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

Chest Pain
Inpatient Hospital

The patient is a man without past medical history who presented to the emergency department (ED) with a chief complaint of intermittent chest pain associated with shortness of breath. One episode was relieved by drinking water. Physical examination was unremarkable except for blood pressure of 160/100 mm Hg. An electrocardiogram (ECG) showed no ischemia. Chest x-ray was unremarkable. The patient was admitted with the suspicion of acute coronary syndrome. Myocardial infarction (MI) was ruled out. Echocardiogram was essentially unremarkable. Nuclear stress test was normal. The patient was found to be hypertensive and started on an antihypertensive. He was discharged in stable condition.

The inpatient stay is under review.  The health plan's determination is upheld. The inpatient admission was not medically necessary. All the services performed were indicated, but they could have been performed at a lower level of care. The patient had a low probability that the chest pain represented an acute coronary syndrome. Prolonged observation to rule out an MI was appropriate. The patient was admitted with the suspicion of acute coronary syndrome. Myocardial infarction (MI) was ruled out. Echocardiogram was essentially unremarkable. Nuclear stress test on 5/28 was normal. Management could have been performed at a lower level with the anticipation that an MI could be ruled out by 8-16 hours. Further, the stress test and echocardiogram could have been performed at a lower level. A full hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Missed abortion

Treatment: Inpatient hospital admission

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

This patient is a female diagnosed with a missed abortion.  She was admitted for a dilation and curettage (D&C) procedure.  The plan was to take the patient to the Operating Room and prepare 2 units of packed red blood cells.  The dilation and curettage procedure could not be performed on a date specified due to emergencies.  The patient decided not to wait for the dilation and curettage in the morning, and accepted conservative management with Cytotec.  The patient was discharged in stable condition.  Follow-up care in the clinic was planned.    

This patient presented with a diagnosis of missed abortion.  The provider decided to do a D&C.  A D&C is an outpatient procedure.  D&Cs are done in offices (see ref 1, 2, 3) and surgicenters.  Dilatation and curettage can be performed safely in the office or other outpatient setting using manual vacuum aspiration.  Admission to an acute level of care is not customary or medically necessary.  There was no reason submitted as to why the patient was admitted. There is no history of uncontrolled bleeding or medical conditions warranting admission.  The patient was stable and could have undergone the D&C the day she presented to the Emergency Department (ED) or, after a period of observation in the ED, she could have been sent home to return at a later date for a D&C.

In this case, no procedure was performed; the patient received Cytotec and went home.  In summary, there was no indication for admission.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital admission is not considered medically necessary for this patient.

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

This is a patient who presented with existing crowns and abfraction on teeth #4, 5, 11, 21. Crowns on teeth #4, 5, 11, 21 are being requested at this time.  The health plan's determination is overturned. According to the provided intraoral images, teeth #4, 5, 11, 21 have existing crowns that show abfraction trauma on the buccal gumline. Abfraction is the pathological loss of tooth structure caused by biomechanical loading forces along the gingival margin. It is important to replace crowns with abfraction trauma as the extent of the abfraction under the crown is unknown, which can compromise the integrity of the tooth, preclude plaque control, and increase the risk for caries and periodontal disease. Based on this discussion and the provided documentation, medical necessity for crowns has been established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unsalvageable dentition
 
Treatment: D0367 Computerized Tomography (CT) scan; D6010 implant placement, Tooth #11, Tooth #13, Tooth #4, Tooth # 6; D6052 Attachment abutment, Upper Arch; D6104 Bone graft at time of implant placement, Tooth# 11, Tooth # 13, Tooth #4, Tooth #6; and D6110 Implant supported upper denture, Upper Arch

The insurer denied coverage for D0367 Computerized Tomography (CT) scan; D6010 implant placement, Tooth #11, Tooth #13, Tooth #4, Tooth # 6; D6052 Attachment abutment, Upper Arch; D6104 Bone graft at time of implant placement, Tooth# 11, Tooth # 13, Tooth #4, Tooth #6; and D6110 Implant supported upper denture, Upper Arch. The denial was upheld.

This patient is a female who presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla.  The treating doctor deemed the remaining maxillary dentition hopeless and has recommended extractions of remaining maxillary dentition and subsequent endosteal implants to be placed in the #'s 4, 6, 11 and #13 sites, associated implant related procedures as enumerated above and an implant retained maxillary denture.  

