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

Diagnosis: Genitourinary /Kidney Disorder
Treatment: Inpatient hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a male who presented to ED with complaints of severe testis pain. He was afebrile and hemodynamically stable on presentation. The white blood cell (WBC) was 11.6. Examination revealed edematous and tender left testicle. Ultrasound showed torsion. He was taken to operating room (OR) for exploration and orchiopexy. Medical necessity for inpatient stay is under review.

The health plan's determination is upheld in whole.

The majority of patients who present with testis torsion can be discharged within 24 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis, or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. The procedure was not done on an emergent basis (done next day). The procedure performed is considered a minimally invasive outpatient procedure and as such in the absence of a "high risk surgical patient" does not warrant acute inpatient care. The information provided and the patient's perioperative clinical status does not suggest the need for acute inpatient care. A lower level of care status for this patient's clinical presentation and post-operative course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous system / Neuromuscular disorder
Treatment: Home Health Care 

The insurer denied the requested personal care worker - 168 hours per week. The denial is upheld in whole. 

The patient with a past medical history significant for coronary artery disease, atrial fibrillation, hypertension, diabetes, gastroesophageal reflux disease, hypothyroidism, depression, insomnia, osteoarthritis, skin cancer, and urinary incontinence. No, the requested health service is not medically necessary for this patient. Additional medical services of 77 hours a week are not noted to be medically necessary. The amount of services provided are adequate to meet the patient's needs. The patient is with multiple medical problems however has become mostly bedbound. The request is for additional medical personal care worker services. 

The Uniform Assessment System (UAS) State of New York as reviewed. Currently the patient has 13 hours a day of live in services, this means that the caregiver starts at 9 AM and is finished at 10 PM. The patient spends most of the time in bed during the day. The real question is whether the patient can be left alone from 10 PM to 9 AM the next morning. There are no specific medical needs such as Activities of daily living (ADLs) or Instrumental Activities of Daily Living IADLs which are required during this period of time. The patient has no open wounds or other medically necessary documented need which would require an assistant to turn the patient during the middle of the night. Incontinence issues can be managed with a bedside commode or other incontinence supplies. Stand-alone services for observation and prevention of falls are typically not considered medically necessary and absence of documented need for ADLs or IADLs. Therefore, the requested 168 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trimalleolar Ankle Fracture
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was upheld.

This is a male patient with a history of uncontrolled diabetes, coronary artery disease and hypertension who sustained a trimalleolar ankle fracture.  The patient was admitted to the hospital for an elective open reduction internal fixation to the left ankle. The patient underwent surgery with a non-complicated post-surgical course. The patient's blood sugars were noted to be elevated after surgery. He received physical therapy (PT) services. The patient was discharged. 

The medical record demonstrates a non-complicated operation and post-surgical course. The procedure itself was performed without problem, and there was limited blood loss.  There were no problems with the patient's wound.  The patient was able to ambulate greater than 30 feet the next day.  The patient was able to tolerate oral medications.  The patient's vital signs were stable.  The patient did not require treatment for other underlying medical conditions. The patient was evaluated with a treatment plan instituted for the "uncontrolled diabetes" prior to admission.  There was no evidence of "uncontrolled diabetes" during the admission.  The patient's blood sugar was monitored with appropriate change in insulin dosage.  There was no evidence of inability to maintain a satisfactory blood glucose or non-compliance.  These services could have been completed at a lower level of case, including post-surgical monitoring, physical therapy, blood sugar testing and discharge planning/Durable Medical Equipment (DME). The patient could have been placed in observation status.  There was no evidence of hemodynamic, pulmonary, neurologic, or metabolic reason for acute level of care. Thus, inpatient admission was not medically necessary for this patient.

The health care plan acted reasonably with sound medical judgment, and in the best interest of the patient.
	
The carrier's denial of coverage for the inpatient admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Achalasia and gastroparesis
Treatment: Botox injections
The insurer denied the botox injections.  
The denial is overturned, in part.

