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

Orthopedic/Musculoskeletal
Inpatient Hospital

Diagnosis: Gout
Treatment: Inpatient Hospital Stay. The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male with history of smoking, alcohol abuse, and gout who presented to the emergency department (ED) with complaints of severe left foot pain. He was febrile, mildly tachycardic with normal blood pressure and oxygen saturation. His mental status was normal. His left foot was painful, swollen and tender around the first MTP (metatarsophalangeal) joint. His lab work revealed a white blood cell (WBC) count of 15.8, and Lactate of 3.7. An x-ray of the foot showed narrowed joint space. With a fever, WBC count and lactate and differential of severe sepsis with cellulitis versus (vs) gout, he was administered intravenous (IV) antibiotics and pain control.

Based on available documentation, the inpatient hospital stay is not medically necessary for this patient. The Initial impression from the clinical documentation supports severe sepsis - fever, tachycardia and lactate of 3.7 along with possible infection ( cellulitis) at the site of foot. Although severe sepsis was in the differential, the initial admission and podiatry consultation favored acute gout as the most likely diagnosis. For this reason, a lower level of care should have been reasonable and patient could have been upgraded as deemed necessary if severe sepsis panned out as a more likely diagnosis. In this case, it did not occur.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain. 
Treatment:  Inpatient hospital stay.  

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

The patient is  with a history of hypertension, diabetes, hyperlipidemia, and gastric cancer.  A myocardial perfusion imaging was performed to evaluate complaints of chest pain. This showed evidence of inferior ischemia.  The  patient presented to the hospital for scheduled cardiac catheterization.  Upon presentation, denied chest pain.  The  blood pressure was 138/75 mmHg with a heart rate of 94 beats/minute.  The  cardiac exam was unremarkable.  The  electrocardiogram was normal. Coronary angiography showed a 90% stenosis in the mid-right coronary artery that was treated with a drug-eluting stent. The procedure was uncomplicated.

The inpatient stay was not medically necessary.

This patient presented for elective cardiac catheterization after myocardial perfusion imaging showed evidence of inferior ischemia.  She denied chest pain upon presentation. She was hemodynamically stable.  Her electrocardiogram was normal. Coronary angiography showed a 90% stenosis of the mid-right coronary artery.  This was treated a drug-eluting stent.  The procedure was uncomplicated.  Accordingly, the care this patient received could have been provided at a lower level of care and an inpatient admission was not medically necessary.

While some period of observation immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, an inpatient admission is not generally required for most patients.  The 2009 Expert Consensus Document From the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes.  Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications.  Moreover, the EPOS (Elective Percutaneous coronary intervention (PCI) in Outpatient Study), a large randomized trial involving 800 patients who underwent elective PCI via a femoral arterial approach, found that same-day discharge after elective PCI is feasible and safe in the majority of patients and does not lead to additional complications, as compared to an overnight stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right foot pain
Treatment:   Inpatient stay.  The insurer denied the inpatient stay.
The determination is upheld.

The patient underwent a subtalar joint arthrodesis, gastrocnemius recession and lateral ankle ligament repair. Following surgery, the patient was admitted to the hospital and discharged the following day. The medical necessity of the inpatient stay is the issue under review.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. There was no medical justification for admitting this patient to the hospital. He was hemodynamically stable with a regular cardiac rhythm and was not suffering from intractable pain. Prior to discharge following surgery, the patient should demonstrate the following:  vital signs must be stable and consistent with age and preoperative baseline; must be able to ambulate with steady gait and no dizziness; minimal nausea and vomiting; pain should at least be controlled by oral analgesics; and no significant post-surgical bleeding (3).  There is no documentation in the medical record that the patient demonstrated anything other than a condition appropriate for discharge based on these criteria and no documentation of any complications related to the surgery performed.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems 
Inpatient Hospital  

Diagnosis: Chest pain 
Treatment: Inpatient hospital stay 

The insurer denied the inpatient hospital stay. The health plan's determination is upheld. 

The patient is a female who presented to the emergency department (ED) with chest pain. Her chest pain started two nights prior. She woke up in the middle of the night to go to the bathroom and then went back to sleep. She felt chest pain again in the afternoon in the sitting position. She then went to urgent care and from there to the ED. 

