluation. This evaluation required prolonged cardiac monitoring as well as ongoing skilled assessment of the patient's lab and diagnostic test results, vital signs, and neurological status that could not be provided at a lower level of care. 

This is a patient that has been diagnosed with asthma and gastroesophageal reflux disease (GERD). The patient was admitted after passing out for five minutes. It was noted the patient complained of chest pain. It was noted that three weeks prior, the patient had similar complaint and testing which included electrocardiogram (ECG) and electroencephalogram (EEG) were negative. 

The note indicated the patient had a syncopal episode; vitals were stable. A magnetic resonance imaging (MRI) of the brain was negative. The patient had become dizzy and passed out. On exam, the patient was not unstable, no abnormal vital signs, persistent confusion, or stroke noted. Imaging was negative; the patient had a similar episode three weeks earlier with negative work up. Observation would have been the appropriate level of care.

"Syncope is the transient loss of consciousness and postural tone, with spontaneous recovery. It accounts for approximately 1% (percent) of all emergency department visits and (dollars) $5.6 billion in healthcare costs annually. In a very small subset of patients, syncope may be a warning sign for serious outcomes or death, but identifying these patients is challenging, as the emergency clinician must distinguish between life-threatening causes and the more common, benign etiologies" (1).

"Syncope is a common reason for emergency department (ED) attendance and it presents a major management challenge with regard to the appropriate workup and disposition. Nearly 50% (percent) of patients are admitted, and for many this is unnecessary" (2).                                                         

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension.
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is upheld.

This patient is an adult male who was hospitalized for hypertension. He presented to the emergency department for evaluation of shortness of breath, diaphoresis, headache, and feeling jittery and not like himself in the setting of having stopped his antihypertensive medication. Vitals were remarkable for elevated blood pressure of 158/110. His past medical history included hypertension, obesity, alcohol abuse, and cirrhosis. Electrocardiogram was remarkable for new lateral T-wave inversions compared with previous tracing and concern for possible lateral ischemia. Echocardiogram revealed ejection fraction of 40 percent and moderate global hypokinesis, which was new. Troponin returned elevated. The clinical impression was hypertensive urgency. Treatment included Lisinopril and aspirin. Ischemic workup by cardiac computed tomography angiography revealed nonobstructive coronary artery disease and the patient was cleared for discharge. The requested claim for inpatient hospitalization was denied based on his policy and the patient is appealing the decision.

The proposed treatment was not medically necessary.

Based on the peer-reviewed medical literature, including the Milliman Care Guidelines (MCG) titled: Heart Failure (ORG: M-190) and Hypertension (ORG: M-197), criteria for inpatient admission is not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by chronic kidney disease and congestive heart failure, hypertension requiring inpatient hospitalization, cerebrovascular accident, pulmonary embolism, aortic dissection, pneumonia, severe electrolyte abnormalities, or any other medical condition or other medical instability or acute care needs for which emergency and observation care have failed or are not considered appropriate and that would require acute inpatient management. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient stay. The care the patient received for new mildly decompensated left ventricular systolic heart failure, in the setting of hypertensive urgency from medical noncompliance, is routinely provided safely and effectively at a lower level of care. Therefore, the proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension

Treatment: Bystolic 10 milligram (mg) tablet

The insurer denied coverage for Bystolic 10 milligram (mg) tablet.

The denial is overturned.
 

This is a patient with a history of hypertension treated with Bystolic 10 milligrams (mg) daily.  On examination she was noted to be hypertensive with a BP of 160/110 and pulse of 102. Physical examination and complete review of systems were without abnormality.  Her physician documents that the patient has been treated in the past with generic nebivolol and developed itching, rash and stomach discomfort.   He is requesting approval for Bystolic.

