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

Bacterial Infection
Inpatient Hospital
This is a patient who presented with a fever and leg swelling. He had fevers which became persistent, with his maximum temperature up to 104 degrees Fahrenheit (F). On the day prior to admission, he went to see his primary doctor and no source of the fever was found. A chest x-ray and streptococcus throat swab were negative at that time, however, his white blood cell (WBC) count was elevated at 23,000. He was given one dose of ceftriaxone and sent home.
The following day he developed redness and swelling over the left lower extremity extending to his ankle, and he was unable to bear weight. He was seen again by his primary doctor and his white blood count was still elevated and he continued to have fevers. He was subsequently referred to the emergency department for further care.
An x-ray of the left lower extremity showed soft tissue swelling of the anterior lateral left lower extremity but no fracture. Orthopedics was consulted and they felt he had cellulitis. He was started on vancomycin and ceftriaxone at that time. There was additional concern because he was not fully immunized and came from an area with a high incidence of methicillin-resistant staphylococcus aureus (MRSA) infection.
He was admitted for further management and was continued on intravenous clindamycin. He was also given intravenous fluids to improve his hydration status. He was intermittently febrile after admission. By the following day, his rash had improved, he was afebrile, and was felt to be stable for discharge on oral antibiotics, with close follow-up as an outpatient.
The health plan's determination is overturned.  The patient had fevers for several days and then developed redness and swelling of his left lower extremity. He also developed difficulty bearing weight. He required prompt initiation of parenteral antibiotics, as well as intravenous fluids to maintain his hydration status, along with close monitoring in an inpatient setting with escalation of treatment as necessary. Children with cellulitis require hospitalization if they have systemic signs with rapid progression of erythema. Care for this child required inpatient hospitalization due to the rapid progression of his infection with ongoing fever, as well as blood tests (white blood count and sedimentation rate) showing inflammation. He required prompt initiation of parenteral antibiotics to obtain control of the infection, as well as intravenous fluids to maintain his hydration status.
Appeal type: Medical necessity
Decision: Overturned

Pes Planus/Flat Feet
Orthotics

The patient has bilateral foot pain due to plantar fasciitis. The patient already wears custom orthotics for flatfoot; however they are now worn out. Conservative treatment has been attempted. A request has been made for custom orthotics.  The health plan's determination of medical necessity is overturned in whole. The requested custom orthotics are medically necessary for this patient. The patient has already been wearing custom orthotics for plantar fasciitis and flatfoot, two conditions for which orthotics are considered standard treatment by the consensus of medical literature. The newly requested orthotics should be considered a continuation of the current treatment, not evaluated as a new treatment modality. There is already clinical evidence that the orthotics have benefited the patient.
Appeal type: Medical necessity
Decision: Upheld

Leukemia
Nursing Services (including Private Duty Nursing)

The patient is a female with past medical history of chronic anticoagulation for deep vein thrombosis (DVT), hypertension, hyperlipidemia and CLL (Chronic Lymphocytic Leukemia) who lives in an upstairs apartment from her granddaughter. The patient had a diagnosis of metastatic colon cancer. The patient had progression of disease more recently and was starting a new chemotherapy. The patient had personal care services 4 hours a day, Monday through Friday. The patient requested increased services to 5 hours a day, 7 days a week. The patient had task assessment tool although there had not been decline in function, the patient was approved for another 3.5 hours a week on Saturday and Sunday. The plan did recommend Home care services to assess for physical therapy (PT) and occupational therapy (OT) needs but the family denied these services. The health plan denied increase of personal care services to 5 hours per day, 7 days a week as not medically necessary.

The health plan's determination is upheld. The Increase in Personal Care Worker (PCW) Service to Total 35 Hours per Week: 7 Days per Week/5 Hours per Day is not medically necessary for this patient.
Based on the task assessment tool, the patient qualified for 4 hours of personal care services Monday through Friday. There had been a request for increased services due to patient's metastatic colon cancer progression, however, there was no significant change on task assessment tool. The plan did allow for 3.5 hours on Saturday and Sunday (in addition to 4 hours per day Monday through Friday) even though she qualified for 4 hours per day Monday through Friday. The patient did not require 24 hour care.
At the time of repeat task assessment the patient did not have increased mental or physical needs that would make personal care services 5 hours per day, 7 days a week, medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
 
Treatment: Orthovisc intra-articular injection

The insurer denied the Hyaluronan or derivative, Orthovisc, intra-articular injection. The denial was reversed.

