Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Uncontrolled Open Angle Glaucoma
 
Treatment: Insertion of Aqueous Drainage Device
     
The insurer denied the Insertion of Aqueous Drainage Device. 
The denial was reversed as all three panelists determined that the requested service, the Insertion of Aqueous Drainage Device, is more beneficial for this patient than other standard treatments. The denial was reversed.    

This patient is an elderly male who has a history of uncontrolled open angle glaucoma.  The documentation indicated he has had prior treatment to include multiple ocular medications. He developed an allergy to Alphagan P, which limited his drop therapy options.  He has a history of trabeculectomy procedure in the left eye in 2011. After a lengthy discussion, both the physician and the patient decided that surgery in the right eye. The XEN procedure was the best option to control the patient's intraocular pressure and limit further progression and vision loss.  The patient did undergo the procedure on in late 2018.  The physician detailed that the patient's surgical intervention provided 
Medical literature indicates that minimally invasive glaucoma surgery aims to provide a medication-sparing, conjunctival-sparing, ab-interno approach to intraocular pressure reduction for patients with mild-to-moderate glaucoma that is safer than traditional incisional glaucoma surgery. results. The XEN gel stent offers an ab-interno approach to creating a fistula to the subconjunctival space. It appears to have a similar efficacy and adverse event profile that is similar to trabeculectomy.  The Food and Drug Administration (FDA) approved XEN Glaucoma Treatment Systems for the management of refractory glaucoma, including cases where previous surgical treatment has failed, cases of primary open angle glaucoma, and pseudoexfoliative or pigmentary glaucoma with open angles that are unresponsive to maximum tolerated medical therapy. The patient was shown to try and fail medication.  When medication fails, a glaucoma patient typically will require surgery as glaucoma is a progressive and blinding disease.  The provider showed that medication in the right eye failed; the requested procedure was appropriate.  The literature does recommend the requested procedure in a patient with a failure of maximum medical therapy; the requested procedure would likely be more beneficial in this case.  

The carrier's denial of coverage for code 0449T- Insertion of aqueous drainage device, without extra-ocular reservoir, internal approach, into the sub conjunctival space; initial device (XEN Glaucoma Treatment System) performed on the right eye should be reversed.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for hypothyroidism and tobacco use who presented to the hospital for evaluation of a persistent cough that he had for 2 months.  The cough was initially nonproductive, but in the last several days that preceded the day of admission, the patient noticed yellowish sputum. The patient reported some improvement of his symptoms after receiving treatment with corticosteroids and DuoNeb.  He was seen by a pulmonologist who agreed with the treatment with antibiotics and oral corticosteroids and also recommended to follow-up on the results of the computed tomography (CT) scan of the chest. The CT scan of the chest demonstrated a small region of hazy opacity at the posterior right upper lobe consistent with a small region of atelectasis and/or infiltrate. The health plan's determination is upheld.

This patient presented to the hospital with complaints of a chronic cough with a recent exacerbation. The cough was associated with mucus production and some shortness of breath related to ambulation. The initial evaluation, which included a chest x-ray, was unremarkable, and the patient's oxygen saturation at rest was within normal limits. Subsequently, the CT scan of the chest demonstrated a small area of hazy opacity that could represent pneumonia. Even if the patient had pneumonia, an inpatient hospital admission was not indicated, based on the calculation of CURB-65 [confusion, BUN, respiratory rate, blood pressure, age greater than or equal to (65) years] pneumonia severity score, which is used for risk stratification in order to decide on the necessity of inpatient hospital stay for patients with community-acquired pneumonia. Based on the calculations the patient received 0 points, therefore he belonged to a low-risk group of patients with adverse outcome. The patient had a mildly elevated troponin level and was evaluated by a cardiologist who suggested that the patient's symptoms and EKG were not consistent with the acute coronary syndrome.