This patient suffers from hypertension and according to medical records submitted by her physician, has been stable on non-generic Bystolic therapy. The treating physician provided documentation that the patient developed a rash and pruritis following use of nebivolol- generic alternative. The health plan noted that Bystolic would be approved once documentation has been provided documenting intolerance to the generic alternative. Current American Heart Association guidelines for the management of high blood pressure in adults recommend treatment of BP greater than 140/90.(Reference 1). This patient has a class I indication for pharmacologic therapy.  Nebivolol is listed in these guidelines as one of the possible treatments for patients with hypertension. Studies have demonstrated that a small number of individuals require reversion to name brand medications following switchover to generic formulations.(2)  Based on documentation and health plan requirements Bystolic is medically necessary for this patient.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Bystolic 10 milligram (mg) tablet is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Abdominal pannus. 
Treatment: Outpatient services (surgery to remove excess skin on abdomen) (15830, 15847) x1. 

The insurer denied: Outpatient services (surgery to remove excess skin on abdomen) (15830, 15847) x1.  The denial is partially overturned. 

The patient is an adult female. This female has lost weight following bariatric surgery. She has an abdominal pannus and complains of recurrent rashes in the folds under the pannus. Dermatology note recommended anti-fungal medication and cleansing soap. Photos show a female with rashes in the fold under her pannus. Panniculectomy and abdominoplasty are planned. 

The panniculectomy is medically necessary; however, the abdominoplasty is not medically necessary. 

A panniculectomy (15830) is medically necessary, but an abdominoplasty (15847) is cosmetic. According to the American Society of Plastic Surgeons (ASPS) Position Paper "Treatment of Skin Redundancy For Obese and Massive Weight Loss Patients" (1), "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature... For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic. Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically, these procedures are performed to improve appearance and are therefore cosmetic in nature." 

The records indicate that the patient has failed conservative treatment for her longstanding rashes including medical treatment by her primary care physician (PCP) for at least six months with nystatin. Photos show she has an overhanging pannus with rashes. A panniculectomy will be sufficient to treat her rashes. This procedure will eliminate the overhanging abdominal skin that predisposes the patient to recurrent skin infections. Removal of redundant upper abdominal skin, diastasis repair and umbilical transposition are component parts of an abdominoplasty that are not necessary to treat the rashes. 

According to the American Society of Plastic Surgeons, "In the case where a panniculectomy is combined with plication of the rectus abdominis muscle and/or translocation of the umbilicus, this may be completed as a single stage procedure but the plication of the rectus abdominis muscle and/or translocation of umbilicus should be considered purely cosmetic..." An abdominoplasty is a cosmetic body contouring procedure that will not confer any additional functional benefit for this patient. A panniculectomy with skin resection is sufficient to treat this patient's infections.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/ Musculoskeletal/Other/Left Hand Pain, swelling, and redness
Treatment: Inpatient Hospital/Inpatient admission 
The health plan has denied the requested service, inpatient admission, as not medically necessary. The health plan's determination is upheld. 

The patient is a male with a past medical history (PMH) of schizophrenia, gastroesophageal reflux disease (GERD), and intravenous (IV) drug use (IVDU) on methadone who was admitted with complaints of hand erythema and swelling after injecting heroin. His vital signs were unremarkable. The physical exam was notable for the left hand dorsum with swelling and erythema, no pain with passive movement, and no tense compartments. Laboratory work was unremarkable. Imaging studies included a right hand radiograph which showed no fracture and a chest x-ray (CXR) which showed no acute pathology. The patient was diagnosed with hand cellulitis and was treated with IV antibiotics. Orthopedics evaluated the patient and recommended IV antibiotics, radiographs, pain control, and stockinette elevation. The patient was discharged against medical advice (AMA).

At issue is the medical necessity of an inpatient admission.
I uphold, in whole, the health plan's determination of medical necessity.

