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

Diagnosis: Lyme disease
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient is a female who initially presented to the emergency department with concerns of a fever, headache, and neck stiffness. Pertinent history included Hashimoto's thyroiditis and questionable Entamoeba histolytica. A computed tomography (CT) scan of the head was unremarkable. A lumbar puncture was performed with clear fluid. Empiric antibiotics and dexamethasone were initiated for concerns of meningitis. The admitting physician documented an impression of questionable aseptic meningitis. A tick panel was sent and ceftriaxone was continued. Neurology consulted and recommended magnetic resonance imaging (MRI) of the cervical (C)-spine and magnetic resonance angiography (MRA) of the neck as well as initiation of gabapentin. Infectious disease consulted, noted erythema migrans on her left hip, and diagnosed her with Lyme disease. There was no mention of meningitis. Recommendations were to initiate doxycycline and discontinue further MRI. The attending physician updated the assessment to acute Lyme infection. At issue is the medical necessity of an inpatient hospital stay.

Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.

The patient presented with concerns for a fever, headache, and neck stiffness. Initial examination documented the patient as alert, oriented, febrile up to 101.8 degrees Fahrenheit (F), and without focal neurologic deficits. Initial evaluation revealed relatively unremarkable laboratory testing and head imaging. A lumbar puncture was performed which ruled out a bacterial process, analysis essentially normal. The treatment plan included empiric antibiotics. Infectious disease consulted, noted erythema migrans, and had an impression of acute Lyme disease. Meningitis was ruled out. Doxycycline was initiated. Following observation care, the patient was afebrile, hemodynamically stable, orientated and tolerating Doxycycline for acute Lyme infection. The hospital course was prolonged for further supportive care for a headache ultimately improved with nonsteroidal anti-inflammatory drugs (NSAIDs). No other issues or complications were documented.

Clinical indications for admission to inpatient care were not met. The patient did not have bacterial meningitis, encephalitis, hemodynamic instability, severe or persistent altered mental status, severe neurologic findings, severe or persistent vomiting, severe or persistent dehydration, severe pain, cerebral bleeding, or increased intracranial pressure.[2]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Injury from Fall.
Treatment:  Inpatient Hospital Stay.

The insurer denied Inpatient Hospital Stay.  The determination is upheld.

The patient is a male who presented to the emergency department (ED) following a fall from a ladder. Comorbid health conditions included no chronic health conditions. He complained of right chest pain and back pain at the time of presentation. There was no loss of consciousness. He was initially evaluated in the ED. At the time of presentation, he was awake and alert with a Glasgow coma score of 15. Imaging with a chest x-ray and computed tomography (CT) scan showed fractures of right ribs 10, 11, and 12 and a nondisplaced fracture of the right lumbar (L)1 and L2 transverse process.
He was admitted to the hospital per the trauma consultation. He was treated with multimodal pain medication and incentive spirometry. Lab data was normal. He was cleared to ambulate. His diet was advanced. 
At issue is the medical necessity of an inpatient stay.
Inpatient hospital admission was not medically necessary in this case. The care and treatment could have been rendered with a lower level of care. This patient presented to the ED following a fall from a ladder in which he sustained right sided rib fractures 10-12 and transverse process fractures of L1 and L2. He was clinically stable at the time of presentation with a normal heart rate, oxygen saturation, and labs. He was able to ambulate and was able to tolerate a diet. He was provided pain medications and was able to participate with physical therapy. He remained clinically stable throughout the period of monitoring. A lower level of care would have provided for the care and treatment necessary for this patient.
Inpatient admission may be indicated in the setting of rib fractures for hemodynamic instability, 3 or more rib fractures, flail chest, acute respiratory failure, pain management, associated injury, infection, hypoxemia, tachypnea, immediate surgery needed or other condition. This patient did have three rib fractures (10-12) and transverse process fractures. However, he was clinically stable with normal vital signs and normal oxygen saturation. Pain management was with a combination of oral medications. He did not require acute surgical intervention. He was stable for discharge within two days of presentation. The care provided in this case could have reasonably and appropriately been rendered with a lower level of care and did not require inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Degenerative Joint Disease, Knee.
Treatment:  Inpatient Admission.

The insurer denied coverage for inpatient admission.  The denial is upheld. 

This patient is an adult female admitted for an elective left total knee replacement. Her past medical history was significant for fibromyalgia, irritable bowel syndrome, and a Body Mass Index (BMI) of 41.66. There was limited blood loss, and no drain was placed. Her post-surgical course was non-complicated. On postoperative day (POD) 1, the physician assistant reported, "patient anticipates DC (discharge) home with outpatient PT (physical therapy) once able, likely later today." 