This is a female with right knee pain and right knee osteoarthritis. She had previously undergone arthroscopic surgery. She was recently evaluated and reported a walking limitation to 1-2 blocks.  Physical therapy (PT) and medications did not provide benefit.  A cortisone injection did not help. X-rays revealed joint space narrowing, sclerosis and osteophyte formation. Her physician recommended a series of injections (viscosupplementation).

The medical record demonstrates that the denial was based upon failure to receive a cortisone injection.  There would have to be documentation of ongoing symptoms to substantiate the course of viscosupplementation.  The physician record denotes ongoing symptoms despite the cortisone injection.  The documentation was present to support the need for the course of treatment. There was consistency of subjective complaint, objective finding and imaging to confirm the diagnosis and the need for treatment. 

Criteria for Hyaluronic Acid Injections:

(1) 	Patients experience significantly symptomatic osteoarthritis but have not responded adequately to recommended conservative non-pharmacologic (e.g., exercise) and pharmacologic treatments, or are intolerant of these therapies (e.g., gastrointestinal problems related to anti-inflammatory medications), after at least 3 months;

(2) 	Documented symptomatic severe osteoarthritis of the knee, which may include the following: Bony enlargement; Bony tenderness; Crepitus (noisy, grating sound) on active motion; Less than 30 minutes of morning stiffness; No palpable warmth; Over 50 years of age.

(3) 	Pain interferes with functional activities (e.g., ambulation, prolonged standing) and cannot be attributed to other forms of joint disease;

(4) 	Failure to adequately respond to aspiration and injection of intra-articular corticosteroids;

(5) 	Are not currently candidates for total knee replacement or who have failed previous knee surgery for their arthritis, unless younger patients wanting to delay total knee replacement. 

Orthovisc (J7324- Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose) is considered medically necessary for this patient.

Based on the above, the medical necessity for Orthovisc (J7324- Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose) is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Asthma
Inpatient Hospital

The patient is a male child with medical history significant for preterm delivery, high-functioning autism, seasonal allergies, albuterol use but no personal or family history of asthma, and obesity who presented to the emergency department (ED) with four-day history of watery itchy eyes treated with Claritin, two-day history of worsening dry cough, one-day history of fever to 101, and one-day history of difficulty breathing with brief shoulder pain. Vital signs included temperature 101, heart rate 119, and respiratory rate 19 with 95% saturation in room air. Physical examination was significant for non-toxic appearance, age-appropriate behavior, moist oral mucosa, no nasal discharge, no eye discharge, poor air entry bilaterally with expiratory wheezing, no retractions, benign abdomen, and non-focal neurologic exam. Laboratory evaluation revealed leukocytosis (white blood cell (WBC) 12.3K with 75% neutrophils), hyperglycemia (glucose 144), normal venous pH and pCO2, and elevated lactate (2.4). Electrocardiogram was obtained because of shoulder pain revealng sinus tachycardia with QTc 484 ms. Chest x-ray obtained revealed pneumomediastinum and a small right pneumothorax, with no focal consolidation or effusion. He was treated with three CombiVents, Solumedrol, magnesium, and a normal saline bolus. He received three continuous albuterol treatments. His presumed pneumonia was treated with ceftriaxone and azithromycin.

The health plan's determination is overturned. This male patient with remote history of respiratory infections and some albuterol use for reactive airway-like disease presented to the ED with signs and symptoms consistent with asthma exacerbation with associated respiratory infection. Chest x-ray revealed air leak (pneumothorax, pneumomediastinum) and possible pneumonia. He remained in the ED for over eight hours receiving both intermittent combination treatments and continuous albuterol in addition to parenteral corticosteroids, broad-spectrum antibiotics, magnesium, and IV fluids. Because of persistent symptoms despite this aggressive approach, he was admitted to the PICU for hourly breathing treatments in conjunction with parenteral corticosteroids. He was placed on supplemental oxygen to wash out the intrapleural and intramediastinal air. Pulmonary was consulted for recommendations for new-onset and acute onset status asthmaticus. He was able to slowly wean from frequent therapies to a course that was appropriate for discharge, and was sent home. By the time he was admitted to the PICU he had been in the ED under observation for over eight hours. Despite the ED interventions, he remained sufficiently symptomatic as to require admission to the PICU. He could not have been managed at a lower level of care. He required acute inpatient admission and management, consistent with current standards of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep impinging overbite
Treatment: Braces