The hospital stay was not medically necessary at an acute inpatient level of care.
The patient presented to the emergency department (ED) with complaints of hand erythema and swelling after injecting heroin. The patient was afebrile, did not appear toxic, and had no unstable comorbidities. He did not have a limb-threatening infection, septicemia, life-threatening infection, necrotizing fasciitis, leukocytosis, features of systemic inflammatory response syndrome (SIRS), animal or human bite with extensive damage, compartment syndrome, pain out of proportion to clinical findings, crepitus, neutropenia, immune-suppression, marked systemic toxicity or worsening symptoms, or inability to take oral medications. This patient was treated with antibiotics and an Orthopedics consultation. The Orthopedics consult did not perform acute surgical intervention, and this could have been safely provided at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastritis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

 
The patient had a history of alcohol abuse and presented with abdominal pain and vomiting. He had a mild sinus tachycardia. There was no abdominal rebound or guarding. There was no leukocytosis. He initially had a creatinine of 2.23 but by the next day it was 1.1. An abdominal computed tomography (CT) scan was negative for acute disease. Intravenous (IV) hydration and antiemetics were given. He was diagnosed with gastritis and was treated with Pepcid. 

Clinical indications for admission for Vomiting are listed in Milliman Care Guidelines (MCG) M-370. These include having a severe metabolic derangement such as ketoacidosis, hemodynamic instability, severe vomiting that is not responsive to treatment, acute renal failure that persists despite appropriate treatment, and an inability to maintain oral hydration after observation care. This patient did not have these conditions. The renal insufficiency rapidly improved with IV hydration. 

Clinical indications for admission for Gastritis are listed in MCG M-560. These include hemodynamic instability, gastric outlet obstruction, perforation, peritoneal signs, dehydration that persists after appropriate treatment, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had gastritis related to alcohol use. IV hydration, antiemetics, and Pepcid were needed. However, this treatment could have been given with observation status. The renal insufficiency rapidly improved with treatment. He did not meet MCG criteria for admission for either Vomiting or Gastritis. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is upheld.

The patient is an adult female with HTN (hypertension) and GERD (gastroesophageal reflux disease). She presented to the ER (emergency room) with shortness of breath and cough.
The patient received IV (intravenous) antibiotics in the ER (emergency room) for pneumonia. The patient was admitted to acute inpatient level of care. During hospitalization, the patient received IV (intravenous) antibiotics and nutrition support.
The hospitalization was denied coverage by the health plan due to lack of medical necessity. This denial is being appealed.

The Inpatient Admission was not medically necessary.

The patient was diagnosed with multifocal pneumonia. At the time of admission, the patient was hemodynamically stable. The patient was not in any distress. The patient was not on high amounts of supplemental oxygen. The patient was tolerating oral diet. The patient was able to ambulate. The patient was not on any invasive drips. The patient did not receive any treatments that could not have been provided safely and effectively at a lower level of care. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral Leg Swelling, Exertional Shortness of Breath
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The health plan's determination is overturned.

The patient is a female with a past medical history significant for hypertension, active crack cocaine and alcohol use, active smoker, type 2 diabetes mellitus, and hypothyroidism. She was brought to the emergency department (ED) by Emergency Medical Services (EMS) for evaluation of worsening shortness of breath and leg swelling. In the ED, notable laboratory studies showed an elevated HS cardiac troponin, and fibrin degradation product (d-dimer) was 1516.
The electrocardiogram (ECG) demonstrated normal sinus rhythm, age indeterminate septal infarction with nonspecific segment (ST) abnormalities. The patient was treated with therapeutic Lovenox and admitted to telemetry service under inpatient level of care for evaluation of chest pain and rule out acute coronary syndrome (ACS). The chest computed tomography (CT) was negative for acute pulmonary embolism (PE). The venous dopplers were negative for deep vein thrombosis (DVT). The echocardiogram was obtained showing normal cardiac function, normal wall motion, and moderate left ventricular hypertrophy (LVH). After ACS was ruled out and patient's shortness of breath resolved, the patient was discharged.

