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

Diagnosis: Pelvic pain and abnormal uterine bleeding

Treatment: Inpatient admission

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

This patient is a female who was admitted for surgery due to a diagnosis of pelvic pain and abnormal uterine bleeding. She underwent a laparoscopic hysterectomy and bilateral salpingectomy and cystoscopy. The procedure was reported as uncomplicated. The estimated blood loss (EBL) was 100cc. The post-operative progress note documented that the patient was stable, however was complaining of severe pain despite a benign physical examination. As of a specified date the pain was controlled with oral medications. The patient was discharged home.

There are many ways of performing 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.

Robotic assisted 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 MCG, Laparoscopic hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure. Inpatient stay may be needed for:
1) Surgical complications (bladder ureter or bowel injury or hemorrhage) 2) Conversion to abdominal hysterectomy 3) Complex surgery (staging of endometrial cancer) 4) Wound complications 5) Comorbidities.

This patient did not have any of the above conditions. Her procedure was uncomplicated. The post-operative phrase was uneventful and the patient was stable. The progress notes did not support the medical necessity for inpatient admission.

Please note that a robotic assisted laparoscopic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required. The inpatient admission was not medically necessary.

The health 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: Menorrhagia
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient was admitted to the emergency room with documented symptomatic anemia. The submitted medical records do not document the patient's pelvic examination or amount of vaginal bleeding. Her vital signs were stable with no evidence of hemodynamic instability. The patient underwent a blood transfusion of one unit over the first admission day, and the hemoglobin improved significantly. There are no submitted medical records to document the patient's medical condition on inpatient admission, including the status of her vaginal bleeding. Her vital signs were normal. She did not have significant co-morbidities to support inpatient admission. Therefore there is no evidence to confirm that the patient required inpatient admission due to her hemodynamic status. Therefore she could have been transfused blood in in a less acute care setting. Transfer to an ambulatory unit or an intermediate patient observation unit would be within the standard of care. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dehydration

Treatment:  Inpatient admission 

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

This patient is a male who presented to the emergency room for acute onset of abdominal pain, vomiting, and diarrhea.  His electrolytes were normal.  He had episodes of vomiting in the emergency room after oral medications.  He had clinical signs of dehydration, and he was admitted and received intravenous fluids.  He improved and was discharged.

This patient needed to be in the hospital due to the dehydration and inability to maintain oral hydration.  However, the patient could have continued to be treated on an observational basis, as he was not hemodynamically unstable.  This patient had a mild case of dehydration, and his electrolytes were normal.  His care was not complex and included intravenous fluids and observation.  He had no significant comorbidities that required a higher level of care.

The health care plan acted reasonably, and with sound medical judgment and in the best interest of the patient.  The approval for admission at the Observation level of care instead of an acute level of care was appropriate.  The inpatient admission was not medically necessary for this case.

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

Developmental Delays/Cognitive
Genetic Testing

The patient is girl with intellectual disability. She was slow to acquire some motor milestones and has had academic difficulties in school. For evaluation of her cognitive impairment, she has been tested with an electroencephalogram (EEG), chromosomal microarray, and fragile X deoxyribonucleic acid (DNA) analysis. None of these tests have revealed the etiology of her cognitive impairment. Her neurologic exam is normal. In an attempt to identify the basis of her condition, the provider has ordered a Whole Exome Sequencing test.

The health plan's determination is upheld. The Genetic Testing: Whole Exome Sequencing is not medically necessary for this patient.
Whole exome sequencing is a recently-developed laboratory technique that analyzes virtually all exons of an individual's DNA in a single setting. In this process, tens of thousands of genes are analyzed simultaneously. As a result, this technique has the potential to elucidate genetic mutations that underlie a patient's condition.
Whole exome sequencing carries a great deal of promise to become a valuable clinical tool in the future. However, at this time, insufficient information is known to allow the data acquired from the test to be clinically useful for most patients. In particular, the technique may allow gene mutations and polymorphisms to be identified, but the clinical significance of those mutations would remain unknown.
In other words, a patient with a neurologic condition, like this patient, may have one or more genetic mutations identifiable by whole exome sequencing, but whether those mutations underlie or contribute to her disease would remain unknown. Furthermore, even if a causative genetic condition is identified by whole exome sequencing, this information is generally useful only for genetic counseling purposes and is almost never valuable for patient management. Thus, for all of these reasons, whole exome sequencing is not considered medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Gastroesophageal reflux disease
Treatment:  Mediator release testing (MRT)
The Mediator release testing is not medically necessary.