The insurer has denied the aforementioned services stating that in their estimation endosteal implants are not the only appropriate treatment and cite that an alternative appropriate therapy is a removable denture which would restore form, function and esthetics.  Therefore the endosteal implants and related services are considered not medically necessary, considered elective and therefore no benefit is available.

Upon review of the objective documentation it is evident that the remaining maxillary dentition is not salvageable and extraction of remaining dentition is recommended and endosteal implants and associated services suggested.  As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, as in this patient, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include a conventional removable denture as cited by the insurer.  Therefore as removable dentures remain a standard of care in general dental practice, the endosteal implants are considered elective and not medically necessary.  Further, although it is suggested that her underlying medical issue of gastroesophageal reflux disease (GERD) is compromising her function there is no specific objective documentation to support or substantiate this claim, nor is there objective findings that document her inability to wear a removable prosthesis. 

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

The carrier's denial of coverage for D0367 Computerized Tomography (CT) scan; D6010 implant placement, Tooth #11, Tooth #13, Tooth #4, Tooth # 6; D6052 Attachment abutment, Upper Arch; D6104 Bone graft at time of implant placement, Tooth# 11, Tooth # 13, Tooth #4, Tooth #6; and D6110 Implant supported upper denture, Upper Arch is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history significant for hypertension, chronic myelogenous leukemia (CML), vitamin D deficiency, gastroesophageal reflux disease, and chronic pain secondary to right total hip replacement. The health plan approved 17 hours per week. The patient is requesting Additional Personal Care Assistance Services (beyond Personal Care Assistance, Level II, 5 Days/17 Hours per Week).

The health plan's determination is upheld. The Additional Personal Care Assistance Services (beyond Personal Care Assistance, Level II, 5 Days/17 Hours per Week) is not necessary for this patient. The assessment noted that the patient had increased level of functioning with limited assistance with bathing and dressing lower body, limited assistance with toilet transfers. The patient is independent with personal hygiene, dressing upper body, walking, locomotion and toilet use. The patient is independent with toilet transfer, bed mobility and eating.
UAs noted that the patient was independent and needed very limited services with ADLs (activities of daily living). She did need help with IADLs (Instrumental Activities of Daily Living) including meal preparation housework, shopping and managing medications. There is no evidence of dementia or incontinence. There is no evidence of recent falls or decompensation. There are no hospital admissions noted. The services being provided are adequate to meet the patient's needs which mainly consists of housework, meal preparation and managing medications. Additional services are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Appendicitis
Inpatient Hospital
The patient is a male who presented with a 2 day history of (h/o) right lower quadrant (RLQ) pain associated with nausea and vomiting. Ultrasound (U/S) demonstrated an enlarged (1.1 centimeter [cm]) appendix with an appendicolith and surrounding inflammatory changes. He underwent an uncomplicated laparoscopic appendectomy and while there was pus in the abdomen, there was no evidence of perforation. He experienced an uneventful recovery. He was discharged home in good condition.

The health plan's determination is upheld.

No, an inpatient level of care was not necessary for this patient.
An inpatient hospital admission was not necessary. An inpatient stay could be justified if there was some diagnostic dilemma (e.g., complicated appendicitis when computed tomography [CT] had been read as uncomplicated), an untoward perioperative event, intraoperative injury or complication, inadequate physiologic recovery, hemodynamic instability, acute organ injury, persistent altered mental status, fever or other signs of septic complications, surgical site complication, management of complex comorbid medical condition or a finding of an occult or new medical condition.
Surgical treatment of otherwise healthy pediatric patients with acute nonperforated appendicitis is usually provided at a lower level of care status. No evidence presented in the appeal documentation or in the primary medical records that would indicate that an acute inpatient level of care was necessary.
Indeed, in one study authored by Aguayo et.al., in over 500 cases, approximately 28% (number [n]=128) were discharged on the day of surgery. Of the remaining patients, 12.9% (n=59) stayed overnight for medical reasons, 0.4% (n=2) stayed for social reasons, 3.9% (n=18) stayed because the operation ended late in the evening, and 82.8% (n=381) stayed because of clinical care habits. Compared with patients who stayed overnight, there was no statistically significant difference in readmission rates (0.7% versus 1.9%, probability [P]=0.6%), follow-up before scheduled appointment (5.4% versus 5.4%, P=1.0), and complication rate (0.7% versus 2.6%, P=0.3). Patients whose operation ended later in the day had a longer hospital stay. Thus, same day discharge is safe for children undergoing laparoscopic appendectomy for non-perforated appendicitis. Indeed, these data strongly suggest that for most patients with acute, non-perforated appendicitis who undergo an uncomplicated appendectomy, observation in the hospital thereafter is entirely appropriate since their needs are low acuity and the recovery is generally smooth and uneventful. 
Thus, based on the literature and widespread experience with modern treatment of pediatric acute appendicitis, an inpatient acute level of care is not justified. The patient could have been treated at a lower level of care status. If patients have evidence of physiologic compromise that would indicate medical necessity for a higher acuity of care, it should be evident in the records.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right below knee amputation

