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


Diagnosis: Chest pain
Treatment: Inpatient Hospital Admission

Summary: This patient presented to the hospital due to complaints of chest pain. She was sent to the emergency department (ED) via emergency medical services, from her Primary Medical Doctors office because of an abnormal electrocardiogram (EKG) in addition to the chest pain. She has a history of chest pain intermittent for the past year. In the ED she reported she was not experiencing chest pain but the previous evening had chest pain that lasted approximately 10 minutes and resolved on its own. On examination it was noted the patient is in no apparent distress and was not complaining of chest pain. She had one episode of chest pain after admission which lasted 2-3 minutes. But she had not had any further episodes of chest pain since the previous day. The patient was admitted to triage with a history of chest pain radiating to both arms which started the previous night.
 
The insurer denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.
 
This patient was admitted to the ED with a complaint of chest pain which had occurred intermittently over the past several months. At times it was described as occurring with exertion and relieved by rest. There was no history of palpitations, dizziness or syncope. Recurrent chest pain was not described when she was at the hospital. Troponins X3 were within normal limits, her EKG showed normal sinus rhythm, left ventricular hypertrophy and non-specific repolarization changes. Her echocardiogram showed apical hypertrophy of the left ventricle. Her physicians decided that she needed a cardiac catheterization, which apparently was not available at the initial hospital. The inpatient hospital stay was not medically necessary. The literature recognizes the use of an observation unit for this type of patient. However, a monitored level of care or telemetry unit is not the same thing and the literature that this reviewer has cited shows that a monitored level of care for this patient was not necessary or appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System (Pulmonary Hypertension and Chitayat Syndrome), Cardiac/Circulatory Problems (Supraventricular Tachycardia), Digestive System/Gastrointestinal (Gastroesophageal Reflux Disease), Orthopedic/Musculoskeletal (Abnormalities of extremities)
Treatment: Inpatient Rehabilitation

Summary: This patient was admitted to the hospital for acute rehab. He has a history of pulmonary hypertension due to meconium aspiration syndrome, supraventricular tachycardia (SVT), and gastroesophageal reflux disease (GERD). He additionally has abnormalities of his extremities. He receives nasogastric tube (NGT) feeds and anti-acids. He and his mother have participated in the infant toddler intensive rehabilitation therapy program.

The insurer has denied coverage for the continued acute rehabilitation admission as not medically necessary. The denial was reversed.

This is a fragile infant with a complicated past medical history and was later identified to have Chitayat syndrome, a condition marked by respiratory compromise, bilateral accessory phalanx resulting in shortened index fingers, hallux valgus and characteristic facial features including prominent eyes, hypertelorism, depressed nasal bridge, full lips and upturned nose. This child has several skilled nursing needs, including maintaining aspiration precautions and monitoring the child's cardiorespiratory status given his complicated history. This child, after being weaned off of propranolol, developed SVT once again requiring attention and restart of this medication.  His feeding will require titration, as they currently are administered over one hour. The hospital has made significant efforts to educate the patient's family. However, it is quite clear that this child, who as of the start of the period in question was to have been discharged, this would have been on oxygen therapy/requiring a monitor, at least 7 medications, and tube feeds administered throughout the day. All of this certainly would require skilled nursing. This infant has many risks, including pulmonary aspiration. The consequences of injuries may include bronchospasm, atelectasis, pulmonary edema, pneumonia, and/or bronchiectasis. In addition, reflux as an exacerbant (or even the cause) of interstitial lung disease and pulmonary hypertension has been reported. This is an important consideration in this child and speaks to the ongoing skilled nursing needs. Hospitalized children with complex chronic conditions, which includes technology dependence, who were discharged to home health care experienced fewer short-term readmissions, subsequent hospitalizationsover a 12-month period versus those not receiving home health care. This point speaks to the insurer's position that this infant has no skilled needs. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung mass
Treatment: Inpatient Hospital Services

Summary: This patient initially presented to her primary care physician with cough and hemoptysis. She was found to have a lung mass and was instructed to present to the emergency department (ED) for further evaluation.  She presented to the ED where she was clinically stable with no signs of bleeding. The patient was admitted to the inpatient service for further evaluation.  She underwent a flexible bronchoscopy with biopsy and endobronchial ultrasound with biopsy.  This ultimately was diagnostic of non-small cell lung cancer.  She did not have any adverse events and was discharged home.
 
The insurer has denied coverage for the inpatient hospital admission. The denial was upheld. 