Summary:
The braces and monthly visits are medically necessary. The patient has a deep impinging overbite with soft tissue damage to the palatal tissues. This is an "automatic qualifying" condition according to the handicapping index scale. The orthodontic treatment is medically necessary to correct this problem. The monthly visits are also medically needed to monitor the treatment and do necessary treatment adjustments with wires and brackets.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Diabetes, osteomyelitis, non-healing diabetic foot ulcer
 
Treatment:  Hyperbaric oxygen therapy

The insurer denied the hyperbaric oxygen therapy.  The denial was reversed.

The patient is a female with a past medical history of diabetes mellitus and asthma, who presented to the Emergency Department with complaints of left toe pain and swelling following an injury.  The patient was treated with intravenous antibiotics, surgical debridement, and wound care for treatment of septic arthritis and osteomyelitis of the middle and distal phalanx of left second toe.  At issue is the medical necessity of hyperbaric oxygen therapy full body chamber for treatment of non-healing diabetic foot ulcer.  Hyperbaric oxygen therapy (HBOT) has been used to treat several medical conditions and currently has Food and Drug Administration (FDA) approved indications for certain types of infections including gangrene, skin/bone infections and non-healing wounds such as diabetic foot ulcer. 
Medicare covers HBOT for diabetic wounds of the lower extremities, if the following apply:  Type 1 or Type 2 diabetes have a lower extremity wound that is due to diabetes; wound classified as Wagner grade III or higher; failed an adequate course of standard wound therapy.
According to medical records, the patient has Wagner grade III since underlying osteomyelitis has been confirmed on MRI.  Although one can argue that the injury ("hot oil spilled on foot") initially caused this infection, subsequent complications, including non-healing ulcer and osteomyelitis, were clearly exacerbated by the patient's underlying diabetes mellitus.  Based on these findings, the patient fulfills the above three criteria for hyperbaric oxygen therapy coverage. 

The carrier's denial of Hyperbaric Oxygen therapy full body chamber is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
 
Treatment: Inpatient Substance Abuse Services

The insurer denied the Inpatient Substance Abuse Services.  The denial was reversed. 

This is a male patient who presented to a detoxification facility for inpatient alcohol and substance detoxification treatment. He had a history of drinking 1-2 pints of alcohol a day, intravenous heroin 3-6 times per week, and smoking hundreds of dollars worth of crack daily. He had a positive toxicology screening for cocaine, benzodiazepines, and THC. It was reported that he had past inpatient detoxification and rehabilitation treatments, and that his longest sobriety had been 8 months. His withdrawal symptoms include body aches, headache, strong urges and cravings, and lethargy. For the first several days of treatment his CIWA score ranged from 12 down to 11. He was put on a Librium protocol and left against medical advice (AMA) several days after his admission. 
According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use multiple serious substances daily. He had past inpatient substance detoxification and rehabilitation treatments, and he also required and needed detoxification medication, including Librium, to modify withdrawal. Furthermore, he needed 24 hour treatment at the time because he was at risk for worsened withdrawal symptoms including severe, complicated, and life threatening withdrawal. He was at high risk for overdose and reportedly had a near overdose 2 weeks prior to admission, so at the time he required this 24 hour inpatient detoxification setting. 

The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use, so he required the entire time including the first 4 days in this inpatient detoxification setting, even as he was discharged on the 5th day. Also, he likely would have relapsed again as evidenced by relapsing after past treatments. So it was not likely that he could safely and effectively be treated for detoxification in an outpatient setting. It was unlikely that he would remain abstinent while having withdrawal symptoms, which he still had. He continued to use alcohol and substances despite negative consequences including losing jobs and relationships and past legal problems. He also had medical issues. 