The inpatient level of care was medically appropriate and necessary. The patient presented with worsening shortness of breath on exertion and leg swelling and was found to have elevated HS cardiac troponin and d-dimer. She admitted to active crack cocaine use. The ECG in the ED was abnormal revealing septal infarct pattern with nonspecific diffuse ST abnormalities. Given the clinical concern for acute PE and ACS, the patient was appropriately admitted to telemetry service under inpatient level of care given the expectation that hospital care services would be needed for at least 2 midnights. Given the patient's calculated History, Electrocardiogram (EKG), Age, Risk Factors and Troponin (HEART) score was 5 with elevated cardiac troponins indicative of moderately increased risk for short-term adverse cardiac events, the inpatient level of care would be supported by the well-validated HEART pathway and the 2022 American College of Cardiology (ACC) expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department (1-3).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Osteoarthritis

Treatment: Straight Cane

The insurer denied coverage for straight cane.

The denial is overturned.

This is a patient with chronic medical problems including heart disease, bipolar disorder and osteoarthritis.  Under review is the medical necessity of a straight cane.

The patient has chronic osteoarthritis.  The patient's use and need for a cane is not in dispute.  According to the Uniform Assessment for New York (UAS-NY) report, the patient uses a straight cane to ambulate indoors and is (modified) independent.  According to the case notes, the claim was never submitted due to a "forged signature."  The insurer (Blue Cross/Blue Shield HealthPlus) denied the request; indicating "The cane can be provided by Medicare."  However, according to the Advance Beneficiary Notice of Non-Coverage (ABN), "Medicare will not pay for a same or similar item paid within the past 5 years."  Based on the patient's clinical condition and functional deficits, the cane is medically necessary.  

From a physical medicine & Rehabilitation/Pain Management perspective, as well as within a reasonable degree of medical certainty, based on the documentation available for review, the requested straight cane is medically necessary.  

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a straight cane is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain
Treatment: Lumbar fusion
The insurer denied a lumbar fusion. The health plan's determination is upheld. 

The patient is a male with R>L (right greater than left) lower back and right lower extremity (RLE) pain for >5 years. He has associated numbness and tingling in the R (right) leg in an L (lumbar) 5 distribution. Physical exam is notable for decreased lumbar range of motion (ROM), + straight leg raise (SLR) on the R. Otherwise, he is neurovascularly intact. Lumbar xrays demonstrated 3 millimeter (mm) retrolisthesis L3/4, severe disc space narrowing L4/5, facet sclerosis L5/S (sacral)1, degenerative changes diffusely but most severe at L4/5.

A Lumbar Fusion - Single Level is not medically necessary for this patient.
His treating pain doctor is recommending a lumbar fusion via what he calls a posterior arthrodesis via lateral approach utilizing an interspinous device. According to NASS (North American Spine Society) Clinical Guideline, "There is insufficient evidence at this time to make a recommendation for or against the placement of an interspinous process spacing device in patients with lumbar spinal stenosis." Products such as the Minuteman are not considered standard of care. Therefore, the requested service is not indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Vertebrogenic Low Back Pain. 
Treatment: Intracept Intraosseous Nerve Ablation System 
(64628, 64629). 

The insurer denied: Intracept Intraosseous Nerve Ablation System (64628, 64629). 
The denial is upheld. 

The patient is an adult male. The appeals letter states the patient has a history of chronic low back pain due to degenerative disc disease that resulted in development of vertebrogenic pain identified by degenerative endplate changes on magnetic resonance imaging (MRI). The patient has pain and has failed treatment for greater than six months. Prior treatments include acupuncture, chiropractic care, epidural steroid injection, and physical therapy. Pain averages 3-10/10. The progress notes indicate that the patient has low back pain that started nine years ago. The pain is located centrally and left-sided. The pain is aggravated with prolong sitting, standing, and walking. 

The health plan should not cover the Intracept procedure. 

From the provided documentation, the requested procedure is not recommended at this time. Although the patient has a history of chronic low back pain, there was lack of documentation of the patient having tried and failed all prior conservative treatments. Additionally, there was a lack of noted Modic type changes on MRI (magnetic resonance imaging) to support to request this procedure. As such, this request is not recommended in this case and the health plan should not cover the Intracept procedure.