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

Diagnosis: Chronic gastroesophageal reflux disease (GERD)

Treatment gastric service (procedure code 43239)

The insurer denied coverage for gastric service (procedure code 43239)

The denial is overturned

This is a patient with a history of hiatal hernia, morbid obesity, hypothyroidism, high blood pressure, and chronic gastroesophageal reflux disease (GERD). The patient underwent a gastroscopy [43239] for evaluation of her condition. The patient noted blood in her sputum but had a negative ear nose throat (ENT) and pulmonary evaluation for this specific complaint. The patient had chronic GERD maintained on famotidine.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The plan did not take into account the fact that the member had blood noted in her sputum with a negative ENT (Ear Nose and Throat) and pulmonary evaluation.

The gastric service (procedure code 43239) is considered medically necessary for this patient.

This patient had blood noted in her sputum with a negative ENT and pulmonary evaluation. As such it is incumbent upon the treating provider to undertake an investigation of her esophagus and stomach, especially in the setting of chronic GERD in a morbidly obese patient. Given the patient has blood in her saliva despite H2 (inhalation of hydrogen gas) therapy further testing is warranted. Therefore, the request for gastric service (procedure code 43239) is considered medically necessary for this patient.

Cleveland Clinic. (2021), "You may need an upper endoscopy if you have unexplained: 

	Abdominal pain
        Bleeding in the upper digestive tract. 
	Nausea and vomiting
	Swallowing problems
	Weight loss

ASGE (American Society for Gastrointestinal Endoscopy) guidelines (2012), " Esophagogastroduodenoscopy (EGD) is generally indicated for evaluating: A Upper abdominal symptoms that persist despite an appropriate trial of therapy."

Ahlawat, R.et al. (2022), "EGD is a diagnostic endoscopic procedure that includes visualization of the oropharynx, esophagus, stomach, and proximal duodenum. It is one of the most common procedures that a gastroenterologist performs"

The insurer's denial of coverage for gastric service (procedure code 43239) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute pancreatitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The medical records indicate the patient has a history of alcohol-induced acute pancreatitis, anxiety, and seizure disorder.

She presented to the emergency department with abdominal pain, chest pain, nausea and vomiting for one week. She was admitted to the hospital the same day. She received intravenous fluids, intravenous antiemetics and laboratory work. The patient left the hospital against medical advice (AMA).

While the patient presented with emesis and electrolyte abnormalities from acute pancreatitis, the care could have been provided in its entirety at a lower level of service.

"Acute pancreatitis (AP) is one of the most common gastrointestinal causes for hospitalization in the United States. In 2015, AP accounted for approximately 390,000 hospitalizations. The burden of AP is only expected to increase over time. Despite recent advances in medicine, pancreatitis continues to be associated with a substantial morbidity and mortality. The most common cause of AP is gallstones, followed closely by alcohol use. The diagnosis of pancreatitis is established with any two of three following criteria: (1) Abdominal pain consistent with that of AP; (2) Serum amylase and/or lipase greater than three times the upper limit of normal; and (3) Characteristics findings seen in cross-sectional abdominal imaging. Multiple criteria and scoring systems have been established for assessing severity of AP. The cornerstones of management include aggressive intravenous hydration, appropriate nutrition and pain management." (Chatila, A. T., Bilal, M., & Guturu, P. 2019)

"Acute pancreatitis is the leading cause of gastrointestinal-related hospitalization in the United States, and its frequency continues to rise in the United States and worldwide. The severity of the disease varies widely, from mild disease needing conservative treatment to severe and complicated disease with high morbidity and mortality." (Gapp J, Chandra S. 2022)  

An inpatient admission to Interfaith Medical Center is not medically necessary. 

Despite the patient's presentation the care, as provided, could have been rendered in its entirety at a lower level of care. The patient did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.