The Botulinum toxin is medically necessary, in part.


Specifically, the provision of Botox for achalasia is an accepted and appropriate and medically necessary procedure. However, the provision of Botox for gastroparesis is not supported and therefore not a medically necessary procedure.

The patient is a female. The patient has a history of achalasia and gastroparesis.

As treatment for those conditions, the patient's provider undertook the provision of Botox for the lower esophageal sphincter and the pyloric sphincter. The plan denied these treatments, which are the subject of this review.

The patient has gastroparesis. The patient is symptomatic. As treatment for this condition, the provider requested provision of Botox as treatment as delivered during endoscopy.

At this time, there is inadequate support in the medical literature to conclude that the provision of Botox for gastroparesis has a positive effect on healthcare outcomes. There are small studies with limited conclusions, and there are no double-blinded studies of sufficient patient enrollment to draw definitive conclusions.

The AGA concludes as follows:

"Intrapyloric injection of botulinum toxin is not recommended for patients with gastroparesis based on randomized controlled trials. (Strong recommendation, high level of evidence)"

Pasricha and Pasricha note as follows:

"Refractory gastroparesis is among the most difficult therapeutic challenges in gastroenterology. Pyloric dysfunction has been described in a subset of patients with gastroparesis, prompting experimentation with botulinum toxin injections into the pylorus, which is relatively safe and has been successfully used in other gastrointestinal disorders. However, causality between pyloric dysfunction and symptoms of gastroparesis has never been demonstrated. Although several open-label studies showed initial promise, 2 randomized clinical trials failed to elicit a difference in clinical outcomes in botulinum toxin versus placebo. Based on current evidence, further use of botulinum toxin for gastroparesis is discouraged outside of a research trial."

There is no medical support to provide Botox as treatment for gastroparesis at this time.

Kumar et. al. note "Endoscopic intrasphincteric injection of Botox (ISIB) is used routinely for the treatment of achalasia esophagus and other spastic motor disorders. Studies show that the ISIB reduces the smooth muscle lower esophageal sphincter (LES) pressure."

Therefore, the Botox as treatment for achalasia is medically necessary, given the wealth of literature in support for this.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Insufficient jaw bones
Treatment: D6010 - Implant placement, Tooth #21
D6010 - Implant placement, Tooth #25
D6010 - Implant placement, Tooth #28
D6013 - Implant placement, Tooth #12
D6013 - Implant placement, Tooth #14
D6013 - Implant placement, Tooth #3
D6013 - Implant placement, Tooth #5
D6013 - Implant placement, Tooth #8
D6013 - Implant placement, Tooth #9

The insurer denied the D6010 - Implant placement, Tooth #21
D6010 - Implant placement, Tooth #25
D6010 - Implant placement, Tooth #28
D6013 - Implant placement, Tooth #12
D6013 - Implant placement, Tooth #14
D6013 - Implant placement, Tooth #3
D6013 - Implant placement, Tooth #5
D6013 - Implant placement, Tooth #8
D6013 - Implant placement, Tooth #9.

The denial is overturned.

The proposed implants are medically necessary. 

The patient has very little jaw bones in her upper and lower jaws. Traditional dentures have very little bone support in this patient and the patient cannot tolerate using denture adhesives, which would normally help stabilize loose dentures. If she can't use denture adhesives and her dentures do not stay in place, the only alternative is to get dental implants placed which will anchor the dentures in place securely without any adhesives. Dental implants are a very predictable way to anchor dentures. The implants are medically necessary and have been requested by her dentist and physician.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain
Treatment: Intracept procedure
The insurer denied Intracept procedure.
The denial is overturned.

The patient is an adult male with axial low back pain. He has failed conservative treatment, as well as RFA (radiofrequency ablation) of the lumbar medial branches. Modic changes are seen on the MRI. An Intracept procedure has been recommended. 