The medical records note a non-complicated post-surgical course. There was limited blood loss from the procedure. No drain was placed. The vital signs were stable. There were no problems with the wound site, and the patient tolerated oral pain medications. Physical therapy records showed the ability to ambulate with a walker for 36 steps on POD 1. There was no need for subspecialty consultation or special studies. There were no complications or problems to support the ongoing length of stay at the acute level. The patient's BMI was taken into consideration. 

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably and with sound medical judgment and in the patient's best interest. The medical necessity for full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse, Hand Tremors, Fall
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

The patient is a female with polysubstance abuse involving alcohol and cocaine, who was admitted to the hospital for hand tremors secondary to alcohol withdrawal. She also experienced a fall, possibly due to syncope, with an injury to her nose. She presented to the hospital complaining of hand tremors, nausea, headache, tinnitus, and visual hallucinations. She appeared anxious. Her typical alcohol intake is one bottle of vodka per day, and she has had similar withdrawal episodes in the past, as well as an episode of a seizure three months before this presentation. Her nose had some bleeding from the fall, and the patient does not recall the duration of unconsciousness as she was inebriated. On exam, the patient appeared tachycardic and anxious, but oriented. A head computed tomography (CT) scan showed no acute intracranial abnormalities, and a chest x-ray showed mild atelectasis. A twelve-lead electrocardiogram (EKG) showed sinus tachycardia, with prolonged QTc at 472.
On admission, the Clinical Institute Withdrawal Assessment (CIWA) score was 5, and the toxicology screen was negative for alcohol or drugs. The medical team placed the patient on Ativan per the CIWA protocol. She had already received 4 milligrams (mg) of intravenous (IV) Ativan in the emergency department. Multivitamin and folate as well as thiamine, were started. The patient complained of dysuria symptoms and had 20-50 white blood cells on the urinalysis. An empiric dose of ceftriaxone was given.
Psychiatry was consulted for an alcohol detoxification plan. They noted the patient has major depressive disorder and anxiety disorder, treated with Wellbutrin and BuSpar. The patient's CIWA score was 0. Scheduled Ativan was maintained at 2 milligrams (mg) every 8 hours. The patient received an additional three as-needed doses the previous day. As needed, Ativan frequency was decreased to 2 mg every 6 hours. The patient was deemed stable for discharge. She agreed to follow up with rehabilitation for alcohol use and with a family doctor. She completed three days of ceftriaxone in the hospital for a presumed urinary tract infection (UTI), and the final urine culture was negative.
At issue is the medical necessity of an inpatient stay.
The patient presented to the hospital with an elevated CIWA score based on tachycardia, tremors, visual hallucinations, and a history of seizures related to alcohol withdrawal during previous hospital stays. Based on the Milliman criteria for substance-related disorders, this is an indication for inpatient admission. The history of seizures caused by alcohol withdrawal definitively increases the patient's risk for negative outcomes, and prolonged hospitalization with monitoring and aggressive treatment is warranted, which could not be accomplished at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Foreign Body in Esophagus.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient is a female with a medical history of iron-deficiency anemia, frequent urinary tract infection, and persistent proteinuria. She presented to the emergency department with an esophageal foreign body sensation for one hour after swallowing a pill. She had gagging with trying to swallow food or liquid. Her vital signs were unremarkable. The physical examination was unremarkable other than the appearance of mild distress. An x-ray of the neck showed a 1.1 x 0.6 centimeter (cm) ovoid density in the cervical esophagus at the level of cervical (C) 6-C7 compatible with ingested body, and vertebra without spondylolisthesis, fracture, or intervertebral disc height loss. A chest x-ray was unremarkable. She was made nil per os (nothing by mouth). She was treated with glucagon without improvement. A gastroenterology consultation recommended urgent esophagogastroduodenoscopy for foreign body in the esophagus. The esophagogastroduodenoscopy showed a medication in the esophagus 16 cm from the incisors; the stomach and duodenum appeared normal, and the recommendation was to discharge the patient home. She was discharged. At issue is the medical necessity for the inpatient level of care.
The inpatient level of care was not medically necessary in this case. The most recent available American Society for Gastrointestinal Endoscopy (ASGE) guidelines for the management of foreign body recommend emergent endoscopy for sharp-pointed objects in the esophagus and urgent endoscopy for objects located in the stomach or duodenum; in this case, it foreign body was a pill in the esophagus [1]. Surgical intervention was not necessary [2]. The patient had appropriate conservative monitoring did not need serial imaging; she did not develop any instability to warrant intervention [1-5]. The care provided, including monitoring, Gastroenterology consultation, and esophagogastroduodenoscopy with uncomplicated foreign body removal, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Right lower quadrant abdominal pain.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