The inpatient hospital admission was not medically necessary for this patient. The patient presented with atypical chest pain. The patient had multiple coronary risk factors, including DM, hypertension (HTN), hyperlipidemia and MI. Her vital signs and physical examination was unremarkable. Her ECG, echo, cardiac enzymes, stress nuclear scan and CXR were unremarkable. The patient was dizzy because of diuretics, and felt much better after the diuretics were stopped. 

Her condition was stable and there were no evidence of acute coronary syndrome (ACS) or congestive heart failure (CHF). The inpatient level of care was not medically necessary. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Respiratory System 
Inpatient Hospital

Diagnosis: COPD 
Treatment: Inpatient hospital 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male with a medical history of hypertension, chronic kidney disease stage 3, alcohol and tobacco dependence, seizure disorder and chronic obstructive pulmonary disease (COPD) who was admitted for an acute COPD exacerbation with symptoms of shortness of breath on exertion, left-sided pleuritic chest pain, chills and a productive cough for one to three weeks prior to admission. 

The inpatient hospital stay was not medically necessary for this patient. On admission, the patient continued to be hemodynamically stable, was afebrile, was not in any acute distress, was not using accessory muscles, had an oxygen saturation of >90% on room air and had normal breath sounds without crackles/rhonchi/wheezes on auscultation of the chest. He did not have documentation/evidence for hypercapnia, hypoxemia or cyanosis, a sustained heart rate >=100 beats per minute, he was alert, awake and oriented, was able to protect his airway and did not require invasive or non-invasive ventilator support. Although he was found to have acute kidney injury on chronic kidney disease with an elevated serum creatinine, it improved to baseline within 24-hours with fluid hydration. Therefore, the patient's condition improved with a lower level of care and the inpatient hospital stay was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: LADA (latent autoimmune disease of adults)
Treatment: Continuous Glucose Monitoring System (CGMS)
The insurer is denied coverage for Continuous Glucose Monitoring System (CGMS).
The denial is reversed.
The patient is a male with LADA (latent autoimmune disease of adults). The patient has tried and failed Trulicity and metformin. His hemoglobin A1C on was 8.6. His hemoglobin A1C was 7.6. The patient is having postprandial hyperglycemia. The patient is requesting the use of DEXCOM CGM. While on a CGM, he has been noted to have improved blood sugars. He checks his blood sugars multiple times a day. The patient has a history of hypoglycemic unawareness.

According to Martin-Timon, I., & Del Canizo-Gomez, F. J. (2015), "CGMS, that can detect
hypoglycemia, represents an important technological advance on the methods used for self -monitoring of blood glucose, and they are welcome to both patients and clinicians. The ability of CGMS systems is to advise patients when glucose levels fall too low or rise too high, and has the potential to reduce de-duration of hypoglycemia and hyperglycemia events."

Howsmon, D., & Bequette, B. W. (2015) states, "The first commercial CGM, the MiniMed
(Medtronic, Northridge, CA), was approved by the Food and Drug Administration [FDA] in 1999, but alarms did not appear on commercial devices until the mid-2000s with the introduction of the Guardian (Medtronic, Northridge, CA) and the STS (DexCom, San Diego, CA) CGMs...Diabetic alarm systems potentially afford more effective diabetes management and an increased quality of life to those living with diabetes. While some signals are only capable of classifying a patient's state as normal and hypo - and/or hyperglycemic, others can estimate blood glucose concentrations. Furthermore, some signals are only suitable for detection of altered glycemic states while other signals can predict these undesirable events. Although standalone alarm systems will become obsolete with the development of the artificial pancreas, alarm systems will form the core safety components and have paved the way for insulin administration algorithms of various complexities."

The patient has LADA and has issues with hypoglycemic unawareness. The patient has tried and failed oral medications. It would be in his best interest to have a CGM. Therefore, the Continuous Glucose Monitoring System (CGMS) is considered medically necessary for this patient. The health care plan did not act reasonably or with sound medical judgment or in the  best interest of the patient.

Based on the above, the medical necessity for the Continuous Glucose Monitoring System (CGMS) is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Genitourinary/Kidney disorder
Inpatient hospital

Diagnosis: Endometriosis
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female s/p vaginal birth who presented to the emergency room. She complained of headaches and abdominal pain. Vital signs were normal. Radiological studies were normal. She was admitted as an inpatient hospital admission. She was provided intravenous fluids and antibiotics. She was afebrile. There is a question of the medical necessity of the inpatient hospital admission.