The patient is an adult male who previously has undergone an RFA of the medial branches, and has failed conservative treatment. He continues to have low back pain. The Intracept procedure (intraosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new FDA-cleared intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically use in patients with significant Modic type I or type II vertebral endplate changes.
  
Alternatives are limited. The patient is trying to avoid invasive surgery. The only alternative is a lumbar fusion, which has not been shown to have good results in the setting of axial low back without symptomatic spondylolisthesis. In fact, most recent articles show less than 50 percent improvement for the treatment of chronic low back pain with spinal fusion.  Spinal cord stimulation is an alternative; however, it has not been shown to have great results in primarily axial mechanical/discogenic type pain.  

Therefore, the Intracept procedure is a reasonable option.  It is FDA-cleared.  Randomized studies are available.  Two-year outcomes have proven high success.  It is not an intradiscal procedure which have not shown to have good results in the literature.  Given that the alternatives do not show favorable outcomes in the literature, the requested Intracept procedure is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male who presented with chest burning, radiating to arms, and dizziness for three weeks. There was a recent change in blood pressure (BP) medications. He was initially hypertensive and admitted for rule out (r/o) acute coronary syndrome (ACS). Risk factors included hypertension, coronary artery disease (CAD), and diabetes. Normal electrocardiogram (EKG), negative cardiac enzymes, echocardiogram ordered and negative nuclear stress test were performed. With no evidence of ischemia, the patient was treated for his elevated BP and discharged.

This patient has a presentation of atypical pain for three weeks with normal EKG, and enzymes. He had hypertension in the ED with patient endorsing recent change in BP medications. The patient was admitted to telemetry, and ischemia ruled out with echocardiogram, normal EKGs, negative serial enzymes, and negative nuclear stress test. He was discharged on similar medications as previously prescribed. 

The determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to provide this care. This documentation of the necessity for care is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were atypical, present for weeks without objective evidence of ischemia and therefore were unlikely to be representative of acute coronary syndrome. Exam (BP normalized) and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. Chest x-ray (CXR) was normal.  Nuclear scan was negative for CAD. The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for ACS such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG).   

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD. In fact, all tests showed absence of ischemia.  While there is always a potential for an adverse event, one did not happen and no actual treatment was added. 

The statement in appeal letter that the care given was "beyond the scope of observation" is not consistent with guidelines or standard community practice. All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

Milliman criteria requirements were not fulfilled as there was never any evidence of ACS present.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute exacerbation of asthma/COPD

Treatment: Inpatient admission

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

This patient is a male with a past medical history of bronchial asthma/chronic obstructive pulmonary disease (COPD), hypertension, prediabetes mellitus, vitamin D deficiency, schizoaffective disorder, substance abuse, and opioid dependence (on methadone).  The patient was brought to the hospital by ambulance. The patient reported that he had difficulty breathing for the last then couple of days. The patient complained of pain.  The patient's vitals showed: temperature of 99.5, blood pressure of 152/107, and oxygen saturation of 98% on room air.  The patient's physical examination revealed wheezing bilaterally.  The patient's laboratory studies revealed: CO2 31, WBC 8.5, lactate 1.4, and BNP 83.7. The patient's venous blood gas revealed pH 7.293, PCO2 70.5, PCO2 44, and HCO3 33.1.  The patient's urine drug screen was positive for cocaine, methadone, and opiates.  The patient's chest x-ray showed hyperinflation but no acute cardiopulmonary disease.  The patient's electrocardiogram (EKG) revealed normal sinus rhythm.  In the Emergency Room (ER), the patient was treated with intravenous (IV) fluids, bi-level positive airway pressure (BiPAP), IV antibiotics, IV steroids, magnesium, morphine, and a nebulizer treatment.  The patient was admitted for a diagnosis of acute exacerbation of asthma/COPD, and the plan was to treat the patient with IV steroids and nebulizer treatments. However, the patient left against medical advice shortly after admission.