This is an adult female with hypothyroidism, who presented with right lower quadrant (RLQ) pain. The patient reported vomiting and denied fever, or chills.  The patient reports having 6 drinks per day and 6 days per week. She has no prior history of alcohol withdrawal. Examination revealed the RLQ abdominal tenderness without rebound or guarding. The concern was for appendicitis. The white blood cell (WBC) count was 16,000.  Computed tomography (CT) of the abdomen showed uncomplicated appendicitis. The emergency room (ED) provider noted the surgical plan to take her to the operating room (OR). Antibiotics were started, and she was admitted to surgery. 

The patient underwent an uneventful laparoscopic appendectomy. As per the brief operative note she had acute appendicitis without peritonitis, with a non-perforated appendix found. Pathology showed acute appendicitis. She did well postoperatively and was discharged.

Based on records provided, the patient did not require acute inpatient admission and should have been managed in an observation status. She did not require an acute inpatient admission but rather observation status, as she did not have any complications from the surgery that warranted inpatient care. The laparoscopic appendectomy was uneventful, and there was no perforation. There was no evidence of a complicated post operative course requiring hospitalization, and the patient was discharged within 23 hours (on the same day of surgery). Thus, the patient should have had the appendectomy performed under an observation status without acute inpatient admission. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Neck, back, shoulder pain.
Treatment:  Pain Management Injection(s) - Occipital Nerve (CPT 64405 x 2, CPT 64450 x 2).

The insurer denied Pain Management Injection(s) - Occipital Nerve (CPT 64405 x 2, CPT 64450 x 2).  The health plan's determination is upheld.

This is a male patient with diagnoses that include Headaches, Post-Concussive Syndrome; Cervical Disc Disorder at C (cervical) 5-C6 Level with Radiculopathy.

Pain Management Injection(s) - Occipital Nerve (CPT 64405 x 2, CPT 64450 x 2) are not medically necessary for this patient. The records did not show that the patient has failed 3 months of conservative treatment including rest, physical therapy or massage, medication, changing activity to avoid pain triggers. Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended for treatment of occipital neuralgia and cervicogenic headaches, with or without corticosteroid...There has been little evidence that greater occipital nerve block (GONB) alone provides any sustained relief, since it seems to work best with concomitant therapy. Successful outcomes for GONB have been limited to small, non-controlled case series. Although short-term improvement has been noted in 50-90% of patients, many studies only reported immediate post-injection results. There is no gold-standard methodology for injection delivery, nor has the timing or frequency of delivery been researched."
There is insufficient evidence to support occipital nerve blocks in this case as they are not standard of care in the general community. Additionally, the provider states the patient had 50% (percent) pain reduction from 8/10 to 4/10 ongoing, yet the patient reported her current pain level of 8/10 and there is no indication as to how long the patient had 50% pain relief. There is no documentation showing the patient has exhausted conservative care. Therefore, medical necessity is not established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Braces

The insurer denied braces. The determination is upheld.

The patient is a female with a Class II malocclusion, mild maxillary spacing and mild mandibular spacing, severe overjet, severe overbite, and missing a mandibular left second premolar. The issue under review is whether the requested health service/braces treatment is medically necessary.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 13 with no auto qualifiers. Auto qualifiers include cleft palate deformity or craniofacial anomaly, deep impinging overbite with severe soft tissue damage, impacted permanent anterior where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the handicapping criteria, and treatment would not be deemed medically necessary. Thus, according to the standard of care, the requested health service/treatment for braces is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Left Flank Abdominal Pain.
Treatment:  Inpatient Admission.	

The insurer denied coverage for inpatient admission.  The denial is upheld. 

The patient is an adult male, who presented to the emergency department (ED) complaining of left flank-abdominal pain. Computed tomography (CT) findings included a 9-millimeter (mm) left ureteropelvic junction (UPJ) stone with hydronephrosis. The patient received intravenous fluids. The assessment showed creatinine 1.3, with no fever or leukocytosis. Urology consultation advised stent placement. The patient initially declined this option but changed his mind due to the large stone size. The patient underwent a cystogram of left retrograde stent placement. The patient tolerated the procedure well and without complications; he was stable postoperatively, was ambulatory, voiding, and had good oral intake. He was discharged home with outpatient urology follow-up. Further evaluation for the finding of a question of liposarcoma would be done as an outpatient.