As such, the care was not medically necessary and could have been rendered at a lower level.                                                         

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

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's dementia, stroke, and heart disease
Treatment: 168 hours/week, consumer direct, personal care aide, 1 client
The insurer denied coverage for 168 hours/week, consumer direct, personal care aide, 1 client
The denial is upheld

This is a patient with Alzheimer's dementia, stroke, and heart disease. At the time of the Uniform Assessment System (UAS) evaluation, the patient was in a skilled nursing facility for rehabilitation after a stroke. At home he lives with his spouse who reportedly also has dementia. His daughter lives in the same building on the second floor. The patient is currently approved for Consumer Directed Personal Care Aide (CDPCA) 112 hours/week and is requesting an increase to 168 hours/week.

According to the most recent UAS, the patient's cognition is described as "moderately impaired." He was confused and disoriented during the evaluation. The patient requires maximal assistance for bathing, personal hygiene, dressing and toilet transfer/use. He is frequently incontinent of bowel and bladder. Extensive assistance is needed for bed mobility and eating. The patient's cognitive deficits and functional impairments support the medical necessity of CDPCA 112 hours/week. However, his condition and functional needs are not at a level or unpredictable as to require the requested CDPCA 168 hours/week. This physician would also agree the patient may require 24-hour monitoring. However, safety monitoring under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by the authorized CDPCA 112 hours/week.  

From a physical medicine and rehabilitation perspective, the increased 168 hours/week, consumer direct, personal care aide (CDPCA) 1 client is not medically necessary.   

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

The insurer's denial of coverage for 168 hours/week, consumer direct, personal care aide, 1 client is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pancreatic carcinoma.
Treatment:  Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

The patient had surgery for pancreatic carcinoma and was receiving chemotherapy. He now presented with vomiting. By the time of admission, he was afebrile, and the vital signs were stable. There was no abdominal rebound or guarding. The WBC (white blood cell) count was 17 .8. The BUN (blood urea nitrogen) was 15.6 with a creatinine of 1.8. IV (intravenous) hydration and antibiotics were given. The CT (computed tomography) scan was negative for intestinal obstruction. The WBC count and the creatinine returned to normal the following day. He responded well to the IV fluids, antiemetics, and antibiotics and was able to tolerate a diet. 

Clinical indications for admission for Dehydration (MCG [Milliman Care Guidelines] M-123) include hemodynamic instability, bowel obstruction, vomiting that persists after appropriate antiemetic treatment, altered mental status, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

Clinical indications for admission for Vomiting (MCG M-370) include having a severe metabolic derangement, hemodynamic instability, severe electrolyte abnormalities, severe pain, bacteremia, acute kidney injury as manifested by both a two-fold increase in creatinine along with mental status changes or worsening cardiopulmonary condition, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient developed vomiting after receiving chemotherapy. He did not have an intestinal obstruction. He required IV hydration and antiemetics and then improved. This treatment could have been given with observation status. He did not meet MCG criteria for admission for either Dehydration or Vomiting. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

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

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

Diagnosis: Gastroparesis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

The patient presented with vomiting, diarrhea, and abdominal pain. She was afebrile but had hypertension. The abdominal exam was benign. The white blood cell (WBC) count was 17.6. An abdominal computerized axial tomography (CAT) scan revealed a hiatal hernia and possible gastritis. She had multiple previous admissions for similar symptoms and had a diagnosis of diabetic gastroparesis. A gastric emptying study was done and showed a delay in gastric emptying. She was treated with metoclopramide and pantoprazole. Her diabetes was poorly controlled. The hypertension improved with treatment. 

Milliman Care Guideline (MCG) clinical indications for admission for Vomiting (MCG M-370) include having vomiting due to a significant metabolic derangement, hemodynamic instability, severe vomiting not responsive to antiemetic treatment in observation care, severe electrolyte abnormalities, severe pain, bacteremia, acute renal failure, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

MCG clinical indications for admission for Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions. 

This patient had gastroparesis and required intravenous hydration, Reglan, and Pantoprazole. These treatments could have been given with observation status. She did not meet MCG criteria for admission for either Vomiting or Undiagnosed Abdominal Pain. 

The health care plan acted reasonably and with sound medical judgment. 

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

Diagnosis: Asthma
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is a male with history of eczema who presented to the emergency department (ED) with difficulty breathing. Additional symptoms include fever, vomiting, diarrhea, and cough. Symptoms began 1-2 days prior to arrival.