The Inpatient Hospital Admission is not medically necessary for this patient. The patient had a vaginal birth with self-reported complaints postpartum. Vital signs were stable and there was no evidence of hemorrhage. She was hemodynamically stable. She had no evidence of intracranial hemorrhage or infarction by radiological scan. Laboratory tests did not show any eclampsia or pre-eclampsia. She had no severe hypertension nor renal insufficiency. She had no evidence sepsis. She was given a diagnosis of endometritis, however, she could have been treated with oral antibiotics at a lower level of care. She could have had extended monitoring and there is no documentation to support the need for inpatient monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Maternal Sinus Tachycardia
Treatment: Inpatient Hospital Admission
The insurer is denied coverage for inpatient hospital admission. 
The denial is upheld. 
This is a female patient who was 36.2 weeks gestation who presented to the hospital after being seen in the clinic. She was sent to the hospital to be evaluated for  maternal tachycardia. Upon initial evaluation her vital signs were: blood pressure was 121/78, pulse was 127, respirations were 20, the temperature was 98.3F, and the blood oxygen level was 98%. The patient denied palpitations, chest pain, abdominal pain, decreased fetal movement, vaginal bleeding, or watery discharge. Fetal heart monitoring revealed a fetal heart rate (FHR) of 140 with moderate variability. Accelerations were present, but there were no decelerations. Tocodynamometer showed no contractions. Laboratory work up was performed that revealed a white blood cell (WBC) count of 14.5, a hemoglobin of 11.7, and platelets of 262, and  a D-Dimer that was 1178. An electrocardiogram (EKG) was done that showed a sinus tachycardia. An ultrasound was performed prior to her arrival to the hospital that revealed a single intrauterine pregnancy with a biophysical profile (BPP) of 10/10 with an amniotic fluid index (AFI) of 23.95. The patient was admitted to the hospital for sinus tachycardia, rule out pulmonary embolus. Cardiology and Maternal Fetal Medicine were consulted. Her treatment plan included intravenous (IV) fluids and Lovenox. A bilateral lower extremity venous Doppler study was performed with negative results for a deep vein thrombosis (DVT). A computed tomography angiography (CTA) of the chest was performed that revealed no evidence of a pulmonary embolism. A transthoracic echocardiogram (TEE) was performed and showed normal left ventricular size and systolic function. The patient's tachycardia continued during her hospital stay. The patient was medically stabilized and was then discharged.

Sinus tachycardia is a normal physiologic response to exercise and conditions in which
catecholamine release is physiologically enhanced or, less commonly, in situations where the parasympathetic nervous system is withdrawn as occurs with fever, hypotension, pain, anxiety, pulmonary embolism, etc.

Once the provider ascertained that the patient was stable, she could have been worked up as an outpatient. Cardiology consult and evaluation, as well as Doppler studies, do not require hospital admission. Once the provider made sure that there was no evidence of a pulmonary embolus, she could have been discharged to be followed up as an outpatient.
Based on all the information submitted, the inpatient hospital admission was not medically necessary. The insurer acted reasonably, with sound medical judgement, and
in the patient's best interest.

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

Diagnosis: Vomiting, nausea, epigastric pain  
 
Treatment: Inpatient Admission  

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

This is a male patient who has a medical history of liver disease and substance abuse.  He presented with nausea and vomiting.  He was also having epigastric pains.  He was afebrile and the vital signs were stable.  There were no peritoneal signs.  There was no leukocytosis.  The renal function was normal.  Computerized Axial Tomography (CAT) scans were negative for acute disease.  He was treated with a proton pump inhibitor (PPI), intravenous (IV) hydration and Zofran and he improved.  

Clinical indications for admission for vomiting (M-370) include intestinal obstruction or a significant metabolic derangement.  The patient did not have these conditions.  He also did not have hemodynamic instability, bacteremia, high fevers, or acute renal failure.  
This patient had vomiting and epigastric pain.  However, he responded to treatment with IV hydration, Protonix, and Zofran.  He could have received this treatment with observation status.  He did not meet MCG criteria for admission for vomiting.  The healthcare plan acted reasonably and with sound medical judgment and in the patient's best interest.  An inpatient admission was not medically necessary.  The denial is upheld.  

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

Diagnosis: Chronic lymphocytic leukemia
Treatment: Genetic testing
The insurer denied Genetic testing. The denial is upheld.

