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

Diagnosis:  Intrauterine Growth Restriction.
Treatment:  Acute inpatient stay.
 
The insurer denied the acute inpatient stay.  The denial was upheld.

This is a female patient at 24 weeks and 6 days of gestation with a history of elevated alpha fetal protein, hypertension, pre-diabetes, and vitamin D deficiency.  This patient presented to the hospital with complaints of intrauterine growth restriction with Absent End Diastolic Flow.  Fetal heart rate ranged from 90-110 beats per minute.  She came from maternal fetal medicine services.  The fetal scan revealed abnormal findings including short long bones, fetal feet small for gestational age, fetal cranium appeared flat in the back and profile was suspicious for possible frontal bossing and micrognathia.  In the emergency room the fetal heart baseline was 130 beats per minute.  The patient was admitted with the diagnosis of intrauterine growth restriction.  She was kept on nothing by mouth.  She was treated with Celestone, intravenous Magnesium Sulfate, intravenous lactated ringers at 125 milliliters per hour, and sequential compression devices.  There was a risk for early delivery before 30 weeks, and the patient was transferred to another hospital with a higher level neonatal intensive care unit.

The patient presented with intrauterine growth restriction with Absent End Diastolic Flow.  Absent end-diastolic flow is an ominous finding.  In other words, the fetus was in severe jeopardy.  It is unclear from the progress notes submitted what was the plan of action on this patient and why she was admitted.  If the plan was to deliver this patient, then the patient would not have been admitted but referred immediately to another hospital with a higher level neonatal intensive care unit.  If the plan was for monitoring, then admission was not medically necessary, and the patient could have been managed at the observation level of care. 

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

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

Diagnosis:  Type 3 Supracondylar Distal Humerus Fracture.
Treatment:  Inpatient hospital admission.
 
The insurer denied the inpatient hospital admission.  The denial was upheld.

This is a male patient who presented to the Emergency Room as a transfer from another medical facility.  The patient had fallen off a play structure injuring his left elbow.  He was diagnosed with a type 3 supracondylar distal humerus fracture.  He was neurologically intact.  He was taken to the Operating Room and underwent closed reduction and percutaneous pinning and placed in a cast.  His post-surgical course was non-complicated.  He was discharged to home. 

The medical record demonstrates a satisfactory course of treatment, which did not require the inpatient admission.  The child was transferred from another hospital.  He underwent surgery.  The diagnosis and procedure were straightforward without problems.  The child did not require treatment for other associated conditions.  He was found to be comfortable and able to tolerate oral medications.  He was discharged. 

There were no hemodynamic, pulmonary, neurological or metabolic reasons to require an acute level of care.  The patient could have received treatment at the Observation level of care. 

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

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

Diagnosis: Unstable angina.
Treatment: Inpatient admission.
The insurer is denied coverage for inpatient admission. 
The denial is upheld. 

This is a male patient with a medical history of hypertension, diabetes mellitus, benign prostatic hypertrophy, and coronary artery disease. The patient presented to the Emergency Department (ED) with complaints of chest pain rating it 5 out of 10 in intensity. The patient's electrocardiogram revealed normal sinus rhythm with no ischemic changes. The patient's chest x-ray revealed clear lungs. The patient's troponin levels and cardiac enzymes were both negative. The patient was admitted to the Telemetry with the diagnosis of unstable angina. The patient received aspirin, statin, and metoprolol as ordered. The patient's echocardiogram revealed normal systolic function and grade 1 diastolic dysfunction. The patient's stress test was negative for reversible ischemia. The patient was discharged home in stable condition with instructions to continue home medications and to follow-up with his primary care physician in one week.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient presented with chest pain. The patient's initial evaluation in the Emergency Room (ER) was unremarkable, including a non-diagnostic electrocardiogram (EKG) and cardiac biomarkers. The patient's inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted, however inpatient admission criteria was not met. There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care.

