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

Diagnosis: Puffiness; nausea; anxiety
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female with no significant past medical history. She presented to the hospital after having utilized a vaping product. She presented with complaints of lightheadedness, headache, shakiness, facial puffiness, nausea, tremulousness and anxiety.  She denied shortness of breath, syncope, hives/rash, slurred speech, facial droop, and loss of consciousness.

In the emergency room, the patient's vital signs were as follows: Temperature 97.9F, pulse rate 74, blood pressure 128/80, oxygen saturation 99% on room air and respiratory rate 18. On physical examination, the patient was well appearing and well nourished. Neurologic examination was normal. She had normal cardiopulmonary examination.  

The patient's laboratory studies noted sodium 125, potassium 4.1, CO2 (carbon dioxide) 23, BUN (blood urea nitrogen) 8, creatinine 0.60, glucose 79, WBC (white blood count) 13.03, hemoglobin 11.2, hematocrit 32.3, and platelets 240.

Electrocardiogram showed normal sinus rhythm at 64 beats per minute. 

The patient was admitted to the hospital for management of hyponatremia. Her management included Xanax, Benadryl, Pepcid, Zofran and intravenous fluids. Further hospital records indicated that patient's repeat basic metabolic panel (BMP) showed a normal serum sodium of 137 after 1 L normal saline bolus.  She left against medical advice (AMA).  

The care that was rendered could have been performed at a lower level of care(observation level) without adversely affecting the patient's health.

The patient was hemodynamically stable on admission. She was admitted for management of hyponatremia; however, repeat lab work after intravenous normal saline bolus showed normal serum sodium.  There was no evidence to support that her serum sodium level failed to correct with emergency treatment.  There was no evidence of altered mental status, seizures, or any other severe medical conditions that would require inpatient management (sepsis, acute respiratory failure, severe allergy/anaphylaxis, stroke, severe heart failure, acute renal failure). 

The Inpatient admission was not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lumbar Spinal Fractures

Treatment: Inpatient Admission

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

This is a female patient who presented to the hospital with complaints of lower back pain. It was reported that the patient had fallen several days prior to presentation. A computed tomography (CT) scan revealed fractures of the transverse processes at L2 and L3. A magnetic resonance imaging (MRI) of the lower back was done which confirmed the CT scan results; fractures in the transverse processes of L2 and L3. The patient continued to complain of pain rating it 7/10 in severity; analgesics were administered for pain management. Physical therapy and Occupational therapy were consulted.  The patient was medical stabilized and was discharged home with a lumbar brace in place. 

According to Philipp, et al. (2018), "Spinal level of [isolated transverse process fractures] is associated with increased likelihood of specific patterns of injury, and additional investigation is warranted." And though there is no accepted standard of care, Gultekin, et al. (2018) study indicate that the transverse process can be treated quickly and effectively after excluding any accompanying organ injuries or other spinal injuries, and that these fractures can be treated with excessive measures or inadequately treated.

Noting the presence of severe subjective complaints associated with significant abnormalities noted on this patient's imaging, inpatient hospitalization for 24 hours was considered medically necessary for this patient. It would not have been possible to avoid serious consequences without the further testing and observation performed while the patient was hospitalized.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for the acute inpatient admission is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection

Treatment: Inpatient Admission

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

This is a female patient with a past history of gastroesophageal reflux disease (GERD) and status post cholecystectomy. She presented to the Emergency Department (ED) with complaints of right lower quadrant abdominal pain. It was reported that she was sent to the ED after being evaluated at an urgent care facility for suspicion of appendicitis. A physical examination was performed that revealed guarding in the right lower quadrant, no rebound tenderness. Laboratory work up was done that showed white blood cell of 9.56, creatinine of 0.4, and she was negative for pregnancy. A computed tomography (CT) scan of the abdomen was done that revealed minimal right hydronephrosis without obstructing. Urinalysis was done and was positive for red blood cell, white blood cell, and nitrites; urine cultures were obtained and sent. Intravenous (IV) fluids, IV antibiotics, and morphine were administered. It was reported that the patient's symptoms improved. After a period of medically stability the patient was discharged home.  

