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

Diagnosis: vomiting and melena

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
The patient had a history of a duodenal ulcer. He was previously treated for H Pylori. He presented with vomiting and melena. He was afebrile and the vital signs were stable. The abdominal exam was benign. The hemoglobin was 7.6. The previous hemoglobin was 11.7. Proton pump inhibitor (PPI) therapy was given. After a transfusion the hemoglobin went up to 8.1. An endoscopy was performed and in the duodenal bulb was adherent blood and friability felt to be due to an ulcer. The area was treated with epinephrine injection and then coagulated for hemostasis.

Medical necessity was determined based on Milliman Care Guidelines (MCG) M-180 for Upper Gastrointestinal Bleeding. Clinical indications for admission include having peptic ulcer disease with high risk endoscopic features such as the need for endoscopic hemostatic therapy. This patient had an ulcer with adherent blood that required an epinephrine injection and coagulation.

The patient had an upper gastrointestinal (GI) bleed with a large drop in his hemoglobin. He had peptic ulcer disease that required endoscopic hemostatic therapy. This met MCG criteria for admission. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient is an adult that presented to the hospital for a cardiac catheterization after presenting with symptoms of worsening dyspnea on exertion. The patient had a past medical history of ischemic heart disease, right coronary artery stent and heart failure with reduced left ventricle (LV) ejection fraction (20 %), and hypertension. A diagnostic cardiac catheterization revealed 70-90% occlusion of the mid and distal right coronary artery and a total occlusion of the left anterior descending artery with right to left collaterals. Left ventricular end diastolic pressure (LVEDP) was severely elevated and the patient was admitted for diuresis in preparation for complex percutaneous intervention.  There was additional testing and treatment including afterload reducing agents and echocardiography. An Impella assisted revascularization was performed. This consisted of atherectomy and stenting to the mid and distal right coronary artery. Post procedure blood pressure was noted to be in the 80-90 range. The patient was monitored until discharge in the inpatient setting.

This patient presented for elective percutaneous revascularization and was noted to have a markedly elevated LVEDP and triple vessel coronary artery disease. The patient required medical therapy prior to planned complex percutaneous intervention. The patient ultimately underwent revascularization to the right coronary artery with Impella circulatory support.  Several investigators have studied the safety of same day discharge following percutaneous intervention.  Patients requiring circulatory support, multivessel revascularization and left main coronary artery revascularization were classified as high risk and could not be managed at a lower level of care (1-4).  Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a higher level of care (4). The patient could not have been managed at a lower level of care.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric and right upper quadrant pain
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 hypertension and hyperlipidemia. She presented to the emergency department with epigastric and right upper quadrant pain, nausea, and vomiting for 1-2 weeks; the nausea and vomiting had subsided four days prior and the abdominal pain had improved the prior weekend. She had been found to have a hepatic cyst on ultrasound. The physical examination was notable for soft, nontender, nondistended abdomen with normal bowel sounds. A computed tomography (CT) scan of the abdomen and pelvis showed no evidence of mechanical bowel obstruction or acute inflammatory bowel disease, no evidence of ascites or adenopathy, and hepatic and renal cysts [1.5 centimeter (cm) subcapsular hepatic cyst in the dome of the liver and a 3.3 x 4.2 cm exophytic cortical cyst in the upper pole of the right kidney]. Magnetic resonance imaging (MRI) of the abdomen showed scattered hepatic cysts, but no suspicious focal hepatic lesions. A gastroenterology consultation concluded that there was no sign of liver neoplasm on MRI or CT scans, normal liver chemistries, and no abdominal or epigastric tenderness; the recommendation was stable for discharge and outpatient management, with a plan for gastroenterology follow-up. She was discharged, with a plan for gastroenterology follow-up. At issue is the medical necessity for the inpatient level of care.

The inpatient level of care is not supported as medically necessary. In this case, the patient presented with increased alpha-fetoprotein and abnormal ultrasound showing a hepatic lesion, as well as recent (but resolved) symptoms including abdominal pain, nausea, and vomiting. She was appropriately evaluated for hepatocellular carcinoma with both CT scan of the abdomen and pelvis and MRI, both of which were not consistent with hepatic malignancy [1-5]. She did not have any decompensated cirrhosis, hemodynamic instability, imaging evidence of biliary obstruction, biliary or pancreatic mass, bile leak, ascending cholangitis, hepatic abscess, or other complications which would support the inpatient level of care. The care provided, including labs, imaging, and gastroenterology consultation, could have been provided without the inpatient level of care. Per the Milliman Care Guidelines for Abdominal Pain, Undiagnosed, the inpatient level of care is not supported.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low Back Pain
Treatment: Nerve Treatment in the spine (intraosseous 
basivertebral nerve ablation)
The insurer denied: Nerve Treatment in the spine (intraosseous 
basivertebral nerve ablation)
The denial is overturned.

The patient is an adult female. The appeals letter notes that the patient has a history of chronic low back pain due to degenerative disc disease that resulted in vertebral-genic pain identified by degenerative endplate changes known as Modic on magnetic resonance imaging (MRI). The patient has pain and failed treatment for greater than six months. Prior treatments 
include massage therapy, physiatrist, physical therapy, back surgery, injections, and medial branch blocks as well as radiofrequency ablation. The patient's pain averaged 7 to 10 out of 10 (7-10/10) in 
intensity.