ED vitals were temperature (T) 37 degrees Celsius (C), heart rate (HR) 150, respiratory rate (RR) 55, oxygen (O2) sat 95% (percent) on room air. The patient was in respiratory distress with subcostal and suprasternal retractions, crackles and wheezes heard on auscultation. The patient was started on Duoneb (ipratropium/albuterol) treatment x (times) 3 and prednisone. Respiratory panel was positive for adenovirus and rhinovirus. Chest x-ray was normal.

Despite treatment in the ED, the patient continued to have retractions, use of accessory muscles, tachypnea, and hypoxemia (91-94% post nebulizers). The decision was made to admit 4 hours after arrival in ED for further management of asthma. While inpatient the family was seen by social work with significant stressors identified (mice, roaches, active domestic violence [DV] case, financial insecurity). The patient was discharged home with a nebulizer to complete a course of albuterol and Decadron.

At issue is whether the inpatient hospital admission was medically necessary for this patient.

The health plan's determination is overturned.

The requested health service of inpatient hospital admission is medically necessary for this patient. This is a male without prior wheezing who presented with acute respiratory distress. He improved with ED treatment, but still required medication and vital sign monitoring at the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Germ cell tumor
Treatment: Magnetic resonance image (MRI) scan (abdomen and pelvis)
The insurer denied the Magnetic resonance image (MRI) scan (abdomen and pelvis)
The denial is overturned.

The patient is a male with germ cell tumor.  The attending physician (AP) has performed magnetic resonance image (MRI) for surveillance every six months.  The patient recurred and underwent retroperitoneal lymph node dissection (RPLND). The attending physician (AP) has requested magnetic resonance image (MRI) scans.

The health plan denied the proposed magnetic resonance image stating that "Per health plan policy guidelines, and per national cancer guidelines (NCCN), CT (computed tomography) scans, not MRI scans, are medically necessary to follow-up testicular cancer.  Follow-up scans three months after surgery, six months after surgery, and 12 months after surgery are approved by the health plan. Then every six months for two more years.  Then, annually through year five.  The timing of your exam, was nine months after surgery.  This does not follow the recommended intervals according to the health plan or the national cancer guidelines."

Yes, the proposed magnetic resonance image (MRI) is medically necessary.
The National Comprehensive Cancer Network (NCCN) does state that magnetic resonance image (MRI) can replace computed tomography (CT) scans for surveillance of germ cell tumor.  The National Comprehensive Cancer Network (NCCN) does not list what circumstances would justify this approach.  However, as this is in line with the National Comprehensive Cancer Network (NCCN) it would be considered appropriate.  In addition, the National Comprehensive Cancer Network (NCCN) does state that the same imaging needs to be used throughout the surveillance protocol.

Following surgery, for stage I seminoma without chemotherapy, the National Comprehensive Cancer Network (NCCN) supports surveillance every six months for the first two years.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: inpatient admission 
The insurer denied coverage for an inpatient admission 

The denial is overturned.

This is a patient that presented to the hospital complaining of shortness of breath and chest pain. The chest pain was continuous and lasted for hours and was exacerbated with exertion. The patient's past medical history was significant for hypertension, chronic lower extremity edema and methadone use. Upon arrival to the hospital, his BP (blood pressure) was 198/106mm Hg (millimeters of mercury) and his pulse was 88bpm (beats per minute). A physical exam revealed bilateral pedal edema. A 12-lead electrocardiogram (ECG) revealed ST (interval on an ECG) elevations in the anterior leads. Serum blood testing revealed an elevated B (brain) type natriuretic peptide (BNP) (528pg (picograms)/ml (milliliters)) and a troponin level of 0.034 ng (nanograms)/ml. The patient was brought for urgent cardiac catheterization that revealed normal coronary arteries. An echocardiogram revealed a preserved left ventricular ejection fraction. Following catheterization, his blood pressure remained elevated (211/115mmH) and the patient was admitted to the CCU (cardiac care unit) for aggressive management of hypertension. He responded to intravenous nicardipine. He was also treated with benzodiazepines and methadone. The patient was being transitioned to oral anti-hypertensive medications when he signed out against medical advice. 