Treatment: non-emergency air and ground ambulance transportation 

The insurer denied coverage for non-emergency air and ground ambulance transportation. The denial was upheld.

This patient is a male who was admitted with an initial diagnosis of sepsis due to Methicillin Susceptible Staphylococcus Aureus (MSSA).  The patient also has multiple other co-morbidities such as diabetes as well as hypertension.  He was admitted with an acute kidney failure as well as anemia and non-compliance with other medications.  The patient also has neuropathy as well as benign prostatic hyperplasia.  The documentation indicated he initially presented to the emergency department with nausea as well as vomiting and altered mental status.  He was found to be septic with hyperglycemia and essential hypertension.  The documentation detailed the patient has had a previous right below the knee amputation as well.  The documentation detailed that he did undergo the amputation due to an infected right ankle fracture and dislocation.  The patient remained hospitalized and received treatment through early 2019. The documentation indicated that this patient was transferred for short-term rehabilitation from the hospital out of state to a rehabilitation facility in New York so that he can be closer to his family.  It was also noted that during transportation the patient remained alert and oriented.  The patient throughout the flight did not have any adverse events.  

According to referenced literature, guidelines have been published to facilitate determination of necessity of inter-facility air transport. The guidelines include multiple conditions for which air transport is typically used and justified. The list of acute medical conditions includes acute neurological emergencies, acute vascular emergencies, acute surgical emergencies, critically ill patients with impending cardiorespiratory decompensation, critically ill obstetric patients, acute cardiac emergencies, critically ill neonate and pediatric patients with potentially compromised cardiopulmonary status, electrolyte disturbances that require lifesaving intervention, transplantation patients, burn patients requiring a burn center, and life- or limb-threatening traumatic injuries.

There is a lack of documentation to support the patient could not have received treatment at a facility closer to the treating out of state hospital. Therefore, the air ambulance transportation was not medically necessary.

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

Based on the above, the medical necessity for non-emergency air and ground ambulance transportation is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cystitis,vaginal/urethral bleeding
Treatment: Inpatient stay 
The Inpatient admission was medically necessary.

The patient is a female whose inpatient admission is under review. The patient has a history of UTIs (urinary tract infection), pyelonephritis, nephrolithiasis, oophorectomy, splenectomy, bilateral tubal ligation, and C-section. She presented with vaginal/urethral bleeding, dysuria, fever, nausea, and bilateral flank pain. She later endorsed obstructive symptoms (needing to bear down to urinate). Her LMP (last menstrual period) was years ago.

The patient's UA (urinalysis) revealed Large blood, >50 WBC, >50 RBC (red blood cells). Urine culture revealed >100,000 E. coli. CT abdomen without contrast revealed no urinary stones or hydronephrosis. Transabdominal u/s (ultrasound) revealed no left ovary torsion, s/p (status post) right oophorectomy.  The patient was admitted for abdominal pain of uncertain etiology, vaginal bleeding, and possible pyelonephritis. She was started on IV ceftriaxone. She left the hospital AMA (against medical advice) the following day.