As per the MCG Health (24th edition) Urinary Tract Infection (UTI), the patient fails to meet clinical indications for admission to inpatient care. The patient was not immunocompromised, or had any hemodynamic instability. The patient was afebrile and did not have altered mental status. The patient denied nausea and vomiting. The patient was not pregnant, and did not have urinary obstruction. There was no indication that the patient required invasive procedure that necessitated inpatient level of care. There was also no indication that the patient's clinical symptoms failed on observation level of care and treatment. Thus, based on this patient's clinical presentation and literature review, this patient's inpatient admission was not medically necessary. 

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

The carried denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Exacerbation

Treatment: Acute Hospital Stay

The insurer denied the acute hospital stay. The denial was upheld.   

This is a female patient with a history of asthma, uterine fibroids, anxiety and depression. She presented to the emergency Department (ED) with complaints of cough, wheezing, congestion and pleuritic chest pain. The patient reported that she ran out of her asthma medication. Bilateral expiratory wheeze was noted on physical exam. A chest x-ray was performed that was noted to be normal. A respiratory virus panel was performed that was positive for rhinovirus/ enterovirus. Laboratory work up was preformed that revealed white blood cell (WBC) count was 14.9K. The patient received nebulized bronchodilators and oral steroids with minimal response. The patient was admitted to the hospital for further treatment. She continued on Duonebs, Mucinex, oral Prednisone, and Doxycycline was added for bronchitis. Her symptoms improved and she was discharged home.

Based on the documentation in the chart, this patient did not need acute inpatient hospitalization.  She was being treated orally.  She was tolerating oral intake.  The patient was in no acute distress.  She was hemodynamically stable.  She was not hypoxic.  There was no evidence of pneumonia, pleural effusion or pneumothorax on chest x-ray.

The patient could have been discharged home on oral steroids and bronchodilators with close follow-up as an outpatient.  The patient was admitted and discharged the next day.  In the hospital, she was treated with oral steroids and bronchodilators.  The patient could have been treated with the same in the outpatient setting without admission to the hospital.  The prior denial is upheld.

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

The carrier's denial of coverage for the acute hospital stay is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Digestive system/gastrointestinal 
Inpatient Hospital 

Diagnosis: Appendicitis 
Treatment: Inpatient hospital 

The insurer denied the inpatient hospital stay. The health plan's determination is upheld.

The patient is a woman who presented to the emergency department (ED) with a history of progressively worsening abdominal pain of 3-weeks duration. Evaluation included physical exam, labs, and a computed tomography (CT) scan. She was without fever at the time of presentation. Vital signs were normal. Lab data identified a white blood cell (WBC) count of 6.0 K. CT scan yielded the diagnosis of acute appendicitis without perforation. 

The inpatient care was not medically necessary in this case. The records indicate that this patient presented to the ED with acute appendicitis and underwent appendectomy. The pre and post-surgical course was uncomplicated. Vital signs remained normal. Diet progression was tolerated following surgery. The records support that this patient could have reasonably and appropriately been treated at a lower level of care. This lower level of care would have permitted pre-surgical assessment, operative treatment, post-surgical monitoring, diet progression, overnight care, and provision of antibiotics.
The records document that this patient was clinically and hemodynamically stable at the time of presentation. Surgery was performed and the perioperative period was uncomplicated. Inpatient stay may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, complications of procedure. In this case none of these conditions existed to warrant an inpatient level of care. 

Inpatient care is indicated when toxicity, active comorbidities or inability to arrange outpatient support. Inpatient admission is also indicated for complicated appendicitis, complications of the procedure, ileus or post-operative bleeding, or other condition that requires inpatient admission. In this case, none of these indications existed to justify an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure.
Treatment: Inpatient admission.
The insurer is denied coverage for inpatient admission.
The denial is reversed.
The patient is a female with a past medical history of anemia and bronchitis. The patient presented to the emergency department (ED) with complaints of being weak and the inability to move her arms and legs. Her blood pressure was 134/93 and her Glasgow Coma Scale was 15. The patient denied pain. A physical exam was performed that revealed her speech was clear; she was able to speak in full sentences. She was negative for a facial droop and her pupils were equal and reactive to light. The patient was not able to elevate her arms or legs and had bilateral weak grasps noted; she had normal sensation in all extremities with no pronator drift. The patient's motor strength was generally decreased. A computed tomography CT of the head was performed with normal results. A chest x-ray was done that revealed no acute cardiopulmonary disease. Neurology was consulted with recommendation for the patient to be admitted to the hospital for further studies; electroencephalogram (EEG), magnetic resonance imaging (MRI) of the brain with the consideration of anticonvulsants. It was reported that the EEG results demonstrated possible partial seizure. The patient was placed on seizure precautions and neurologic checks every 8 hours. The MRI of the brain was performed with normal results. The EEG was normal. The patient was discharged in stable condition.

