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

The patient is a male with metastatic cholangiocarcinoma, status/post (s/p) Whipple procedure, a history of (h/o) left hip fracture requiring surgical intervention who developed drainage from the left hip surgical site, dyspnea, hypotension, and tachycardia while visiting in Florida. He presented to a hospital in Florida with a fever, dyspnea, and hemodynamic instability. Laboratory testing at that time demonstrated an elevated C-reactive protein of 145, abnormal liver function tests, marked leukocytosis (white blood cell count of 36,000), elevated serum lactate level of 4, hyponatremia (serum sodium 127), and anemia. Based on this evaluation, he was diagnosed with septic shock. The following day, he was transported by air ambulance. The issue for review is the medical necessity of inter-facility air and ground ambulance transportation. The health plan's determination is upheld. 

The documents note that the patient requested air ambulance so his regular physicians could manage his care. There is no documentation from the treating physicians in Florida that suggests it was their recommendation for the patient to be transferred because the appropriate care could not be provided at the Florida hospital or a closer location. Given the severity of his illness, it seems more reasonable for the patient to be stabilized in the Florida facility or a closer facility prior to risking air travel. Based on the documents provided, the air ambulance cannot be considered medically necessary. The best practice would have been to stabilize this patient at the initial Florida hospital or a closer facility prior to air travel.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hypertension, bicuspid aortic valve aortic stenosis and ascending thoracic aortic aneurysm
Treatment:  CT angiography of Chest 

The CT angiography of Chest was "medically necessary".

Summary:
The patient is a female with a history of hypertension, bicuspid aortic valve aortic stenosis and ascending thoracic aortic aneurysm.  The patient had a prior CT of the chest in 2015.  Repeat CT scan for the size of the aorta was ordered and performed.  The medical necessity of the CT scan is being reviewed.

The patient has a known diagnosis of ascending aortic aneurysm.  According to the denial letter, the Chest Imaging Guidelines recommend CT imaging once a year for aortic aneurysm 3.5 to 4.5 cm in diameter and every six months for 4.5 cm or larger.  Her last CT imaging was over a year prior to this evaluation; therefore, repeat evaluation of the size of the aorta for assessment of progression of the aneurysmal dilatation is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This patient is under consideration for bariatric surgery. The patient was 71 inches tall and weighed 319 lbs. This corresponds to a body mass index (BMI) of 44.2 kg/m2. The patient has comorbid health conditions of diabetes, hypercholesterolemia, hypertension, and obstructive sleep apnea. The patient has attempted weight loss with dietary efforts transiently losing as much as 50 lbs. Unfortunately, the patient has not been successful with significant sustained weight loss. Because of persistent morbid obesity, the patient was deemed a suitable candidate for bariatric surgery (sleeve gastrectomy).

The health plan's determination is overturned. In this case there is documentation of a body mass index (BMI) of >40 kg/m2 with the comorbid condition of diabetes, hypercholesterolemia, hypertension, and obstructive sleep apnea. The patient has successfully completed a multidisciplinary evaluation with nutritional and mental health evaluations. Sleeve gastrectomy is in accordance with generally accepted standards of medical practice, is clinically appropriate and considered effective for the member's disease, is not cosmetic or experimental, is proven to be more medically effective than any standard nonsurgical care and treatment, and is not for the convenience of the member or physician. The proposed sleeve gastrectomy is medically necessary for this patient and is consistent with the standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Angina
Issue under review:  PET imaging

The PET imaging is medically necessary.

The patient is an adult male with a history of coronary artery disease (CAD), s/p (status post) coronary artery bypass graft (CABG).  He was evaluated for anginal equivalent/dyspnea.  The patient underwent an exercise nuclear stress test (SPECT), which was reported as equivocal for a septal defect.  A PET perfusion imaging stress test was requested due to equivocal SPECT results.

According to the current standard of care, cardiac PET scanning may be considered medically necessary as a technique to assess myocardial perfusion defects when the patient has at least intermediate risk for coronary artery disease AND the following criteria are met:  1)  Indeterminate noninvasive imaging tests (e.g., SPECT scan, myocardial perfusion imaging, stress echocardiogram); OR 2)  Patient may be prone to artifact that could lead to an indeterminate imaging test (e.g., patients who are morbidly obese, i.e., BMI > 40 kg/m2).

