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

Diagnosis: Anemia

Treatment: Inpatient admission

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

This patient is a female with a history of inflammatory arthritis and Crohns' disease. She sustained a fracture to the left tibia and fibula and underwent ORIF in mid-2019. She was evaluated in ED with bleeding from surgical site. Her cast padding was soaked in blood. She was admitted for anemia. Her hemoglobin had dropped from 9.4-8.3. She was on Warfarin. She was discharged in stable condition. 

She required continued anti coagulation due to high risk of thromboembolic complication. The medical records demonstrate no acute treatment was provided. The patient did not require a transfusion. Her hematocrit could have been monitored as an outpatient. Warfarin could have been managed as outpatient. Her vital signs were stable. She was ambulatory and able to tolerate oral medications. She received no additional orthopedic management. There was no cast change, inspection of wound or special imaging completed. She did not receive treatment for other underlying medical conditions. Her management of Warfarin and sequential blood tests would be possible in outpatient facility. At the very most, observation level of care would be applicable. There were no extenuating circumstances to substantiate the admission and length of stay. 

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

Diagnosis: Rule out gastroenteritis or biliary colic

Treatment: Inpatient admission

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

This patient is a female who presented to the Emergency Department (ED) at 29.5 weeks gestation with complaints of lower abdominal cramping associated with nausea and diarrhea.  Gastroenterology (GI) was consulted.  The patient was admitted to the antepartum unit to rule out either a diagnosis of gastroenteritis or biliary colic.  She received Lactated Ringers, Pepcid and Maalox. A gallbladder ultrasound revealed a small polyp, but otherwise no evidence of acute gallbladder or biliary abnormality. A gastrointestinal (GI) exam noted the patient's abdomen was soft and non-tender, and the pain was possibly secondary to biliary colic that may have resolved with the passage of a stone.  It was noted that the pain had resolved.  The patient was discharged with outpatient instructions to follow up with Obstetrics/Gynecology in one week and also Gastroenterology in 1-2 weeks.

This patient presented with abdominal pain.  However, her examination showed a benign abdomen.  She was afebrile and her vital signs were stable.  An abdominal ultrasound did not reveal any pathology necessitating surgical intervention.  The fetal heart rate was reactive.  There was no evidence of uterine contractions and the pain was not severe enough to warrant admission.

Ideally, this patient could have been observed in Labor and Delivery, received intravenous (IV) fluid and then reevaluated a few hours later.  If upon reevaluation no worsening of symptoms were observed, then the patient could have been sent home to be followed up as an outpatient. Please note that neither the patient nor the fetus were in any jeopardy.  There was no bleeding and vital signs were stable.  The fetal heart rate was reassuring.  There was no evidence of ruptured membranes. Admission for gastroenteritis is usually unnecessary unless the patient is hemodynamically unstable.

Based on the above, since this patient was stable, admission to the hospital was not medically necessary.  This is in accordance with standard of care and MCG.

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

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

Diagnosis: Breast drainage
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a female. She presented to the Emergency Department (ED) for fevers up to 102 and right breast pain. She was at the hospital two days prior for breast drainage. Cultures from a prior ED visit grew Klebsiella, Corynebacterium and Coag negative staph. Due to positive breast cultures obtained previously, she arrived at the ED. She has a history of diabetes and had undergone bilateral breast reduction surgery on late 2018. She has been taking oral antibiotics prior to arrival. 

In the ED, the patient was started on IV antibiotics. Examination indicated surgical related swelling of the breasts with no local signs of infection. CT of the chest indicated a hematoma. WBC (white blood count) was 6.5. Vital signs were unremarkable. Subsequent blood cultures had no growth. 

There was no indication of a WBC elevation or fevers in the emergency department or during admission. The clinical exam did not indicate active infection or drainage. CT imaging did not indicate an abscess or need for additional surgery. 