As noted in Up to Date, "Hospitalization may be required for patients who have a first seizure associated with a prolonged postictal state, incomplete recovery, or serious seizure-related injury." This patient had persistent weakness and inability to move her arms and legs necessitating admission for evaluation. Given these persistent findings suggesting that the seizure could be symptomatic of another condition, admission for evaluation was appropriate.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Headache, numbness in lips and left arm
Issue under review: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the acute inpatient admission was not medically necessary. 

The patient is a female with a history of obesity, hyperlipidemia, hypertension, alcohol use disorder and tobacco use who presented with the complaint of headache, dizziness and numbness of her lips and left arm for five hours. National Institute of Health (NIH) stroke scale score was zero at presentation. Magnetic resonance image (MRI) of the brain was negative for acute infarct. 

The patient had no significant deficit at presentation and MR imaging was negative for acute stroke. Based on the patient's history and clinical presentation, risk stratification guidelines do not support acute inpatient admission. The clinical evaluation, monitoring, diagnostic studies and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Developmental delay
Issue under review: Genetic testing

Determination: 
The health plan denied Genetic testing. The health plan's denial is overturned.

The patient is a teen-aged boy for whom whole exome sequence (WES) genetic testing was denied.

As noted, this patient's history and presentation are strongly suggestive of an underlying genetic condition for which a clinical diagnosis has not been established by previous testing. He has multiple dysmorphic features (widow's peak, metopic depression, long palms, pigmented macules on his back, short stature, and relative macrocephaly), neurological abnormalities (hypotonia, intellectual disability, autism spectrum disorder, verbal apraxia), renal abnormality (hydronephrosis), and psychiatric disorder (obsessive-compulsive disorder and anxiety). In patients similar this, WES has been able to identify a specific genetic etiologic diagnosis in 30-40%. Multiple clinical studies have demonstrated the clinical utility of whole exome sequencing (WES) in identifying genetically-based conditions for which prevention, early identification and/or specific treatments are available that can improve treatment effectiveness (e.g., by identifying pharmacological response to medications), quality of life, and long-term prognosis. Further, many individuals with severe intellectual/developmental disabilities are not able to adequately communicate changes in their health status with caretakers and unrecognized/inadequately treated health conditions, including cardiac and neoplastic diseases, contributing to potentially preventable early death.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Developmental delay
Issue under review: Genetic testing

Determination: 
The health plan denied Genetic testing. The health plan's denial is overturned.

The patient is a teen-aged boy with global developmental delay, autism spectrum disorder, verbal apraxia, obsessive-compulsive disorder, anxiety, short stature with relative macrocephaly, some dysmorphic physical features, failure to thrive, history of hydronephrosis, and hypotonia. His Chromosomal MicroArray was normal, as was his family history. Growth hormone studies were normal. His attending physician (AP) has requested whole exome sequencing to identify an etiology for his multiple medical and developmental problems, refine his prognosis, direct his future medical and developmental cares, and hopefully improve his outcomes.

Evidence-based medicine and published, peer-reviewed, authoritative medical literature render this testing medically and clinically appropriate in this teen-aged boy with growth failure, intellectual disability, and autism spectrum disorder. Whole Exome Sequencing (WES) to identify novel or unusual genetic disorders is now viewed as medically and clinically appropriate. It is consistent with the generally accepted "best practices" in medical genetics. It meets the generally accepted standards of medical genetics practice and is consistent with the views of the major professional medical genetic organizations in the United States. It is clinically appropriate for individuals with unusual combinations of medical problems that are not explained by any known genetic or nongenetic syndrome, neurogenetic disorders, unusual combinations of birth defects and congenital anomalies, unexplained intellectual disability, autism spectrum disorders, dysmorphic features and developmental delays. The available published, peer-reviewed scientific evidence clearly demonstrates the utility and efficacy of Whole Exome Sequencing for identification of specific gene mutations underlying developmental anomalies, anatomic birth defects, unusual clinical syndromes, mental retardation, developmental, and autistic syndromes to be effective in improving health outcomes. It is clinically appropriate in its type, frequency, extent and delivery settings. It is appropriate to the adverse health condition for which is provided and used and is expected to produce the desired outcome of a specific clinical and genetic diagnosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal mass
 
Treatment: Prospective outpatient excision of a benign lesion (11402)

The insurer denied coverage for prospective outpatient excision of a benign lesion (11402). The denial is reversed. 