The patient is an adult male with CLL (chronic lymphocytic leukemia) treated with FCR (fludarabine, cyclophosphamide, rituximab) with resulting development of MDS (myelodysplastic syndrome). His AP (attending physician) performed NGS (next generation sequencing) panel testing.

There is no evidence that molecular profile testing is of any clinical value for the evaluation and treatment of patients with therapy-related MDS. This testing is not routinely supported by the NCCN. In a patient with MDS related to FCR with underlying CLL, molecular profile testing would not influence the recommendation for allogenic SCT (stem cell transplantation).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic lymphocytic leukemia
Treatment: Genetic testing
The insurer denied Genetic testing. The denial is overturned.

The patient is an adult male with a history of pancytopenia following chemotherapy.  A bone marrow biopsy was equivocal.  The AP (attending physician) ordered a GEN SEQ ANALYSIS to further diagnose and characterize his myelodysplastic syndrome.

The NCCN considers the molecular abnormalities tested for by this assay as prognostic and helpful for further management of this patient's myelodysplastic syndrome.

The requested molecular testing will be able to determine if the patient may require an allogenic stem cell transplant.  This procedure, although not without potential drawbacks, may be curative.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic lymphocytic leukemia
Treatment: Genetic testing
The insurer denied Genetic testing. The denial is upheld.

The patient is an adult male. The patient in this case has been diagnosed with chronic lymphocytic leukemia (CLL).  He was initially diagnosed a few years ago. He was treated with fludarabine, cyclophosphamide and rituximab (FCR) chemotherapy. Following completion of that treatment, he developed new pancytopenia.  This was felt to be concerning for autoimmune cytopenia versus myelodysplastic syndrome.  He was treated for possible autoimmune cytopenia and failed to respond.  Cytogenetic testing of his bone marrow was notable for an extra chromosome 8 (+8), loss of the Y chromosome.  He was also found to have a DNMT3A mutation in his marrow, and histologically there were ringed sideroblasts and evidence of dyserythropoiesis.  He was felt to possibly have MDS (myelodysplastic syndrome).  Molecular testing was done to look for acquired gene mutations, as that information was felt to possibly impact treatment recommendations.

Based on provided records, this patient was felt to likely have MDS based on bone marrow results, cytogenetic results and mutational testing.  Records say he had been found to have loss of the Y chromosome, gain of an extra chromosome 8, and also had been found to have a mutation in DNMT3A.  All of these changes are consistent with a diagnosis of MDS.  The presence of dyserythropoiesis and ringed sideroblasts in the bone marrow biopsy are also consistent with a diagnosis of MDS.  

NCCN guidelines indicate that mutation testing can be considered as a means of confirming a diagnosis of MDS, but NCCN does not say that such testing is necessary for treatment decision making.  This patient had already undergone bone marrow biopsy with the above findings before the molecular testing at issue was performed (based on provided documentation).  As there was no clear documentation of diagnostic uncertainty and as records indicate the testing was done rather to aid in treatment decision making, which NCCN does not support as routine and standard, the testing in this case cannot be considered to have been more likely to be beneficial than treatment decision making based on clinical, pathologic, cytogenetic and mutation testing already available before the further molecular testing at issue in this case was performed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hypertension.
Treatment:  Inpatient stay.
The insurer denied the inpatient stay.  The health plan's determination is upheld. 

This is a male with history of hypertension, who presented to the emergency department (ED) with a complaint of neck pain.  Pain began in his shoulders and then moved up to the back of his neck.  The patient went to urgent care where they found his blood pressure to be 200/140. 

The Inpatient Hospital Admission was not medically necessary for this patient.  Despite the patient having a systolic blood pressure over 200, there was no evidence of acute or worsening target organ damage.  The patient was treated with oral anti-hypertensive medications.  There were no clinical needs that required inpatient care.  This patient could have been monitored and treated at a lower level of care.

This patient did not have evidence of hypertensive encephalopathy, cerebral infarction, intracranial hemorrhage, myocardial ischemia, heart failure, aortic dissection, increased creatinine, papilledema, retinal hemorrhage, hemolytic anemia, seizure or other acute or worsening end organ damage due to severe hypertension.  Based on review of the available medical records and Milliman Care Guidelines (MCG), none of the severity of illness criteria were present to support inpatient admission.