As noted in Reference 1 and 2- appropriate identification of risks and clinical findings can help stratify those that require inpatient admission versus outpatient management and avoid treatment failure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: Inpatient Admission

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

This is a female patient with a history of hypothyroidism and a C-section.
She presented to the Emergency Department (ED) with complaints of abdominal pain and vomiting. On physical examination it was noted that the patient abdomen was mildly tender to palpation without guarding or rebound.  Laboratory work up was performed revealing an elevated white blood cell count of 23.05. Computed tomography (CT) of the abdomen was performed that revealed an appendicitis with associated cecal wall thickening and small amount of fluid adjacent to the appendiceal base and cecum. Surgery consulted on the patient. Intravenous (IV) antibiotics were administered. The patient underwent a laparoscopic appendectomy without complications. The patient was medically stabilized and discharged home. 

Based upon MCG Health Inpatient and Surgical Care 24th Edition Appendectomy, without Abscess or Peritonitis, by laparoscopy ORG: S-175 (ISC) optimal recovery course includes floor to discharge with the following milestones completed: hemodynamic stability; successfully uncomplicated lap appendectomy; no evidence of post operative or surgical site infection; diet tolerated; pain absent or managed; no evidence of ileus or bowel obstruction; oral medications and oral diet. Based upon the records provided, the patient reached these milestones, and could have been discharged following observation, which would have been well within a 23-hour observation period. 

Furthermore, according to the MCG, the goal length of stay is ambulatory. The patient did not have any comorbidity that warranted inpatient admission. The patient's procedure was uncomplicated and did not present with the MCG criteria for extended stay beyond the observation period. The patient did not have any wound infection, wound dehiscence, or enterocutaneous fistula that required continued observation, percutaneous drainage, or reoperation. The patient did not have continued ileus with inability to tolerate oral intake. The patient was noted to be doing well post-operatively, and was able to tolerate diet and ambulate within 23-hour period. The patient did not meet the MCG guideline criteria for inpatient admission.

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

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

Diagnosis: Pulmonary Embolism
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a female with history of migraines, depression, anxiety with palpitations and migraines. She presented to emergency room (ER) and was found to have subsegmental pulmonary embolism in right lower lobes. The patient was admitted for anticoagulation.

The patient was hemodynamically stable and did not require supplemental oxygen. The CT-chest did not reveal RV (right ventricle) strain. The blood work was with in normal limits. The patient could have been started on oral anticoagulation in ER and discharged home. 

The patient was hemodynamically stable and did not require supplemental oxygen. The CT-chest did not reveal RV strain. The blood work was with in normal limits. The patient could have been started on oral anticoagulation in ER and discharged home. The low risk pulmonary embolism can be safely treated in an outpatient setting. The acute in hospital level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skeletal Class I, Maxillary and Mandibular Crowding and Impacted Canines.  

Treatment: D8080 braces

The insurer denied D8080 braces. The denial was upheld.   

This is a female patient who consulted an orthodontist for orthodontic therapy. Diagnostic studies were performed that included lateral cephalometric radiograph, panoramic radiograph, and a montage of extraoral and intraoral clinical images. Comprehensive orthodontics was recommended due to skeletal Class I, maxillary and mandibular crowding and impacted canines. A completed the Handicapping Labio-Lingual Deviations (HLD) index was done.  

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated.  This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care.  This reviewer concurs with the findings of the insurer of attaining 18 points on the HLD index (3 points overjet, 3 points overbite, 10 anterior crowding, 2 points labiolingual spread).

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies including:

Beglin, et al. "A comparison of the reliability and validity of 3 occlusal indexes of orthodontic treatment need." Am J Orthod Dentofacial Orthoped, 2001; 120: 240-6, 

Parker. "A study of 1000 malocclusions selected by the HLD Index." Am J Orthod Dentofacial Orthoped, 1999; 115:343-51, 

Theis, et al. "Eligibility for publically funded orthodontic treatment determined by the handicapping labiolingual deviation index." Am J Orthod Dentofacial Orthoped, 2005; 128:708-15.
 
Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

The carrier's denial of coverage for the D8080 braces and D8670 monthly visit x4 is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth pain and sensitivity

Treatment: Nerve treatment on tooth 8 and the nerve retreatment on tooth 7

The insurer denied coverage for nerve treatment on tooth 8 and the nerve retreatment on tooth 7. The denial reversed.