Per Milliman Care Guidelines (MCG) Health 27th edition: Renal colic and kidney stone patients fail to meet guidelines for admission to patient care. Urologic Surgery or procedure: Patients meet the discharge indicators within 24 hours of postop. Per the guidelines, the procedure is performed in the ambulatory surgery setting.

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably and with sound medical judgment and in the patient's best interest. The medical necessity for an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 Braces, D8680 Retainer, D8670 Monthly Visit
The insurer denied: D8080 Braces, D8680 Retainer, D8670 Monthly Visit
The denial is overturned.

The patient is an adult female. The request is for orthodontic benefits with monthly visits and a retainer. She has a Class I skeletal malocclusion with Class II canines. She has moderate upper and mild lower crowding, with a congenitally missing upper left lateral incisor. The health plan denied coverage of the request due to the patient not achieving a score of 26 on the handicapping index scale. The denial is being appealed.

The D8080 Braces, D8680 Retainer, D8670 Monthly Visit are medically necessary.

The patient has a deep, impinging overbite with soft tissue damage on the palate. This is an automatic qualifier according to the handicapping index scale. The monthly visits are needed to make sure the treatment is progressing properly, and the retainer is needed at the end of treatment to prevent relapse. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism.
Treatment: Inpatient Stay.

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

The patient is a male, who presented to the emergency department with concerns about shortness of breath and near syncope. Initial vital signs revealed a temperature of 98.8 degrees Fahrenheit (F), heart rate (HR) of 81, blood pressure (BP) of 112/81, respiratory rate (RR) of 16, and pulse oximetry of 95 percent (%) on room air. Initial examination documented the patient as alert and oriented. Initial laboratory testing revealed a white blood cell count (WBC) 4.7, Hemoglobin (HGB) 12.1, PLT (platelets) 261, D-dimer 445, Glucose 87, blood urea nitrogen (BUN) 15, Cr (creatinine)1.0, carbon dioxide (CO2) 25, and brain (or B-type) natriuretic peptide (BNP) 32. The electrocardiogram (EKG) was relatively unremarkable. A computed tomography angiography (CTA) Chest revealed bilateral pulmonary emboli with bilateral alveolar infiltrates and without right heart dysfunction. The patient was placed in the hospital after that with an impression of an acute pulmonary embolism. 

The inpatient hospital admission was not medically necessary.
The patient had a simplified pulmonary embolism severity index of 0, which would classify as low risk. In this case, the patient had no significant medical history and presented with concerns about the shortness of breath. Initial examination documented the patient as afebrile, alert, oriented, hemodynamically stable, and without hypoxia. Initial evaluation revealed relatively unremarkable laboratory testing, unremarkable electrocardiography, and computed tomography (CT) findings suggestive of bilateral pulmonary emboli without associated right heart dysfunction. Treatment included therapeutic anticoagulation without documented issues or complications. Following observation care, the patient denied symptoms.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Grave's disease
Treatment: CT scan of the neck
The insurer denied the CT scan of the neck.
The determination is upheld.

The patient is a female with a history of hypertension, anxiety, obesity, gastroesophageal reflux disease (GERD), headache, anemia, paresthesias, and Grave's disease status/post (s/p) thyroidectomy. She presented for an annual wellness exam and reported persistent pain over the surgical site of the thyroidectomy. She reported to her provider that iultrasound was performed and she was told that the radiologist had concerns that the surgical clips were being rejected. Although the operating surgeon thought clip rejection was rare, a computed tomography (CT) scan was ordered. The patient was in no acute distress and not ill appearing. A physical exam revealed a non-tender anterior neck surgical scar. There was no tenderness or masses. Neck ultrasound reports were found in the medical records provided. Neither report noted any concern regarding the rejection of surgical clips. Also, an operative report documenting a total thyroidectomy was reviewed. There were no complications. The medical necessity for a neck CT scan is under review.
The requested health service/treatment of neck CT was not medically necessary for this patient.
Based on a review of the information provided, the requested neck CT scan was not medically necessary. The physical exam was unremarkable and the report of two neck ultrasounds did not document evidence of clip rejection or any other unexpected findings. Neck discomfort after thyroidectomy without any significant cause is very common. Subjective pain without associated objective findings does not in and of itself support the need for advanced imaging. In this case, a CT scan is very unlikely to identify the cause of the patient's symptoms, and due to radiation, it is not risk free. The risks of radiation are cumulative over a life time and unnecessary radiation should be avoided in younger patients. Based on the standard of care, as well as the peer reviewed literature cited in the references, the neck CT scan was not medically necessary.