The health plan acted reasonably 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 should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Graves' orbitopathy thyroid eye disease

Treatment: Nasal/sinus endoscopy, surg (CPT code 31292/claim 29466149) and orbitotomy (CPT code 67445/claim 29466150)

The insurer is denied coverage for nasal/sinus endoscopy, surg (CPT code 31292/claim 29466149) and orbitotomy (CPT code 67445/claim 29466150).The denial is overturned. 

The patient is a female who was noted to have thyroid eye disease. The patient was initially seen when she had just discontinued the methimazole. The patient had punctal plugs in place. The patient's diagnosis was Graves' orbitopathy, thyroid eye disease. The patient's ocular examination was stable. The patient had significant proptosis and wished to undergo bilateral orbital decompression. The patient was noted to have disfiguring proptosis with exposure keratopathy on the left. Per the office visit note the patient was being seen for Graves' ophthalmopathy. The patient had been taking methimazole for several years but stopped a month prior to presentation and had a normal thyroid function. The patient had been using punctal plugs for dry eyes. The patient's physical examination by nasal endoscopy revealed that the patient had an S-shaped, non-obstructing nasal septum, patent nasal passages bilaterally, normal healthy nasal mucosa, patent middle meatus, and normal posterior nasal passages. The patient underwent bilateral lateral orbital decompression and bilateral endoscopic medial orbital wall decompression with BrainLab image guidance.

As noted in Up to Date, in the presence of "Excessive proptosis leading to exposure keratitis, corneal ulceration, or debilitating cosmetic defect" surgical approaches which involve removing the lateral wall, the roof or the medial wall and floor are effective. They also note the effectiveness of orbital decompression based on long term follow up.

Based on the review of the medical record and literature, the nasal/sinus endoscopy, surg (CPT code 31292/claim 29466149) and orbitotomy (CPT code 67445/claim 29466150) is considered medically necessary for this patient. The nasal /sinus endoscopy was medically necessary to assess the periorbital anatomy in a patient with thyroid eye disease and orbital decompression.

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 nasal/sinus endoscopy, surg (CPT code 31292/claim 29466149) and orbitotomy (CPT code 67445/claim 29466150) should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

CHF
Inpatient hospital

The patient is a man with left bundle branch block, nonischemic cardiomyopathy, congestive heart failure and a left ventricular ejection fraction of 38%. He presented to the hospital for scheduled implantation of a biventricular implantable cardioverter defibrillator for cardiac resynchronization and primary prevention of sudden cardiac death. The procedure was uncomplicated. Post-procedure, the patient was admitted to the hospital. He remained stable overnight and was discharged. Coverage for an inpatient admission is at issue.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This patient presented for elective biventricular implantable cardioverter defibrillator (ICD) placement. He was hemodynamically stable and the procedure was uncomplicated. While admission for overnight observation after this procedure is still the preferred approach for many implanting physicians, this can generally safely be accomplished at a lower level of care. An inpatient admission is not medically necessary for the vast majority of patients. In fact, same day discharge after ICD implantation (including biventricular device implantation) is an increasingly common practice and has been shown to be feasible and safe in most cases, with no increase in death, readmission or procedural complications when compared to patients who were admitted overnight. Per the Milliman Care Guideline, Electrophysiologic Study and Implantable Cardioverter Defibrillator Insertion (ORG: W0011), an uncomplicated ICD implantation for primary prevention purposes can be performed at a lower level of care. An inpatient admission is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration
 
Treatment: inpatient hospital

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

This patient is a female who presented to the Emergency Department with complaints of weakness.  The patient also complained of chills; however, there was no fever.  On physical examination, she appeared lethargic with generalized weakness.  The physician indicated she was hypotensive, but not tachycardic.  There were no focal deficits.  The physician detailed that there was possible dehydration; however, there was no vomiting or diarrhea. The recommendation was made for the patient to undergo multiple laboratory and diagnostic studies.  The physician reviewed laboratory studies which were notable for acute kidney injury (AKI).   The patient's creatinine level was 2.75.  There was no lactic acidosis and no leukocytosis.  The patient did receive 1-1/2 L of intravenous (IV) fluids and stated she felt better.  Her blood pressure did respond to a fluid bolus.  The physician detailed that the patient likely was dehydrated; however, it was recommended that she be admitted for further evaluation.  The documentation the following day detailed that the patient's blood pressure was 115/71 after IV fluids were continued.  Documentation also indicated that she did have improvement in symptoms and repeat laboratory studies revealed a creatinine of 2.05.  She was recommended to continue treatment, but she left Against Medical Advice (AMA).