The patient is a male with GERD (gastroesophageal reflux disease).  His symptoms continued despite traditional treatments with antacids, antihistamines, proton pump inhibitors.  He changed his diet, but the AP wanted the patient to have Mediator Release Test to see what foods were causing adverse effects. 

According to UpToDate:  Basophil histamine release is not standardized and is considered an investigative tool for drug, food, and environmental allergens.  When well-characterized allergens are used, this test is similar to skin testing in accuracy.  The test relies on living cells and thus requires that blood samples are submitted and tested within 24 hours.  Only a few laboratories perform the test. 

In addition, this test is not used for the evaluation of foods that cause GERD.  There is no testing that is approved to look at food sensitivities.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Major Depressive Disoder
Treatment: Transcranial Magnetic Stimulation
The health plan should cover the proposed treatment, Transcranial Magnetic Stimulation.

The requested service, Transcranial Magnetic Stimulation, is not unproven or experimental/investigational with regard to the scientific literature pertinent to this case. The services provided are in keeping with prevailing standards of medical practice for the condition under treatment in this case with evidence-base treatments; and, the requested services/treatment being provided in this case is clinically appropriate, and backed by credible scientific evidence known to benefit patients with the condition diagnosed in this case.

The requested health service or procedure, Transcranial Magnetic Stimulation, is likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease in this case scenario. 

The patient is an adult male with a history of treatment refractory obsessive compulsive disorder (OCD). The patient has had multiple medication trials with SSRIs (Prozac, Zoloft and Luvox); SNRI (Effexor); Wellbutrin; and Remeron. He has also received augmentation treatment with mood stabilizers (Lamictal and Lithium). The patient has received cognitive-behavioral therapy combined with his psychotropic medications. None of these standard treatments have produced a response or remission or sustained therapeutic benefit. Thus, the proposed Transcranial Magnetic Stimulation is reasonable and in the patient's best interest, and reflects sound medical judgment with regard to the next step in management of the patient's treatment refractory OCD. Repetitive TMS in this case is clearly supported by the scientific literature including randomized clinical trials and standards of medical practice. The proposed treatment is more likely to produce a clinical response or remission in this case with a reasonable degree of medical certainty based on the submitted documentation and the scientific literature, referenced below.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Major Depressive Disoder
Treatment: Transcranial Magnetic Stimulation
The health plan should not cover transcranial magnetic stimulation .

The requested health service is not likely to be more beneficial than any standard treatment for the insured's condition or disease. 

Given the information provided, this request is not recommended because the physician has not provided any objective information, for example via the provision of medical notes, indicating that this patient has, in fact, tried and failed treatment with the medications noted above. Also, there are no provided therapeutic notes indicating that this patient has had an appropriate trial of cognitive behavioral therapy. Additionally, the patient's diagnosis is not clear. The physician indicates that the patient has treatment resistant OCD (obsessive compulsive disorder); however, it is noted that other documents indicate that the patient has major depressive disorder, current, severe without psychotic features. It is also noted that TMS is not approved for the treatment of treatment resistant OCD.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Major Depressive Disoder
Treatment: Transcranial Magnetic Stimulation
The health plan should not cover the proposed treatment.

There is suggestive evidence that dTMS may prove to be an effective treatment for OCD, but at this time there is insufficient evidence to assert that the procedure is likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease. 

While the patient's YBOCS (Yale-Brown Obsessive Compulsive Scale) score has improved, there is insufficient evidence to attribute this to the specific treatment as opposed to other factors, such as patient expectations, placebo, confirmation bias, unknown changes in the patient's life, etc. 