In this case, the patient underwent a nuclear SPECT stress test, and the result was reported as equivocal.  Given the risk factors, as well as presentation with chest pain, further evaluation for ischemia is reasonable, to determine the treatment strategy. Therefore, the use of PET scan as an imaging modality in a patient with an equivocal SPECT would be a medically necessary procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis
 
Treatment: Inpatient admission, surgery, monitoring, medication

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

The patient was a female who presented to the Emergency Department (ED). The patient had a past medical history of anxiety, depression, morbid obesity, and a sleeve gastrectomy. The patient had subjective complaints of worsening, intermittent epigastric pain x2 days. The patient had associated symptoms of nausea, vomiting and chills. The pain was rated 9-10/10 scale. The patient's blood pressure was 107/69. The patient underwent an ultrasound which revealed cholelithiasis.  The patient was admitted and treated with intravenous antibiotics. She underwent a laparoscopic cholecystectomy. The findings revealed extensive gastric adhesions which required lysis. The patient tolerated the surgical procedure.  No complications were noted. The patient was treated with pain management post-operatively.  The patient was stabilized and discharged.

The Milliman Care Guidelines indicate that a cholecystectomy is generally performed on an ambulatory basis. An inpatient stay may be appropriate for patients who have a failure to achieve discharge status criteria or those who have active comorbidities. The guidelines also indicate that an exception for ambulatory surgery would include patients in need of an emergent procedure. The records indicated that the patient had a history of anxiety, depression, morbid obesity and a sleeve gastrectomy. The patient was not noted to need an emergent procedure as she did not go from the emergency room straight to the operating room. The records failed to support that the patient could not have been observed instead of being acutely admitted prior to the procedure.

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

The patient suffered a complete spinal cord injury in early 2019 and is classified as AIS (American Spinal Injury Association Impairment Scale) A at the T11 level. The patient has been receiving intensive outpatient therapy since late 2018 in the Locomotor Training Program. The continued Intensive Outpatient Physical Therapy Program is under review.

The health plan's determination is overturned. The intensive outpatient physical therapy program is medically necessary for this patient. Per the documentation submitted, the patient has made slow and steady progress in the program. At the time of admission, the patient was wheelchair bound. Currently, the patient is walking with a rolling walker and is progressing to being able to walk with lofstrand crutches. Per the medical literature, the Locomotor training program has shown promise in training patients with spinal cord injury to walk safely and effectively. Given the myriad medical complications of immobility in spinal cord injury patients, this would benefit the patient in terms of mobility as well as prevention of complications. Therefore, the requested outpatient physical therapy program is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Gynecomastia
 
Treatment:  Mastectomy for gynecomastia and suction-assisted lipectomy.

The insurer denied a mastectomy for gynecomastia and suction-assisted lipectomy.  The denial was modified.

This male has lost weight following bariatric surgery and has pendulous breasts.  He complains of frequent rashes in the folds under his breasts.  According to a letter from his dermatologist, the rashes have persisted for longer than a year despite medically supervised treatment with topical and oral anti-fungal and antibiotic medications.  His surgeon recommends bilateral mastectomies for gynecomastia with liposuction.

The photos show a male with large ptosis breasts and rashes in the inframammary folds.  The medical treatments for his rashes have failed.  The most appropriate next treatment is mastectomy for gynecomastia to remove the excess breast skin and fat that creates the folds under which moisture accumulates, leading to rashes.  There is no other treatment that is likely to cure his chronic rashes.

Liposuction is a cosmetic body contouring procedure that does not confer any health benefit.  The liposuction removes fat to improve appearance and is a cosmetic procedure.  The records do not document any health problems that will be improved with liposuction treatment. 

The carrier's denial of coverage for CPT code 19300-50 Mastectomy for gynecomastia and CPT code 15877-50 Suction-assisted lipectomy- trunk is modified.  Approve CPT code 19300-50 Mastectomy for gynecomastia.  Deny CPT code 15877-50 Suction-assisted lipectomy.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female who presents to the office of her dental provider for evaluation and treatment of teeth #7, 8, 9, 10.  Included with records for review are a narrative from the patient's daughter, full mouth radiographic images, American Dental Association (ADA) claim forms, and health plan language.  In question is the medical necessity of the planned treatment of porcelain fused to metal abutment tooth for fixed partial denture # 6 and 11(6750) and porcelain fused to metal pontic tooth for teeth #7, 8, 9, 10 (6240).
Previous denials have been on the basis that there is insufficient evidence of restorative need for replacement of the current restoration.  Based on the provided documentation there is not decay nor any evidence of failure of the current fixed dental prosthesis (FPD) from 6-11.