Taking into consideration all of this information, neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male who presented to the emergency department (ED) on with left arm abscess. He was seen by his primary medical doctor 3-days prior to presentation and was started on Bactrim and Augmentin. At the time of presentation, he was well-appearing. There was localized swelling of the left forearm with 2-centimeter (cm) abscess and surrounding erythema. He was without fever and vital signs were normal. The white blood cell (WBC) count was 10.6 thousand (K). He was started on intravenous (IV) antibiotics (Vancomycin). Surgical consultations was requested. He underwent surgical incision and drainage of the left forearm. He was considered to be stable for discharge from the inpatient setting with continued oral antibiotics.

The health plan's determination is upheld.

No. The submitted hospital records do not support the medical necessity of inpatient care. The patient presented and was admitted to the hospital with an abscess of the left arm and associated cellulitis. The submitted records support that the patient was clinically stable with normal vital signs at the time of presentation. He did require prompt surgical assessment, and incision and drainage (I&D) of the left arm abscess as was performed. He was appropriately treated with perioperative IV antibiotics (Vancomycin). The patient did not have leukocytosis or clinical indications of sepsis. He was clinically stable, and the care and treatment provided could have reasonably and appropriately been rendered at a lower level of care status, which would have allowed for surgical treatment, provision of IV antibiotics and overnight monitoring.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of polymyositis.  The patient was admitted to the hospital for decompensated biventricular heart failure and severe pulmonary hypertension.  The patient was diagnosed with interstitial lung disease.  The patient was given 500 milligrams (mg) of SoluMedrol and then prednisone 60 mg daily.  The patient was given rituximab per rheumatology's recommendation.  He is supposed to be worked up for a lung transplant.  The patient is on digoxin and diuretics.  Spirometry showed severe restrictive lung disease.  The health plan's determination of medical necessity is upheld.  
There are no adequate or well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature that established the long term efficacy and safety of rituxan for the treatment of this patient's medical condition.  There is no high-quality literature showing an improvement in health outcomes with the use of Rituxan for this patient condition.  Therefore, the patient does not meet criteria for medical necessity of the requested medication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain on exertion
Treatment: Inpatient admission
Inpatient level of care was not medically necessary.
This patient underwent evaluation for surgery that revealed coronary artery disease (CAD). Symptoms were present for six months and the patient was electively admitted. Radially performed, he had a successful procedure without complications. 

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 give this care. This 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 present for six months and discovered during routine pre op evaluation. Exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. CXR was normal. Echocardiogram showed no wall motion at rest.  Orders did not include medical therapy for acute coronary syndrome (ACS) such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG). The review of procedure did not show other deviation from standard care. Uncomplicated radial artery approach led to placement of left anterior descending (LAD) stent.

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only cardiac care provided post procedure 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 complications that required inpatient care.  While there is always a potential for an adverse event, one did not happen and no actual inpatient treatment was added.

Milliman criteria requirements were not fulfilled as there was never any evidence of ACS present. The patient did not have unstable angina as symptoms present for six months and when ischemia was discovered led to an elective approach.

No evidence was presented that any of the care could not "be managed in an outpatient setting". Per the standard in the community, catheterizations and PCIs are routinely performed an outpatient setting. 

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.

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

Diagnosis: Coronary Angiogram 

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.  

This is a male patient who presented to the hospital in early 2019 for a coronary angiogram due to an abnormal stress test.  His stress test had shown a small size, mild severity defect in the basal inferolateral wall which was reversible and suggestive of ischemia. Patient has history of hyperlipidemia, stroke and tobacco use. He underwent coronary angiography with failed attempt at revascularization of a 100% occluded left circumflex artery. There was no procedural, clinical, or hemodynamic complication. 
The patient was admitted but discharged home later the same day. 

Per MCG 22nd Guideline Cardiovascular Surgery or Procedure GRG: SG-CVS (ISC GRG), cardiac catheterization is an outpatient procedure. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

The patient is a man with a history of diabetes, chronic kidney disease (nephrotic syndrome), tobacco abuse, and hypertension. He presented to the emergency room with a one-day history of nausea, vomiting, abdominal pain, and diarrhea. Two days previously he had been started on furosemide. On physical exam, his vital signs were normal and he was in no distress. There was some left upper quadrant tenderness and trace lower leg edema. Labs were notable for a creatinine of 3.4 (baseline was 2.0). The patient was admitted to observation for further treatment and evaluation.