The requested health service is medically necessary.

Based on the documentation provided, the requested procedure is recommended at this time. The patient continues to have chronic pain despite prior treatments, including conservative treatment, such as physical therapy, physiatrist, and medication as well as activity modification. The patient had tried and failed injections and radiofrequency ablations as well as back surgery. The patient continues to be symptomatic, and magnetic resonance imaging does demonstrate Modic type changes. The requested procedure is recommended for such type findings on imaging.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8020 braces

The insurer denied coverage for D8020 braces.

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to a deep impinging overbite among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required stating the patient exhibits the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary. Per the insurer, the clinical circumstance does not meet this required handicapping malocclusion medical necessity requirement on the HLD index. The patient's mother is appealing on behalf of the patient.

Upon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labio-Lingual 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 deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition is met and supports comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D8020 braces is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: endometriosis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

The patient underwent a laparoscopic hysterectomy. Moderate adhesions and evidence of endometriosis were noted upon surgery requiring meticulous lysis of adhesions and bilateral ureterolysis during the procedure. The procedure was uncomplicated
Postoperatively the patient was stable. Blood loss was 100 cubic centimeters (cc).

There are many ways of doing a hysterectomy. The trend has been towards less invasive procedures. Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions.
Laparoscopic hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary.

According to Milliman Care Guidelines (MCG), Inpatient and Surgical Care 27th Edition, Laparoscopic hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure. Inpatient stay may be needed for:
Surgical complications (bladder ureter or bowel injury or hemorrhage)
Conversion to abdominal hysterectomy
Complex surgery (staging of endometrial cancer)
Wound complications
Comorbidities.

This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. Post operatively, the patient was stable. Nothing in the submitted clinical information suggested any serious problem that warranted admission. Please note that laparoscopic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required.

The length and the complexity of the surgery did not warrant hospital 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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke
Treatment: Continued Skilled Nursing Facility
The insurer denied: Continued Skilled Nursing Facility
The denial is upheld.

The patient is an elderly female with history of general debility and ambulatory difficulty status post right frontal lobe cerebrovascular accident (CVA) with computed tomographic angiography (CTA) showing right carotid occlusion and with left hemiplegia. She also presented with bilateral acute pulmonary embolism that was evident on computed tomography (CT) of the 
pulmonary arteries, cerebral infarction, etc. Also, she has dysarthria and swallowing difficulties. During admission, she was placed on a percutaneous endoscopic gastrostomy (PEG) tube.
The patient's relevant past medical history includes pulmonary embolism, gastroesophageal reflux disease (GERD), obstructive metaplasia of the esophagus, idiopathic hypertrophic subaortic stenosis, cerebral infarction, multiple joints osteoarthritis, hypertension, right side hearing loss, vitamin D deficiency, breast cancer status post lumpectomy, dysarthria, etc. Ongoing medical issues include treatment for nothing by mouth with PEG (percutaneous endoscopic gastrostomy)-tube feeding, decubitus ulcer, pain, deep vein thrombosis (DVT) prophylaxis, etc. Prior to admission the patient was living alone in a two-story house, independent with activities of daily living (ADLs), and driving while going to work as a college professor. She was admitted to a skilled nursing facility (SNF). As of one month after admission, she had not shown any tangible improvement in most activities of daily living and remained totally independent with ambulation, transfers, stand-pivot, standing; maximum assistance with upper body dressing, moderate assistance with bed mobility, and minimum assistance with supine-sit, sit-stand, contact-guard with rolling, and teeth brushing.

The Continued Skilled Nursing Facility was not medically necessary.

The patient was admitted to the skilled nursing facility. As of one month after admission, she had not shown any tangible improvement in most activities of daily living and remained totally independent with ambulation, transfers, stand-pivot, standing; maximum assistance with upper body dressing; moderate assistance with bed mobility; and minimum assistance with supine-sit, sit-stand, contact-guard with rolling, and teeth brushing. She will be better served in a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness and dizziness
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult male. He presented to the emergency room (ER) with a complaint of dizziness. He had nausea and diarrhea. He had left-sided chest pain for few minutes. Other symptoms were chills and cough. He is an active smoker. He has a history of asthma. Physical exam was remarkable for no respiratory distress. He had rales on auscultation. The patient's vital signs in the emergency room were temperature 98.3, heart rate 113, respiratory rate 20, and pulse oximetry 94% (percent). His lab data revealed white blood cell count was 24K (thousand), hematocrit 33, sodium 134, glucose 147, and blood urea nitrogen (BUN) and creatinine 12/0.7. Electrocardiogram revealed sinus tachycardia. Troponin was normal. Chest X-ray revealed left upper lobe consolidation. The patient was admitted to medical services with community acquired pneumonia. He was given intravenous antibiotics, inhaled and systemic steroids, and bronchodilation. Oral methadone was continued. He was discharged on day # (number) 3. Inpatient hospital admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The inpatient hospital admission was not medically necessary.