The health plan's determination is upheld. 

No, the requested health service/treatment of Bridge replacing teeth number 7, 8, 9, 10 and 11 is not medically necessary for this patient.  There is no evidence from the provided documentation that there is any decay at the margins or any type of failure of the restoration.
The space under the pontic sites is not an indication for replacing the fixed partial denture. The space under the pontic site from the radiographs shows the bone in close proximity to the pontics themselves. All speaking sounds such as F, V, S are determined by the incisal edges of the teeth and not the space under the pontic.  The anterior teeth are involved in cutting food off, and the chewing of the food is done by the posterior teeth.  As the fixed partial denture is not failed and not moving, it does not prevent eating nor chewing and its efficacy for speaking and chewing remains unchanged from the time of fixation.  
There is no restorative need for replacement of the current restoration.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical dilation and bulging membranes
 
Treatment: Inpatient admission

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

The patient is a Gravida 4 Para 0030, who was admitted at 19.6 weeks gestation because of cervical dilation and bulging membranes.  The patient was counselled extensively about her options and decided to proceed with an amniocentesis and rescue cerclage. The day after admission she underwent an amniocentesis to rule out an infection. The following day she underwent a rescue cerclage. The procedure was uncomplicated. The next day the patient was stable and was discharged home.

Cervical cerclages are ambulatory procedures.  This patient was found to have a dilated cervix.  There was no evidence of pre-term labor or ruptured membranes.  The procedure itself was uncomplicated and the post-operative course was uneventful.  Ideally, the patient would have had the cerclage placed on the day of admission and then discharged home that same day.  There is no reason given for keeping the patient in the hospital.  There was no fever, no evidence of infection and no bleeding.  Both the mother and fetus were stable.  Please note that ambulatory procedures include appropriate post-operative monitoring and an overnight stay if required.  So based on all of the above, inpatient admission was not medically necessary.

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

The patient  with a past medical history significant for alcohol abuse, alcohol pancreatitis, seizure disorder related to alcohol withdrawal, hypertension, and anxiety. He presented to the emergency department (ED) with  1 week of epigastric pain with radiation to the back and associated with nausea and vomiting. The patient was admitted to the hospital for alcoholic pancreatitis and alcohol abuse with a history of severe alcohol withdrawal. The health plans determination of medical necessity is overturned in whole . The requested inpatient admission was medically necessary for this patient. This patient met Milliman Care inpatient criteria for pancreatitis given that it  met 2 out of 3 criteria, for abdominal pain and CT scan findings showing pancreatic inflammation. The  lipase was not 3 times normal but given his past history of pancreatitis, he may have an exacerbation of chronic pancreatitis and not be able to mount a significantly elevated lipase level.
Also, the patient was at high risk for going through severe alcohol withdrawal given the  chronic alcohol abuse and history of alcohol withdrawal seizures.
Appeal type: Medical necessity
Decision: Upheld

The patient with a past medical history significant for asthma, Lyme disease, and food allergies who presented to the emergency department with complaints of palpitations.  The patient was admitted to the telemetry floor and underwent a workup, which included a transthoracic echocardiogram, thyroid stimulating hormone (TSH).  The transthoracic echocardiogram was normal.  The health plan's determination of medical necessity is upheld in whole.  The patient's condition significantly improved within a short period of time with a resolution of tachycardia, palpitations, and normalization of QT interval.  Taking into consideration all these circumstances, a short admission at a lower level should have been considered for further evaluation of sinus tachycardia, which was not fully explained at the time of the initial evaluation.
At the same time, there was no evidence that the patient developed any serious medical condition that would require treatment necessitating admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Status post laparoscopic appendectomy 
Treatment: Inpatient hospital stay

Summary:
There is no clinical documentation to support the need for inpatient admission.  The patient remained hemodynamically stable throughout the period of care. There was no fever or documented complication of surgery.  This patient's clinical needs could have been satisfied with an observational level of care.  This level of care would have provided for surgical assessment including overnight observation.  IV antibiotics could have also been provided with this lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the hospital for an elective cardiac catheterization and possible PCI (percutaneous coronary intervention). Prior to admission, the patient was diagnosed with angina. The patient reported worsening chest pain, dyspnea, and dizziness for last few weeks. The patient also was complaining of lower extremity (LE) swelling and orthopnea. 