The patient does not meet the criteria for simple uncomplicated cystitis that can be treated as an outpatient as given by the Infectious Diseases Society of America (1). First she had evidence of systemic infection (pulse of 117). Also, she had complicating factors, including severe abdominal pain and vaginal bleeding, both of which were new symptoms, the etiology of which was unclear, and which needed urgent inpatient evaluation (especially given fever). Observation (as an outpatient or observation unit) would have been highly inappropriate and against standard of care.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department (ED) on with chest pain of 1-2 hours duration and pain going down both legs. The patient had a history of hypertension and hyperlipidemia. An electrocardiogram (ECG) showed no evidence of ischemia. Physical examination was unremarkable except for tenderness on palpation in the right gluteal sciatic area. Laboratory studies showed an elevated glucose. The patient was admitted. An Echocardiogram was normal. A Spine computed tomography (CT) showed moderate spinal stenosis. An magnetic resonance imaging (MRI) was recommended but due to patient's claustrophobia, and it was decided to perform an "open" MRI as an outpatient. A myocardial infarction (MI) was ruled out by serial biomarkers. The patient was discharged in stable condition. The inpatient stay is under review. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient had chest pain that may have been an acute coronary syndrome. It was not unreasonable observe the patient for several hours to rule out an acute coronary syndrome and perform electrocardiographic monitoring. However, a full inpatient admission was not medically necessary. An echocardiogram could have been performed at a lower level of care. All the services performed were appropriate for this patient's presentation, however, they could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, back pain, flank pain
Treatment: Inpatient admission

Inpatient level of care was not medically necessary.

This patient had atypical pain for two weeks that was treated for musculoskeletal cause. The original trivial elevation of troponin was thought to be muscle or pulmonary emboli. Never was ACS a serious consideration in treatment or testing. NSAIDs and treatment of her elevated lipids were felt to be sufficient. 

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; and highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome. Exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia.  Echocardiogram showed no wall motion abnormality. The physicians' treatment did not reflect any serious concern about the 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).  
 
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 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 coronary artery disease (CAD). In fact, all tests showed absence of ischemia.  While there is always a potential for an adverse event (and in this case a very low probability), 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 patient could not be adequately cared for in a lower level of care is not supported by the actual care provided, guidelines, or community standards. 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.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative colitis, lymphocytic colitis and seronegative inflammatory arthritis
Issue under review: Cimzia

Determination:
The Cimzia is not medically necessary.

This patient with ulcerative colitis and seronegative inflammatory arthritis (possible rheumatoid arthritis) developed a paradoxical plaque and pustular psoriasis following treatment with the TNF (tumor necrosis factor) inhibitor Humira.  Humira was thus discontinued, and this patient ultimately required a course of oral cyclosporine to control her psoriasis.  Progress notes indicate that the patient's ulcerative colitis is in remission, her skin disease is improving, and she has left shoulder pain with normal inflammatory markers.  The requested Cimzia is a TNF inhibitor, just like Humira, and has also been associated with the paradoxical development of psoriasis in both children and adults, as referenced below.  

A 2017 systematic review of published cases of TNF-a inhibitor-induced psoriasis identified 88 articles with 216 cases of new-onset TNF-a inhibitor-induced psoriasis.  Per this review, "the majority of patients received skin-directed therapy, though patients who discontinued TNF therapy had the greatest resolution of symptoms (47.7%) compared with those who switched to a different TNF agent (36.7%) or continued therapy (32.9%)."  Therefore, the use of a different TNF inhibitor (i.e., Cimzia) in this patient who developed psoriasis following the use of the TNF inhibitor Humira may not be the best clinical option.  

The Plan-preferred agent Xeljanz is FDA-approved for the treatment of rheumatoid arthritis, psoriatic arthritis and ulcerative colitis.  As an oral agent with a different mechanism of action, Xeljanz would be a more appropriate choice for this patient.  This patient prefers to avoid oral agents due to fear of GI side effects and worsening of NASH, but was tolerant of treatment with oral cyclosporine, which can also lead to GI distress, hepatotoxicity, and numerous other side effects.  Additionally, the Plan-preferred agent Stelara is FDA-approved for the treatment of psoriasis, psoriatic arthritis and Crohn's disease, and would be a reasonable subcutaneous option for this patient with seronegative inflammatory arthritis, and preferable to an alternate TNF inhibitor such as Cimzia.  Due to concern for paradoxical recurrent flare of psoriasis with Cimzia and more appropriate Plan-preferred options (i.e., Xeljanz, Stelara), the proposed Cimzia is not medically necessary for this specific patient.