According to current literature, bronchoscopy (diagnostic and interventional) is typically an ambulatory procedure indicated for patients with abnormal results on chest imaging or hemoptysis or with a mass seen on plain chest x-ray or computed tomography (CT) scan. While documentation of hemoptysis and a mass visualized on CT scan does support the need for bronchoscopy, there is no documentation to support inpatient admission for two days. Indeed, she was discharged home following the procedure without adverse event.  The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Wound infection
Treatment: Inpatient admission

The proposed treatment -- admission at an acute inpatient level of care -- was not medically necessary. 

First, the patient's wound was "chronically draining" since surgery. Therefore, without an acute change in her clinical status, there was no medical necessity to admit the patient at an acute inpatient level of care. 

Second, according to the Infectious Diseases Society of America, in the setting of an open wound, treatment is warranted if a patient has "temp >38 degrees Celsius, white blood cell count >12,000, erythema >5 cm from incision with induration or any necrosis". This patient met none of these criteria; and according to the Infectious Diseases Society of America, she only required: "dressing changes", which could have been provided at a lower level of care. 

Based on the patient's history and physical, and according to guidelines from the Infectious Diseases Society of America, the patient did not require acute intervention -- intervention necessitating admission at an acute inpatient level of care. She needed "dressing changes", which could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right-sided groin and hip pain
Issue under review: Right pelvic floor repair

Determination:
The right pelvic floor repair was medically necessary.

The patient presented with classic signs and symptoms of a sports hernia. He had failed medical therapy. He had diagnostic imaging that demonstrated a problem, and this was surgically corrected. 

The health plan considers surgical treatment for athletic pubalgia as unproven. However, the effectiveness of this approach has been established. Surgical repair is the only viable option after conservative therapy has failed, as in this particular case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle cell disease
Treatment: Inpatient stay 
The proposed treatment of inpatient stay is deemed medically necessary.
This male patient with a history of sickle cell disease presented to the ER for further evaluation/management of sickle cell crisis with associated chest, back, knee and hip pain.  He rated his pain as severe 10/10.  He received Dilaudid IM every three hours for pain control and aggressive oral fluid hydration due to poor venous access.  His pain levels gradually improved and he was subsequently discharged in stable condition. 
Per Acute Adult InterQual 2018 inpatient criteria, this patient meets criteria for inpatient hospitalization based on having evidence of a vaso-occlusive crisis resulting in acute pain which failed outpatient analgesics and requiring inpatient analgesics three or more times over 24 hours.  For these reasons, the proposed treatment of inpatient stay is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal (Knee pain)
Treatment: Pharmacy/ Prescription Drugs (Hyaluronan injection)

Summary: This patient has a history of left knee pain. The duration was 2.5 months, occurring with exercise. Consultation was completed with an Orthopedic Surgeon. An x-ray was reported to show mild medial joint space narrowing. The patient was treated with Meloxicam. A magnetic resonance imaging (MRI) scan demonstrated a full thickness chondral defect. Euflexxa injections were initiated in 2017.

The insurer has denied coverage for the Hyaluronan injection as not medically necessary. The denial was upheld.

The scientific literature had recommended viscosupplementation for the treatment of osteoarthritis if all other courses failed prior to surgery. The recommendations for use of Viscosupplementation have changed. A review of the Clinical Practice Guideline by the American Academy of Orthopaedic Surgeons (AAOS) cites: The 2013 osteoarthritis (OA) knee treatment clinical practice guideline (CPG) contains one significant recommendation change from the 2008 CPG, and this is with regard to the issue of viscosupplementation. The 2008 OA knee CPG included an "inconclusive" recommendation regarding the use of intra-articular hyaluronic acid (HA) injections that was largely the motivating factor for the expedited update of the CPG. The second edition CPG recommendation reads "We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA of the knee," with a "strong" rating, based on supporting evidence from three high-quality and 11 moderate-quality research studies that met the inclusion criteria. The work group understands the potential impact that this recommendation could have on clinical practice. Nonetheless, the CPG's best evidence synthesis does not support the efficacy of viscosupplementation. Although statistically significant outcomes were seen in some studies with higher molecular weight HA preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement (MCII). (For more information on MCII, see "The Importance of Clinical Significance in AAOS CPGs," AAOS Now, May 2013.) The Orthopedic group reports "strongly do not recommend use." The denial would thus be appropriate and consistent with current practice. Based on the above, the medical necessity for the Hyaluronan Injection is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