The provider's assertion that there is a wealth of evidence of supporting OCD as an indication for dTMS, and his referring to it as the "gold standard" are not accurate. Also, the provider's citing approval by the FDA is misleading, as the FDA approval of dTMS for OCD is specifically as a Humanitarian Use Device (HUD), which clearly means the FDA considers there to be inadequate evidence of efficacy at this time. The FDA HUD approval was based on a single study involving 99 patients. Other published "studies" implying FDA approval is reprints by the manufacturer of the device and fails to note the HUD status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Excessive overjet, and deep impinging overbite.

Treatment:  D8080- Comprehensive Orthodontic Treatment and D8670- Periodic orthodontic treatment

The insurer denied coverage for D8080- Comprehensive Orthodontic Treatment and D8670- Periodic orthodontic treatment.  The denial was upheld.

This patient is a male child who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to excessive overjet, and deep impinging overbite.  The orthodontist has completed the HLD index as required and has chosen 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, as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 12 points on review by internal reviewers.

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, a Handicapping Labio-Lingual Deviation Index is utilized.  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 criterion is not met as there is no evidence of soft tissue damage, and does not support comprehensive orthodontic care.  In this case, the clinical circumstance does not meet criteria to justify orthodontic care.  This reviewer concurs with the HLD index of the insurer attaining 12 points (5 points overjet, 4 points overbite and 3 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.  Each of the peer reviewed articles cited 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 healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for D8080- Comprehensive Orthodontic Treatment and D8670- Periodic orthodontic treatment visit is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder-Severe-recurrent and PTSD.
 
Treatment: Repetitive TMS

The insurer denied the Repetitive TMS. The denial was reversed.

This is an elderly female patient with a history of Major Depressive Disorder-Severe-recurrent and PTSD. She had past history of abuse/trauma and had anxiety and post-traumatic stress syndrome (PTSD) symptoms as a result of it. It was noted that she had past psychiatric hospitalization for suicidal thoughts. Her presenting symptoms include severely dysphoric mood, suicidal ideation, anhedonia, poor sleep, decreased appetite and weight loss, feelings of guilt and helplessness, isolating, concentration and memory problems.  She reported that she has tried multiple antidepressant medications. She completed transcranial magnetic stimulation therapy in mid-2019 with positive results.  She reported that she had taken antibiotics and had worsened depression and was requesting another series of transcranial magnetic stimulation therapy treatments.

DSM V reports that for Major Depressive Disorder if there was remission of symptoms for 2 months it is considered in remission. If there is another major depressive episode after remission it is considered another episode which was the case with this patient as she had transcranial magnetic stimulation therapy treatment which was completed and resulted in a good response and remission but she worsened her symptoms after taking antibiotics due to medical issues so this was considered another treatment episode and not maintenance treatment. 

Transcranial Magnetic Stimulation Therapy was cleared by the FDA in October 2008 and indicated for the treatment of major depressive disorder in patients who failed or who did not have satisfactory improvement from 1 past antidepressant medication at or above minimal effective dose and duration in the current episode. Neurostar TMS Therapy System was the largest multisite (23 centers) randomized sham controlled trial ever conducted with transcranial magnetic stimulation therapy. This was the principal study for the FDA's approval of transcranial magnetic stimulation therapy for major depressive disorders in October 2008.  

Based on the above, the medical necessity for repetitive TMS is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Right lower quadrant pain
Treatment:  Inpatient admission

The patient is a male.  He presented with 12 hour history of abdominal pain.  The pain was initially periumbilical, now migrating to the RLQ (right lower quadrant).  The pain was 8/10 associated with nausea and vomiting.  There was tenderness in the RLQ on physical exam, and CT imaging was consistent with acute appendicitis.  The patient's WBC (white blood count) was elevated at 11.37, with mild left shift. 

The patient was taken to surgery, and he recovered as expected.  His diet was advanced, and he was discharged on PO (postoperative) day #1.  There was no perforation or pus seen during surgery. 

After either open or laparoscopic appendectomy for nonperforated appendicitis, patients may be started on a clear liquid diet and advanced as tolerated to a regular diet.  Antibiotics are not required postoperatively.  Most patients are discharged within 24 to 48 hours of surgery.  Same-day discharge is feasible, most commonly following a laparoscopic appendectomy.