The patient had one loose bowel movement and one episode of emesis prior to admission, but was able to tolerate oral intake at the time of admission.  Her creatinine was found to be elevated to 2.75 from an unclear baseline, but with a chart history of "chronic kidney disease [CKD]." This would be consistent with acute kidney failure as summarized in Up to Date.  However, her orthostasis resolved with IV fluid administration and the creatinine began to improve prior to the patient leaving against medical advice. There was no evidence of severe hyperkalemia, uremia or acidosis.  Thus, there was no need for inpatient admission. The patient could have been hydrated in observation and when as noted there was marked improvement in her renal status with no complicating issues, further management could be done as an outpatient.

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

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

Diagnosis: Mental health /high risk suicide  
Treatment: Inpatient hospital. 
The insurer denied the inpatient hospital stay. 
The denial is over turned in whole. 

Summary:
This case involves a patient with a history of chronic headaches after traumatic subarachnoid hemorrhage approximately three years before this episode. The patient, presented to the hospital by Emergency Medical Services (EMS), after overdosing on an unknown amount of amitriptyline and cyclobenzaprine.
Yes, the requested health service/treatment of inpatient stay is medically indicated for this patient. This patient was brought into the hospital with a suicide attempt, taking an unknown amount of cyclic antidepressants as well as muscle relaxants. The   Glasgow Coma Scale was 7, and the patient  was intubated for airway protection in the field. the  over sedation persisted, and the patient  was managed in the intensive care unit, with serial EKGs, following the QTC, and QRS widening.
Overdose on tricyclic antidepressants is particularly dangerous, carrying high morbidity and mortality, and requires inpatient hospitalization. Intubation for airway protection also is 1 of the clinical indicators for admitting the patient to an inpatient stay. Additionally, the patient was found to have metabolic acidosis, which required bicarbonate treatment. Furthermore, the patient required a psychiatric risk assessment. Per the psychiatric team assessment, the patient was deemed to be a candidate for inpatient involuntary hospitalization, for persistent suicidal ideation.
As a result, the acuity and complexity of this treatment course exceeded the lower level of care and required inpatient hospitalization. Therefore, the inpatient hospital stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal.
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. The denial was upheld in whole. 

The patient is previously healthy male who presented to the hospital on with a history of progressively worsening abdominal pain of 6-hours duration. His evaluation included physical exam, labs, and computed tomography (CT) scan. He was without fever at the time of presentation. Lab data identified a normal white blood cell (WBC) count of 10.3 thousand (K). CT scan yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was obtained.
The patient underwent laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. He was provided IV fluid and perioperative antibiotics. Vital signs remained normal throughout the hospitalization without fever. Diet was advanced and pain management was converted to oral medications. He was discharged home. 

The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld in whole. 

Inpatient stay was not medically necessary for this patient. This patient presented with abdominal pain. The evaluation with examination, lab data, and CT scan suggested the diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, and appendectomy performed. The early post-surgical course was uncomplicated, and the patient was clinically stable for discharge from the hospital on the first post-surgical day. 

The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient presented with abdominal pain and underwent uncomplicated appendectomy. A lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male. He has a past medical history significant for HTN (hypertension), thyroid nodule, and paroxysmal atrial fibrillation, last episode requiring cardioversion. He presented to the ER with complaints of irregular heartbeat and was found to have atrial fibrillation with rapid ventricular rate. 

The patient's BP (blood pressure) was stable. The cardiac enzymes were negative. ECG (electrocardiogram) revealed atrial fibrillation with rapid ventricular rate. He was given a dose of IV diltiazem in the ED for rate control and was started on Lovenox. The patient was admitted to telemetry. 