Based on the above, the medical necessity for the inpatient substance abuse services is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Primary Diagnosis:  Joint Problem/Pain
Primary Treatment:  Inpatient Hospital

The patient is a male with a history of partial anomalous pulmonary venous return.  He presented to the emergency department (ED) with right leg pain and limping that began that morning.  He had been ill with nausea, poor appetite and fever throughout the week prior.  The day before presentation, he was active and running around outside. The patient was admitted to the hospital. 

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  The patient had a straightforward clinical picture consistent with transient synovitis, a post-viral inflammatory process which is common at this patient's age and typically responds quickly to ibuprofen.  The patient was given Toradol and/or ibuprofen and symptoms resolved completely without further intervention.  Elevated ESR and CRP would be expected with transient synovitis.  The normal WBC, nontoxic appearance, and benign musculoskeletal examination are not consistent with septic arthritis, which would be the other potential concern.  The patient could have been observed in the ED for response to ibuprofen over 1 to 2 hours, and subsequently discharged home with pediatric follow up in 1 to 2 days.  No imaging studies were warranted for this diagnosis, and the inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis

Treatment: Inpatient hospital admission

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

This patient is a female who presented to the Emergency Department for chief complaint of abdominal pain and vomiting that began early one morning.  The patient reported the pain was initially dull and rated as mild.  The pain increased gradually throughout the night and the patient complained of vomiting that was non-bloody and non-bilious.  The pain was intermittent and radiating and the patient reported feeling weak. The patient denied any changes in her diet and was not concerned about having eaten spoiled food and had no past medical or surgical history.  Physical examination findings revealed that the abdomen was diffusely tender to palpation, the patient was guarding.  The abdomen was soft and non-distended with no rigidity, no rebound tenderness.  The physician did note positive right lower quadrant tenderness to palpation.  There was an abnormal white blood cell count documented at 16.77, bp of 102/61, pulse of 84, respiratory rate of 16, and a temperature of 97.7 F.  There was a CT of the abdomen and pelvis with an impression of the appendix is identified, the findings are equivocal for appendicitis.  The treatment plan included consulting surgery for diagnosis of appendicitis.

The Milliman Care Guidelines state that a goal length of stay for acute appendicitis is ambulatory or a 1-day postoperative stay.  After surgery the patient was transferred to PACU and then to the surgical floor and was discharged early the next morning after she was able to tolerate a diet.  The patient was not a high risk patient and had an uncomplicated procedure and recovery.  Such as, the guidelines recommend a goal length of stay for acute appendicitis as ambulatory to a 1-day postoperative stay, the inpatient hospital admission was not medically necessary. 

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 hospital admission is upheld.  The inpatient level of care is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholangiocarcinoma
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The Society of Interventional Radiology Standards of Practice Committee Quality Improvement Guidelines for percutaneous transcatheter embolization states that for minor complications requiring nominal therapy, an overnight hospital admission may be considered. However, this patient underwent an uneventful portal vein embolization with no periprocedural complications and had an unremarkable postprocedural stay with right upper quadrant pain and a headache that was treated with IV acetaminophen. There were no "red flags" to warrant an overnight hospital admission. The inpatient admission from was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Light headedness, chest pain, dizziness
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient presented with chief complaint of light headedness. He also endorsed left sided chest pain and dizziness. He had co-morbidities of HTN (hypertension), DM (diabetes mellitus), hyperlipidemia and prostate cancer. 

The letter of appeal stressed that the management of this patient could not be done in an outpatient setting and that complex inpatient treatment was necessary. However, there is no evidence to support that any test ordered or treatment given were inappropriate as an outpatient. 

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. 

In this case, the patient's symptoms were atypical and unlikely to be representative of acute coronary syndrome (ACS). His exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. CXR was normal. Echocardiogram showed no wall motion abnormality.  Nuclear scan was negative for CAD (coronary artery disease). The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for ACS, such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG (nitroglycerin).   

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no "complex" care that required inpatient level of care in this patient. This patient had no evidence of CAD. In fact, all tests showed absence of ischemia.  While there was always a potential for an adverse event, one did not happen, and no actual treatment was added.

Milliman criteria requirements for inpatient admission were not fulfilled, as there was never any evidence of ACS present, nor any findings that would support medical necessity for inpatient level of care. All testing and therapy that were provided would have been appropriate, safe and guidelines-consistent in a lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.