This patient is a female that presented to the dentist with complaints of pain and sensitivity to hot and cold on the anterior maxillary dentition, right maxilla and for evaluation and comprehensive dental treatment.  Endodontic therapy was recommended on tooth #8 due to carious lesion encroaching on the pulp and retreatment #7 due to failing root canal on #7.  The insurer has denied these services stating that the services are not medically necessary as the documentation was insufficient to support the treatment.  The patient is appealing the decision.

Upon review of radiographs, they support the recommended treatment. Tooth #8 has a large carious lesion involving the pulp chamber radiographically and periapical pathology/radiolucency is noted on root canal treated #7.  Both teeth require endodontic therapy as identified by the dentist and endodontist.  Both have adequate residual coronal structure for support of crowns and minimal periodontal alveolar bone loss.  The standard of care in general dental practice would be endodontic therapy for these teeth which would have an excellent long term prognosis with the recommended treatment.

Reverse denial and approve coverage for the nerve treatment on tooth 8 and the nerve retreatment on tooth 7 as medically necessary as the clinical and radiographic documentation support these services, and these services would be a standard of care in general dental practice. The health plan did not at reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the nerve treatment on tooth 8 and the nerve retreatment on tooth 7 is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's Disease
Treatment: Inbrija
The proposed treatment with Inbrija is not medically necessary.

The patient is a male with Parkinson's disease who reported wearing off symptoms.  He has been treated with carbidopa/levodopa immediate release and selegiline. 

There is no reason the patient cannot be treated with the preferred formulary agents, either pramipexole or ropinirole. The patient does not have a contraindication to using these medications and potential side effects do not preclude trials of these agents. Both of these medications are FDA indicated for his condition and are considered standard of care treatment options. There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Inbrija relative to these medications.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rhinitis
Issue under review: Laboratory testing

Determination:
The Laboratory testing was medically necessary.

The patient is an adult male with history of rhinitis.  He is being evaluated for allergies, both food and environmental.  He was sent for immunoglobulin E (IgE) testing via blood work. 

Per physician note, this is a patient with food allergies and environmental allergies - for which the patient is being evaluated for via IgE testing via blood.   

IgE testing is a valid method for testing for food and environmental allergies if deemed necessary and if the patient has symptoms concerning food allergy or environmental allergies.  IgE testing helps in determining which foods or environmental triggers are responsible for causing symptoms. This will help so that patients can avoid foods that they are allergic to and also environmental measures for environmental triggers if they are allergic.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain 
Treatment:  Inpatient admission
The Inpatient admission was not medically necessary.

The patient has a past medical history significant for heroin abuse, now on methadone, and smoking.  He presented to the ER for complaints of left-sided chest pain, non-exertional, intermittent, started after being arrested by the police. 

The patient was hemodynamically stable.  The ECG (electrocardiogram) revealed sinus bradycardia with no ischemic changes.  The cardiac enzymes were normal.  The patient was admitted to telemetry to rule out ACS (acute coronary syndrome).  Echocardiogram revealed normal LV (left ventricle) systolic function.  Stress test was offered, but refused by the patient.  The patient was discharged.

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 ECGs were non-ischemic, and the echocardiogram revealed no wall motion abnormalities (WMA).  There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. 

The standard of care for patients presenting with chest discomfort, and in whom the diagnosis of acute coronary syndrome is unclear, is observation in ED or chest pain unit with serial cardiomarker measurements to rule out an acute myocardial infarction, followed by a non-invasive ischemic workup (stress test, CT angiogram).  This standard of care is in concert with ACC/AHA clinical guidelines.  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 a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic calculous cholecystitis

Treatment: Inpatient hospital admission

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

This patient is a male who presented to the hospital for a laparoscopic cholecystectomy. The patient was noted to have preoperative diagnoses of chronic calculous cholecystitis and a past medical history of thyroid disease. The patient had one prior hospital admission for acute cholecystitis. The history and physical revealed mild right upper quadrant pain. The ultrasound of the abdomen revealed hepatomegaly with steatosis and cholelithiasis. The patient underwent a laparoscopic cholecystectomy. The records indicated that there were no complications. The patient was noted to be awake, and stable postoperatively per the assessment in the Post Anesthesia Care Unit. The patient's blood pressure remained stable throughout the admission. On a specified date the nurse's notes stated that the patient complained of progressive dizziness, dry mouth, nausea, headache, and his blood pressure was trending low. The patient was seen by the physician and re-assured that he was being monitored. The patient was discharged. 