As per the MCG Health guidelines for Asthma, observation level of care is clinically indicated for patients with 1 or more reasons. In this case, the patient did not have pure asthma but a combination of COPD and/or asthma exacerbation. The patient had low grade fever, suggesting acute bronchitis, but had no pneumonia on chest x-ray. The patient did not have hypotension. The patient's urine drug screen was positive for methadone and opiates; hence, his carbon dioxide and low pH was likely related to the respiratory suppression caused by these drugs. In the Emergency Room, the patient was treated with BIPAP for hypercapnia and hypoxic respiratory failure. Based on the reviewer of the MCG guidelines, the observation level of care would have been appropriate until the patient's pH improved to 7.30 or more and his oxygen was satisfactory. Since this patient did not have pneumonia or congestive heart failure or unstable vital signs, inpatient level of care was not medically necessary. The patient could have been discharged home from observation status with oxygen if medically necessary. This patient's inpatient hospitalization was not medically necessary in the absence of unstable vital signs, high fever, sepsis, or congestive heart failure.

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

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

This is a patient with a history of prematurity and a current diagnosis of central precocious puberty, confirmed by clinical and laboratory testing; the patient was started on Lupron Depot.  Treatment was briefly discontinued because of poor growth velocity but her growth has not improved so the physician is asking to restart treatment to try to improve final height.  The patient's current height prediction is 54 to 55 inches.  At issue is the medical necessity of Lupron Depot-PED.

The health plan's determination is overturned.

A primary goal of treatment for central precocious puberty (CPP) is to allow a child to grow to a normal adult height.  Therefore, the decision to treat should include analysis of the predicted height benefit from treatment, this patient has a very poor height prediction so it is reasonable to restart treatment.  Similarly, the duration of gonadotropin-releasing hormone (GnRH) agonist therapy should be long enough to optimize final adult height.  Based on the current recommendations, the decision of when to discontinue GnRH agonist therapy is individualized; contributing factors include the age of the child, bone age and height age, predicted height, and desire to have pubertal progression concurrent with their peers.  Thus, it is reasonable to continue therapy for this patient and the requested Lupron-Depot-PED is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Ingestion
Inpatient hospital stay

The patient is a pediatric patient who presented to the emergency department after an accidental ingestion of Flexeril. Mother states that patient was found sucking on a half-eaten pill with about 5 or 6 pills on the floor. There were approximately 7 pills unaccounted for based on the mother's pill count, and therefore it was thought that the patient had likely ingested 1 to 2 pills. Patient was described as irritable and crying after the event and had no vomiting or diarrhea. Patient was subsequently brought to the emergency department for evaluation. In the emergency department patient was  active and alert, eating and drinking well and had no neurologic symptoms. The poison control team was consulted and recommended obtaining a baseline electrocardiogram (EKG) with repeat 6 hours after the ingestion. The EKG revealed nonspecific ST changes, and cardiology follow-up was recommended within 2-3 weeks. While  being prepared for discharge,  the patient  developed inspiratory stridor and a croupy cough. Patient was treated with a dose of intramuscular (IM) Decadron and the decision was made to admit  to the hospital for ongoing cardiorespiratory monitoring, racemic epinephrine as needed, as well as intramuscular Decadron. The HP determination of medical necessity is overturned in whole. This is a very young patient who presented after accidental ingestion of an unknown quantity of Flexeril pills who was appropriately observed in the emergency department setting, however developed respiratory symptoms prior to discharge and the decision was made for admission for ongoing monitoring. Patient also had nonspecific ST changes on EKG. Ingestion of Flexeril can cause anticholinergic effects, central nervous system (CNS) depression, and serious arrhythmias. This patient required admission for continued cardiac respiratory monitoring with additional intervention as needed. Importantly, the safety and effectiveness of Flexeril in pediatric patients below 15 years of age has not been established.