This patient is a female with a history of diabetes and hypertension. The patient presented to the physician's office for the evaluation of a mass on the left side of the abdomen that started as a pimple four months prior. The patient denied pain or discharge from the site. The patient had no history of trauma. The patient's exam revealed a flank mass measuring 1.5 x 2 cm, which was soft, non-tender without discoloration or discharge. The clinical impression of the mass was lipoma of the left flank; and the plan was to excise it.

Although the clinical diagnosis was lipoma, the patient was concerned and wanted it removed. As noted by Goldstein in the overview of benign lesions of the skin (UpToDate Jan. 2020), individuals may acquire a multitude of benign skin lesions over the course of a lifetime; and many of these lesions are easily visible, and patients often ask clinicians to confirm that new growths on the skin are benign. Though most benign skin lesions are diagnosed on the basis of clinical appearance and history, this article supports that if the diagnosis of a lesion is uncertain or if a lesion has exhibited unexpected changes in appearance or symptoms, a diagnostic procedure (e.g. biopsy, excision) is indicated to confirm the diagnosis. The article states that benign lesions that are symptomatic or cosmetically bothersome can often be managed with simple procedures such as excision.

In addition, Johnson CN, et al. noted in "Lipomatous Soft-tissue Tumors" that lipomatous soft-tissue tumors are the most common neoplasms encountered by physicians. These tumors range from benign lipomas to high-grade liposarcomas. Liposarcomas are malignant and tissue diagnosis is the only way to confirm the diagnosis. Furthermore, Nguyen, et al., noted in "Skin conditions: benign nodular skin lesions" that the benign subcutaneous lesions are a common reason that patients visit family physicians; and that the only definitive management is surgical excision with complete removal of the cyst wall or capsule, using minimal-scar segmental extraction or conventional surgical removal.

Based on the review of the literature and the medical records provided, excision of the abdominal mass is supported. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the prospective outpatient excision of a benign lesion (11402) is substantiated. The insurer's denial is reversed.
Appeal type: Formulary Exception
Decision: Overturned

Cardiac/Circulatory Problems
Pharmacy/Prescription Drugs

Diagnosis: Hyperlipidemia
Treatment: Livalo
The insurer denied Livalo. The health plan's determination is overturned. 

The patient is a male with hypertension, coronary artery disease status post bypass, and hyperlipidemia. The patient has tried Pravastatin, Rosuvastatin, Simvastatin, Lovastatin, Fluvastatin, and Atorvastatin. All of these agents caused dyspepsia. The patient has been treated with Livalo, which he has tolerated.

The provider has documented that the patient was intolerant, due to dyspepsia, to all formulary statins Pravastatin, Rosuvastatin, Simvastatin, Lovastatin, Fluvastatin, and Atorvastatin). In addition, the patient has tolerated therapy with Livalo. In summary, all 6 formulary statins have caused adverse events for this patient.

Livalo is Food and Drug Administration (FDA) approved for hyperlipidemia, which the patient has.  The patient has a goal low density lipoprotein (LDL) less than 50 due to having atherosclerotic cardiovascular disease status post cardiac bypass.  The patient has failed to tolerate all other statins and has tolerated Livalo without side effects. It is indicated for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Worsening chest pain
Issue under review: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld.

The patient is a female with a past medical history significant for HTN (hypertension), dyslipidemia and diabetes mellitus, who presented to the hospital for complaints of chest pain and generalized muscle pains. The patient was hemodynamically stable. Her BP (blood pressure) was elevated. Her physical examination was grossly unremarkable. The ECG revealed normal sinus rhythm with no ischemic changes. Chest X-ray was unremarkable. Troponins were negative. 

The patient was admitted to rule out ACS (acute coronary syndrome). CT of abdomen and pelvis was obtained for complaint of flank pain and was unremarkable. She was seen in consultation by cardiology and her symptoms were found to be atypical. No inpatient ischemic work-up was recommended and the patient was discharged home with a plan for outpatient follow-up with cardiology, possible outpatient stress test.

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. The chest pain was felt to be atypical by treating physicians and no inpatient ischemic testing was planned. There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care.