The patient, presented to the dental provider's office for evaluation and treatment of tooth #4,18,19,20,21, and 22. Radiographic images show that #18 and 19 have extensive decay involving the cusps. The patient is missing tooth #21 while teeth #20 and 22 have no evidence of decay. . The health plan's determination of medical necessity is overturned in part. The requested health service/treatment of porcelain fused to base metal crown (2751) for teeth #18 and 19 is medically necessary. For sites #20 and 22, there is no evidence of decay, there is only a missing tooth. As such, the treatment of a fixed partial denture is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Non-accidental trauma
 
Treatment: Inpatient admission, diagnostic testing, monitoring

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

This child was brought by Emergency Medical Services (EMS) to the ER for evaluation. This child was reportedly punched on the left side of the face by an adult male. There was no loss of consciousness; the child cried immediately; no bleeding after being struck in the left parieto-temporal region. About two hours after the incident the patient had a small amount of non-bilious vomiting. The patient's vital signs and exam were all normal in the ED. No hematomas or active bleeding, except for a small scratch to left side of scalp. The case was reported to ACS (Child Protective Services). The patient was admitted for further work-up for Non-Accidental-Trauma (NAT) per the recommendation of the Pediatric Child Abuse Team: it was the recommendation by the Child abuse team to admit for skeletal survey, dilated eye exam and brain MRI. MRI of the brain, skeletal survey and ophthalmology work-up were within normal limits. The patient was discharged home with ACS follow-up. 

The MCG clearly states that inpatient admission is warranted for suspected abuse or neglect without other community options for management. Based on the MCG Health criteria for Pediatric admission and the mitigating circumstances in the encounter, the in-patient admission was medically necessary. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

This patient presented with syncope that occurred after standing up.  The patient had multiple episodes of syncope in a short period of time and presented to the hospital for evaluation and treatment. Upon arrival, the patient was in atrial fibrillation with a rapid ventricular rate.  Evaluation in the ED revealed no evidence of intracranial pathology on CT head.  AF spontaneously reverted to normal sinus rhythm, and echocardiographic study revealed a structurally normal heart.  Serum blood testing was significant only for marijuana use.  The patient was discharged the following day. 

This patient presented with neural reflex syncope, a benign process.  According to the European Society of Cardiology, this patient was a low risk patient for future morbidity and mortality (Reference 1). In a study of individuals presenting to the emergency room, patients that were low risk or intermediate risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing (Reference 2).  In this case, the patient falls into a low risk category, and he could have been managed a lower level of care. It would have been appropriate to manage the patient at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to emergency department (ED) with abdominal pain, and was found to have normal vital signs and a white blood cell count (WBC), but an ultrasound (US) suggested acute appendicitis. The patient was admitted for intravenous (IV) antibiotics and fluids. The patient underwent a laparoscopic appendectomy. The health plan's determination is upheld. The patient was stable on admission and during recovery. There was no evidence of abdominal sepsis from the acute non-perforated appendicitis. The procedure was straightforward, uncomplicated, and well-tolerated. The patient's recovery was uneventful.
Appeal type: Medical necessity
Decision: Overturned

This patient presented to the hospital with fever and diarrhea. The fever was initially reported at 38.6C but later recorded as 39.2 rectally.  Heart rate 199, respirations 45, white blood count was 15.63, and urinalysis was negative. The patient was admitted due to suspected sepsis. Lumbar puncture was performed and was reassuring. The patients management was completely appropriate and in accordance with all current guidelines for management of a febrile infant.  Babies less than eight weeks of age are considered to be at risk for a serious bacterial infection, and most centers would perform a complete sepsis work-up for this age group that includes blood, urine, and cerebrospinal fluid cultures, especially if they meet High Risk criteria for serious bacterial infection, even if not ill-appearing.  If the patient is High Risk, he/she must undergo a lumbar puncture, be admitted, and be treated with antibiotics pending culture results. While awaiting results of these cultures and observing the patient in the hospital, monitoring for any signs of clinical deterioration, the patient is administered intravenous antibiotics. This is standard management even if the patient has no abnormal finding on physical examination and looks good".  Patients at this age may not manifest any focal signs or hemodynamic instability, but still can have a serious bacterial infection, such as late onset group B strep or Escherichia coli.
The insurer denied coverage for the inpatient hospital services. The denial was reversed. 
The patient was High Risk because she had a white blood count greater than 15,000/microL, increased band count of 11%, and presence of diarrhea (which ultimately turned out to be Yersinia infection, which has the potential to be in the bloodstream as well). Moreover, vital signs were abnormal; out of proportion to the fever (heart rate 199 and respirations 45).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-Ischemic Cardiomyopathy
Treatment: Wearable Cardioverter Defibrillator (LifeVest)