The health plan's determination is upheld. The patient underwent coronary angiography and coronary intervention on severely (80%) stenosed RCA. The RCA stenosis was due to chronic atherosclerotic lesion. The patient underwent coronary intervention with coronary stent placement. The procedure required only local anesthesia and conscious sedation. The procedure went as planned, without complications. Post procedural period was uneventful. The patient was observed on telemetry according to routine protocol. Based on above, the patient's condition was stable, she was treated for angina and her coronary lesion was chronic. The procedure was not complicated and performed electively. Her condition and her management did not meet inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient admission
The proposed treatment, inpatient level of care, was not medically necessary.
The patient had a second seizure in her life. Having two seizures is indicative of a diagnosis of epilepsy, and starting ongoing antiepileptic management is considered to be within standards of care. The patient was otherwise clinically stable, had normal vital signs, did not have status epilepticus, and did not require any intravenous therapies or electrolyte abnormalities; therefore, the inpatient stay was not necessary. Considering that the decision to start antiepileptic medicine is chiefly based on the number of seizures occurring to the date - a total of two- the inpatient level of care (the admission with video electroencephalogram [EEG] testing) was not medically indicated and was not expected to change the management. The patient could have been managed at the lower level of care; her EEG or video EEG testing could have been performed at a lower level of care. Therefore, the acute inpatient stay was not medically necessary, and therefore the health plan act reasonably.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient hospital admission
The inpatient level of care was not medically necessary.
This patient presented with marked hypertension, risk factors for coronary artery disease (CAD), but there was no evidence to suggest active ischemia. While it is appropriate to rule out presence of ACS, the tests and treatment to accomplish this in this case did not require inpatient level of care. The presence of an increase TIMI score represents the possibility of having ACS, but does not represent the presence of ACS itself. 
In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome. Exam (blood pressure [BP] normalized) 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. The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for ACS such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG). In fact, beta blockers were decreased.
The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring, treatment of her high blood pressure and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of active CAD. All tests showed absence of ischemia.  While there is always a potential for an adverse event, one did not happen and no actual treatment was added.
Milliman criteria requirements were not fulfilled as there was never any evidence of ACS present. The statement that inpatient level of care was necessary for her favorable outcome is not consistent with actual treatment provided. All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest tightness and dyspnea
Treatment: Inpatient hospital admission
The inpatient level of care was not medically necessary.
This patient presented with hypertension, atypical chest pressure for four days, and risk factors for CAD.  There was no evidence to suggest active ischemia.  While it is appropriate to rule out presence of ACS, the tests and treatment to accomplish this in this case did not require inpatient level of care.  The presence of an increased thrombolysis in myocardial infarction (TIMI) score represents the possibility of having ACS, but does not represent the presence of ACS itself.  In this case, the symptoms were atypical, present for four days without changes in enzymes and unlikely to be representative of acute coronary syndrome.  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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain with History of anemia, Charcot's joint of right foot, diabetes mellitus, hypertension, neuropathy and left eye retinal detachment

Treatment: Inpatient admission, blood work, diagnostic testing, fluid restriction and medication administration/adjustment

The insurer denied the inpatient level of care. The denial was upheld.

This patient presented to the emergency room (ER) with complaint of shortness of breath (SOB) for the prior three days, orthopnea, exertional dyspnea and pitting edema. His past medical history was significant for hypertension, insulin dependent diabetes mellitus and congestive heart failure. The History and Physical documented non-labored respirations, clear lungs, oxygen saturations 98% on room air, no jugular venous distension (JVD) and 2+ pitting edema. He received Lasix intravenously (IV) in the ER. An EKG showed normal sinus rhythm. A CXR showed chest congestion. The Pro-BNP was 1773, BUN 31, creatinine 1.61 and negative Troponin levels. On admission, he was noted to be hemodynamically stable. He was admitted with a diagnosis of CHF. Following an initial evaluation and treatment, the patient signed out against medical advice (AMA).

Based on the documentation provided, the patient does not meet the Heart Failure Guidelines for inpatient admission. There was no documentation of hemodynamically instability, severe electrolyte abnormalities, precipitating cause for decompensation, cardiac arrhythmias, acute cardiac ischemia or severe or persistent pulmonary edema. Inpatient admission was medically necessary. The services could have been rendered in the observational setting.