In this particular case, the patient presented with nonperforated appendicitis with no evidence of sepsis.  This was also confirmed on both diagnostic imaging (CT) and operative visualization.  There were no untoward events during the minimally invasive procedure, and the patient recovered in stable condition, as expected.  This patient could have been managed in a lower level of care setting.
Appeal type: Medical necessity
Decision: Upheld

Diabetes
Inpatient Hospital

The patient with a past medical history significant for uncontrolled diabetes mellitus, diabetic neuropathy, retinopathy, hypertension, dyslipidemia, hepatitis C virus, chronic pancreatitis, right eye blindness, depression, alcohol dependence, and cocaine abuse who presented to the emergency department for detoxification from alcohol. During the evaluation in the emergency department, the patient's blood glucose was found to be over 500. In the emergency department, she received treatment with intravenous fluids as well as subcutaneous insulin. The health plans determination of medical necessity is upheld in whole. The requested health service/treatment of inpatient stay was not medically necessary for this patient.
The patient did not have any glycemic emergencies, her blood sugars were brought down fairly quickly, and her dehydration and acute kidney injury were treated adequately within a short period of time. The patient presented to the hospital with elevated blood sugars, acute kidney injury, pseudohyponatremia due to hyperglycemia.
At the time of the initial evaluation and during the hospital stay the patient had no signs of glycemic emergencies including diabetic ketoacidosis or hyperglycemic hyperosmolar state.
There was no evidence that the patient had altered mental status, significant hypovolemia or dehydration, intractable nausea or vomiting, severe electrolyte abnormalities, or any concomitant infection. The patient's hyperglycemia and mild acute kidney injury responded to treatment fairly quickly.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suspected infection  

Treatment: Inpatient hospital admission

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

This patient is a male child with a history of sickle cell anemia and lead poisoning. This patient presented to the Emergency Department with complaints of fever (101.2 F by history) and a sore throat for 2 days.  Physical examination showed an alert and awake boy with normal skin turgor, 100.6F temperature with other vital signs normal, spleen enlarged palpable about 6 cm below costal margin splenomegaly, scleral icterus, and oropharyngeal erythema without exudates. The only significant abnormal lab findings were abnormal only for borderline elevated white blood cell count of 14,900, with 70% neutrophils, increased reticulocyte count (7.7%), and bilirubin (8.2mg/dL). 

This reviewer disagrees with the hospital that the patient could not have been safely treated in an outpatient setting. In fact, there is no evidence in the chart to support a suspicion of acute sickle cell crisis or bacteremia. The ED physician's medical decision-making statement was that the rapid strep came back neg., clinically, the patient did not show any sign suggesting a crisis, no symptom other than sore throat, but considering the patient's WBC was elevated and the patient was still febrile on repeat of T, he would be admitted for suspected infection. 

Note that bilirubin could be elevated as a baseline. The elevated lactate (440U/L) in the appeal letter appears incorrect (the units U/L are applicable to Lactate dehydrogenase (LDH) not lactate, and the LDH was mildly elevated as can be seen in children even in the absence of or mild infection. There was no evidence of dehydration, sepsis, bacterial infection, or documentation of increasing splenomegaly (no baseline available). The documentation did not include his baseline spleen size. If indeed he was manifesting an acutely increasing spleen size, this would be from a sequestration crisis due to trapping of a significant proportion of the blood volume, and there would a rapid drop in the hematocrit with hypovolemia, and thrombocytopenia (Reference Ware et al, 2017).

The hospital appears to be incorrectly using these MCG for Inpatient admission: 

1) "Other significant finding or clinical condition judged not to be within scope of observation care, and 

2) "Treatment or monitoring requiring inpatient admission ... Other treatment or monitoring requiring inpatient admission." 
Both of these are very subjective criteria. 

They are also using InterQual guidelines fever as need for IV hydration when there was no evidence of increasing splenomegaly. It would be clinically appropriate in this case to use anti-infectives followed by outpatient follow up, pending results of blood culture (Reference Yawn et al, 2017).
  
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 hospital admission not substantiated.  The insurer's denial is upheld.