The patient could have been evaluated in the ER for his symptoms of dizziness and chest pain. Subsequent care could have been provided at a lower level of care than inpatient. The patient had no worsening of respiratory status while in the ER requiring higher FiO2 (fractional inspired oxygen concentration) or invasive or non-invasive ventilation. He had no hemodynamic instability. His mentation was clear. He could tolerate oral intake. He did not require any surgical intervention. The patient's pneumonia score measured by CURB 65 (confusion, blood urea nitrogen, respiration rate, blood pressure, Age 65+) was 0, and his pneumonia severity index (PSI) score was 57 points. Both of these scores recommend outpatient treatment. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Reconstructive surgery on left foot, secondary to infection and reconstruction of Charcot joint.
Treatment: Skilled Nursing Facility
The insurer denied Skilled Nursing Facility.
The determination is partial overturn.

This is a male patient who recently underwent reconstructive surgery on his left foot, secondary to infection and reconstruction of Charcot joint. He had evidence of an infection. The patient was initially treated and transferred to skilled services for rehabilitation subsequent to the initial hospitalization.
He had a past medical history significant for diabetes mellitus type 2 with neuropathy and Charcot joint with chronic ulcer, osteomyelitis enteropathy.
Services were denied for the following: For continued skilled nursing admission, the patient must be shown a therapeutic response to treatment, participating in rehabilitation, needs skilled services that cannot be managed at a lower level of care and also be making progress in therapeutic services such as physical therapy (PT), occupational therapy (OT). Information provided does not show that the patient needs skilled services that cannot be managed at a lower level care. At issue is the medical necessity of continued skilled nursing facility stay.
Continued inpatient skilled services were medically necessary in part.
The patient has multiple medical problems, most recently left foot surgery from a diabetic Charcot joint with reconstruction and external fixation device. The patient needed ongoing inpatient services for continued frequent wound care services. Physical therapy services were discontinued stating the patient met goals. It was clear from the provided notes stated that the patient's family was either unwilling or unable to take care of him at home with an external fixator device. The patient had evidence of delayed healing with drainage, redness and an abscess after the device was placed. The patient had a high likelihood for subsequent complications without proper wound care. Ongoing wound cleaning 3 times a day was medically necessary for continued healing. There was no notation in the medical record that the visiting nurses/wound care services could actually be arranged on a 3 time a day basis, which is necessary for his treatment recommendations. The patient had the external fixator device removed. No further inpatient services were medically necessary subsequent to that.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gender Dysphoria
Treatment: Revise Previous Gender Affirming Surgery (top surgery)
The insurer denied: Revise Previous Gender Affirming Surgery (top surgery)
The denial is upheld.

The patient is an adult non-binary individual. They underwent top surgery for gender reassignment. The patient has healed well but has lateral tissue excess on both breasts. According to the patient's mental health specialist, the dog ears are contributing to worsening of their gender dysphoria.

The requested surgery is not medically necessary.

The patient has already had top surgery. According to the mental health professional, the dog ears are contributing to worsening of the patient's gender dysphoria. The patient has a masculinized chest, and therefore it is not clearly evident that dog ears would exacerbate gender dysphoria. The procedure will primarily change the appearance of the patient's already masculinized chest and, therefore, is a cosmetic procedure. The requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male who presented to the hospital with a complaint of abdominal pain associated with nausea of 1-day duration. His past medical history includes coronary artery disease, hyperlipidemia, and thrombocytopenia. He also has a known history of gallstones. His vital signs included a heart rate of 60 beats/minute and a blood pressure of 115/48 millimeters of mercury (mmHg) at the time of presentation. He was tender in the right upper quadrant. The white blood cell count (WBC)  was normal at 6.3 thousand (K). Liver enzymes were normal with a bilirubin of 1.0. An ultrasound showed gallstones without a thickened gallbladder wall. The common bile duct was 0.3-centimeters (cm). He was admitted to the hospital and started on intravenous (IV) antibiotics.
The surgical history and physical (H&P) states that the patient had cholecystitis. It was the patient's preference to avoid surgical treatment and so he was treated with nothing by mouth (NPO) status and antibiotics.
His diet was advanced and the pain was controlled with oral medications.  He remained clinically stable and was discharged from the inpatient setting with plans to follow as an outpatient for an elective laparoscopic cholecystectomy. He was continued on oral antibiotic therapy post discharge.
An inpatient level of care was not medically necessary in this case. This patient presented to the hospital with complaint of abdominal pain associated with nausea. Imaging and surgical consultation were completed and established the diagnosis of cholelithiasis/cholecystitis. It was the patient's preference to avoid surgical treatment and he was treated with NPO status and antibiotics.
At the time of presentation and at the time of surgical assessment , the patient had normal vital signs and was without a fever. An abdominal ultrasound was completed that identified cholelithiasis without findings of acute cholecystitis. Lab data identified a normal complete blood count (CBC) and liver enzymes. The period of monitoring was uncomplicated and the patient had normal vital signs and tolerated a diet. He was discharged from the inpatient setting with continued oral antibiotics and plans for surgical follow up. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care.