The health care plan did act 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. A laparoscopic cholecystectomy is generally performed as an ambulatory procedure. The patient was not noted to have complications to support the need for an admission. The patient could have been monitored post-operatively under Observation status. 

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hypertension, morbid obesity, and heart failure with preserved ejection fraction, obstructive sleep apnea and paroxysmal atrial fibrillation. She presented to the hospital for elective catheter ablation for atrial fibrillation. The procedure was uncomplicated. Post-procedure her blood pressure was 126/73 millimeters of mercury (mmHg) with a heart rate of 69 beats/minute. Her respiratory rate was 18/minute with an oxygen saturation of 100%.The health plan's determination is upheld.
This patient presented for an elective catheter ablation for atrial fibrillation. The procedure was uncomplicated. Post-procedure the patient was in normal sinus rhythm with normal vital signs. Given the technical complexity of catheter ablation for atrial fibrillation, with transseptal punctures, catheter manipulation and ablation within the left atrium, full dose anticoagulation, and the proximity of the ablation lines to the esophagus, the complication rate is higher than that of catheter ablation for other supraventricular arrhythmias. Accordingly, despite at least two reports demonstrating the safety of same day discharge after this procedure, most electrophysiologists admit patients for overnight observation post-procedure. This patient's procedure was uncomplicated, and she was hemodynamically stable. While overnight observation was reasonable and prudent, the records provided do not indicate that an inpatient level of care was medically necessary.
The Milliman Care Guideline for intracardiac catheter ablation (ORG: W0012) was provided for review. Per this document, indications for inpatient care include: need for extended monitoring (e.g., discontinuation of antiarrhyhmic drug before ablation, dangerous arrhythmia detected or suspected); unstable comorbidity; procedural complication. This patient met none of these criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Failure to thrive
Treatment: Inpatient stay 

Summary:
The patient is a male. At presentation, he was a former 32 weeks gestation, low birth weight, 3 pounds and 9 ounces, preterm male infant who was born by spontaneous vaginal delivery to a mother with pregnancy-induced hypertension.  The infant was admitted to a neonatal intensive care unit after birth secondary to prematurity and low birth weight.  The infant had no significant complications during his neonatal intensive care unit hospitalization and was discharged home.  Discharge weight was 4 pounds and 9 ounces.  Because of frequent spit ups the infant was discharged home on Nutramigen formula.  

The infant was admitted to the hospital to supervise mother preparing the infant's formula, supervise the infant's feedings, monitor the infant's weight and evaluate failure to thrive.  On admission, the infant's labs showed that his nutritional status was within normal limits.  The infant tolerated his feedings and was discharged home with Pediatric Gastroenterology follow up one week after discharge.  

Because this infant's vital signs were normal; the infant was in no acute distress; the infant had no clinical evidence of dehydration; the infant had gained an average of 12 grams per day over the nine day period preceding this admission; admission labs showed the infant's nutritional status was within normal limits; the infant did not have a gastrointestinal tract obstruction, significant metabolic/electrolyte derangement, severe malnutrition, significant dehydration, hemodynamic instability, severe and persistent vomiting, serious intercurrent illness or significant medical problems; the infant did not require treatment with intravenous fluids; there were no psychosocial circumstances that put the child at risk for harm; there was no failure to respond to several months of outpatient management; there was no need for precise documentation of energy intake; there was no evidence of extreme parental impairment or anxiety; there was no documentation of an extremely problematic parent-child interaction; and there was no practicality of distance, transportation, or family psychosocial problems that precluded outpatient management; acute inpatient hospitalization was not medically necessary.  The infant could have been managed under observation status.