Summary: This patient with a past medical history notable for non-ischemic cardiomyopathy, hyperlipidemia, chronic obstructive pulmonary disease (COPD), and tobacco use disorder underwent aortic valve replacement in 2018 and underwent echocardiography. This revealed a left ventricular ejection fraction of 29%. His postoperative course was marked by hypotension, shock liver, and acute renal insufficiency.  He recovered and was set up for an outpatient wearable cardioverter/defibrillator (LifeVest). 
 
The insurer has denied coverage for the wearable cardioverter defibrillator as not medically necessary. The denial was upheld.

The LifeVest is Food and Drug Administration (FDA) approved for prevention of sudden cardiac death; however, the use of LifeVest for the dates under review is not medically necessary. Despite the patient's high-risk status for sudden cardiac death and ventricular arrhythmia's, LifeVest technology has not been shown to be beneficial compared with standard-of-care medical therapy for newly diagnosed cardiomyopathy. There was no aborted sudden cardiac death or sustained ventricular arrhythmia's noted in the clinical history to justify an immediate permanent implantable cardioverter defibrillator (ICD). There was no contraindication to implantable ICD technology, other than the required 90 day waiting period after diagnosis with cardiomyopathy. Therefore, a LifeVest for the dates under review is not medically necessary. The patient's clinical presentation and the absence of extenuating circumstances do not support the medical necessity for use of a LifeVest.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis
 
Treatment: Inpatient admission and surgical intervention

The insurer denied the coverage. The denial was upheld.

This is a female patient who presented to the emergency department late 2018 with complaints of abdominal pain as well as nausea/vomiting/diarrhea.  The patient also has a history of irritable bowel syndrome as well as PCOS.  She complained of abdominal pain, nausea, and vomiting that began the day prior.  She also complained of right lower quadrant and right flank pain specifically.  The physical exam did not reveal any significant abnormalities.  She was recommended to undergo multiple laboratory and diagnostic studies.  The CT scan did reveal acute appendicitis.  It was recommended the patient receive IV medications to include antibiotics and be admitted for surgical intervention. She underwent surgical intervention during the admission without complication.  
 The insurer stated that the inpatient admission was not medically necessary because the patient underwent an uncomplicated ambulatory laparoscopic appendectomy.  
 According to current literature a patient may be admitted to inpatient services when there is evidence of complicated appendicitis as such as the discovery or development of peritonitis.  Furthermore, if there was a wound infection, dehiscence or fistula a patient may be admitted.  Additionally, if there is evidence of post-operative bleeding that may require reoperation or a continued ileus the patient may be appropriate for admission.  Otherwise, an uncomplicated laparoscopic appendectomy without evidence of peritonitis is typically an ambulatory procedure.  Therefore, while it was noted the patient did have a uvular hematoma, there is no documentation to support the need for inpatient services.  The patient could have undergone surgical intervention and been monitored for a brief time post-operatively at a lower level, such as the ambulatory surgery setting which allows for overnight monitoring if needed.  The insurer's denial is upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has GERD for which LINX has been requested and denied as experimental/investigational. At issue is whether the LINX procedure is likely to be more beneficial than any standard treatments for the patient. The health plan's determination is overturned. The evidence demonstrates that the device is more beneficial than the alternative surgical option of fundoplication.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has GERD for which LINX has been requested and denied as experimental/investigational. At issue is whether the LINX procedure is likely to be more beneficial than any standard treatments for the patient. The health plan's determination is upheld. While this patient has proven pathologic esophageal acid exposure, preserved esophageal motility and no precluding hiatal hernia, the records do not include a recent history and physical exam or consultation report that documents prior treatment efforts, prior surgical history, past medical history, and current body mass index. In the absence of such clinical detail, its benefits for this patient over standard treatments cannot be assessed.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has GERD for which LINX has been requested and denied as experimental/investigational. At issue is whether the LINX procedure is likely to be more beneficial than any standard treatments for the patient. The health plan's determination is upheld. Although the LINX is a standard treatment for GERD, there is insufficient information provided to determine if the patient is an appropriate candidate.