Echocardiogram was obtained and revealed normal LV (left ventricle) function. The patient was seen in consultation by cardiology and outpatient evaluation for sleep apnea, as well as outpatient consideration of ablation was recommended. His anticoagulation was switched to Xarelto, and he was started on metoprolol for rate control. He was noted to have hematuria, and urology evaluation was obtained. There was no decrease in hemoglobin. Urine cytology and renal ultrasound were obtained and were unremarkable. The patient was discharged home with a plan for outpatient follow-up.

No, the Inpatient admission was not medically necessary.

The patient with a history of paroxysmal atrial fibrillation presented for evaluation of recurrent atrial fibrillation. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. His rate was controlled with medical therapy and he was started on anticoagulation. He was also evaluated for hematuria. Ultrasound imaging and cytology were obtained. There was no need for surgical intervention or transfusion. The patient remained stable on medical therapy and was discharged with a plan for outpatient follow-up. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care that was required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Orthopedic /Musculoskeletal/Joint problem.
Treatment:  Physical therapy.

The insurer denied Physical Therapy Services.  The denial is overturned in part. 

Records provided indicate that the patient has a history of a total knee replacement.  Records show the patient began physical therapy from a provider, and the providers were seeking authorization to provide coverage for these billed therapy services to include evaluation, two units of therapeutic exercise each on three separate days, one unit each of manual therapy and neuromuscular reeducation on three separate days, and two units of therapeutic activities.

The requested health service/treatment of physical therapy services was partially medically necessity for this patient.  The physical therapy evaluation was medically necessary.  The billed therapy services to include two units of therapeutic exercise each on three separate days, one unit each of manual therapy and neuromuscular re-education on three separate days, and two units of therapeutic activities were not medically necessary.

Per Department Of Health And Human Services Centers for Medicare & Medicaid Services, current procedural terminology (CPT) code 97163 is for physical therapy evaluation: high complexity, requiring these three components:  1) a history of present problem with three or more personal factors and/or comorbidities that impact the plan of care; 2) an examination of body systems using standardized tests and measures addressing a total of four or more elements from any of the following: a) body structure and function, b) activity limitations, and/or participation restrictions; 3) a clinical presentation with unstable and unpredictable characteristics; 4) and clinical decision-making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.  Typically, 45 minutes are spent face-to-face with the patient and/or family.  The physical therapy initial evaluation completed  meets these criteria.

However, regarding the remaining physical therapy services in question, progress notes for these three dates of service to include two units of therapeutic exercise each, one unit each of manual therapy and neuro-muscular reeducation, and two units of therapeutic activities billed did not include details for the treatment rendered on these dates to include specific exercises, number of reps, specific amount of time on each activity, etc. just require documentation support services billed.  Therefore, the physical therapy evaluation was medically necessary, and the remaining services in question were not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left shoulder greater tuberosity fracture

Treatment: Physical therapy services (procedure code 97110)

The insurer denied coverage for physical therapy services (procedure code 97110). The denial is overturned.

This patient is a female who sustained a left shoulder greater tuberosity fracture due to a skiing accident. The patient began physical therapy. Currently under review are requested additional requested physical therapy services (procedure code 97110). Based on the review of the medical record, the physical therapy treatment notes provide sufficient objective clinical evidence to support the medical necessity of the services provided for the treatment dates under review.  The clinical records also demonstrate the medical necessity of continuing a structured outpatient physical therapy treatment program.  The physical therapy notes consistently demonstrate substantial improvement.  The most recent physical therapy note included for review.  According to this note, "AROM left shoulder 0-138 degrees flexion, 0-105 abduction, 0-35 external rotation, 0-30" which is significantly improved compared to the prior note; "AROM left shoulder 0-130 degrees flexion, 0-90 abduction, 0-35 external rotation, 0-25."  Additional physical therapy should result in improved active range of motion, allow for ongoing strengthening and increase overall functional capacity. 
 
From a physical medicine and rehabilitation/pain management perspective as well as within a reasonable degree of medical certainty, additional requested physical therapy services (procedure code 97110) are medically necessary.

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 additional requested physical therapy services (procedure code 97110) should be overturned.  The medical necessity is substantiated.