The health care plan did not act reasonably, with sound medical judgment and in the best interest of the patient.  A hypertensive emergency is defined as BP > (greater than) 180/120 with target organ damage. (Reference 1) In this patient, the BNP was elevated and consistent with left ventricular target organ damage. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction. (Reference 2) Given this patient's failure to respond to initial medical therapy, admission to the hospital for aggressive blood pressure management was necessary. In fact, American Heart Association guidelines recommend admission to the ICU (intensive care unit) for management of hypertensive emergencies (Reference 1). In conclusion this patient should have been managed at a higher level of care. A hospital admission was medically necessary.  
The insurer's denial of coverage for a hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain
Treatment: Chiropractor services
The insurer denied coverage for chiropractor services
The denial is upheld

The letter to the patient outlined reasoning for denial of services as being not medically necessary and that the benefit plan provides benefits for chiropractic services if certain clinical criteria are met. It was determined that the requested health service does not meet these medical criteria.  

This letter also indicated that the member had reached Maximum Therapeutic Benefit (MTB), or no significant clinical change was demonstrated. A request for continued care at a rate of 2x/week was not supported in the clinical records.

No significant exacerbations were documented, and flare ups were due to "simple activities of daily living."  

The CCGPP [Council on Chiropractic Guidelines and Practice Parameters] guidelines indicate, "When the patient's condition reaches a plateau, or no longer shows ongoing improvement from the therapy, a decision must be made on whether the patient will need to continue treatment."

The notes reviewed did not support lasting improvement or meaningful change from treatment and suggests maintenance care for a chronic condition is being provided and not covered per the health plan. Denial is appropriate. 

CCGPP guidelines state that for a trial of care to be considered beneficial, it must be substantive, meaning that a definite improvement in the patient's functional capacity has occurred.  Examples of measurable outcomes and activities of daily living and employment include the following: pain scales, pain diagrams, outcome assessment forms. The PCN (primary care network) did not support appropriate use of successive objective measurements for improvement, nor did the records support that the clinical condition displays meaningful and lasting improvement in response to therapy. Denial is appropriate.

The records suggest physician dependency for supportive care.  The notes do not support weaning the patient off of supportive care and onto a HEP (home exercise plan) or self-management. This ongoing care, without meaningful improvement is not medically necessary, per the healthcare plan.    

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

The insurer's denial of coverage for chiropractor services is upheld. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abscess
Treatment: Hospital admission
The insurer denied coverage for the hospital admission.
The denial is overturned.

This is a female patient with a past medical history significant for coronary artery disease, diabetes, hypertension, hyperlipidemia, and post-traumatic stress disorder, who presented to the emergency room with complaints of redness and irritation of the mons pubis area.

Vitals on presentation included: Temperature 38.2 degrees C (Celsius) , Blood Pressure 115/85, Pulse 110, Respiratory Rate 16, oxygen saturation at 97% on room air. Laboratory results included the following: WBC (white blood cell count) 19.1, HGB (hemoglobin) 14.0, HCT (hematocrit) 39.5, creatinine 0.6, and a glucose of 196.

The patient was admitted for a mon pubis area abscess. She was treated with intravenous fluids and intravenous antibiotics (vancomycin and Zosyn). A CT (computed tomography) scan of the abdomen/pelvis showed left perinephric edema, anterior pelvic wall edema and left paramidine subcutaneous wound versus surgical defect. She underwent an incision and drainage procedure. Culture grew methicillin-resistant Staphylococcus aureus (MRSA). The patient remained afebrile, hemodynamically stable, and was discharged on oral antibiotics to continue follow-up as an outpatient.

The patient was febrile (38.2 C) with tachycardia (HR (heart rate) 110) and laboratory results showed an elevated WBC (19.1) and hyperglycemia (glucose-196). Based on these abnormalities, there was concern for complications of infection that warranted hospital admission for administration of intravenous antibiotics and surgical intervention.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.