Upon admission, the patient was treated with intravenous fluids. The following day, he continued to report nausea and diarrhea. The creatinine remained elevated at 3.2 and an abdominal computed tomography (CT) scan revealed thickening of the distal ileum and proximal right colon. He was admitted to inpatient. Intravenous hydration was continued. The next day, the patient was feeling better and the creatinine was down to 2.5. He was discharged.

The health plan has denied the inpatient admission as not medically necessary. The health plan's determination is overturned. Based on a review of the information provided the acute inpatient admission was medically necessary. The justification of the acute inpatient stay was the need to aggressively treat a complex patient with a potentially life-threatening acute condition. Specifically, the patient has chronic kidney disease with the nephrotic syndrome who acutely developed worsening renal failure. The services provided throughout the inpatient hospital stay could not have been safely provided at a lesser level. The acute kidney worsening renal function was most likely due to severe dehydration from a possible viral gastroenteritis. However, the abdominal CT scan abnormalities of uncertain etiology, along with the necessity due to the patient's nephrotic syndrome to avoid overhydration, was a clinically complex situation necessitating acute inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea, Shortness of breath
Treatment: Inpatient admission 
The proposed treatment inpatient admission is not deemed medically necessary. 
This is a male patient with a history of recently diagnosed pancreatic cancer, deep venous thrombosis (DVT) and pulmonary embolism (PE) who presented to the ER for further evaluation/management of worsening dyspnea. Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. Examination was non-focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities. Laboratory and ECG testing was also within normal limits with no significant abnormalities noted including no evidence of acute end organ damage. The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where he received supportive care with intravenous (IV) fluids and continued cardiac monitoring. He responded well to the prescribed therapies and was subsequently discharged in stable condition. There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.
Appeal type: Medical necessity
Decision: Overturned

The patient presented for evaluation and treatment of tooth # 30. Provided for review are previous letters of appeal and denial, a single peri-apical radiographic images from an unknown date, one page of claim forms, clinical notes from 5/9/19 and health plan documentation. In question is the medical necessity of the planned treatment of (3425) apicoectomy molar first root #30, (3426) apicoectomy (3426) molar additional root #30, (3430) and retrograde filling per root x2 #30. From the documentation provided the patient has symptomatic peri-apical periodontitis after having previous root canal therapy. The health plan's determination is overturned. 

The requested health service/treatment of Apicoectomy, (1st and 2nd tooth root), and retrograde filling (tooth #30) medically necessary for this patient. For the current diagnosis of symptomatic peri-apical periodontitis with previous endodontic therapy, the desired therapy of apicoectomy and retrograde fill are common treatments and are medically necessary. As the apex of the roots of #30 have been previously instrumented and filled yet still represent with retrograde infection, it is generally accepted that accessory canals exist at the apex that are more predictably removed using an apicoectomy procedure. With the removal of the tissue there is a necessity to ensure that a neoplasm of malignant origin is not present, however incisional biopsy was previously approved by the health plan. Hence, the treatment of (3425) apicoectomy molar first root #30, (3426) apicoectomy (3426) molar additional root #30, (3430) retrograde filling per root x2 #30 are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting and diarrhea
Treatment: Inpatient admission

Inpatient admission was not medically necessary.

Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of five years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications.

This patient presented to the ED with vomiting and diarrhea, failing outpatient management with Pedialyte and antacid as provided by the pediatrician. She was hypoglycemic upon presentation to the ED and continued to vomit despite fluid resuscitation (she was not given an antiemetic). Following admission, she had not yet voided and had two more episodes of vomiting with advancing diet. After a fluid bolus and administration of Zofran, she was able to tolerate advancing diet and began voiding. Despite the vomiting, she remained hemodynamically stable. She did not require acute inpatient admission, but could have been safely managed at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: RLE swelling and dyspnea 
Treatment: Inpatient admission
The inpatient admission was medically necessary.
Although the patient does not meet initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (1), her allergy to penicillin, presence of diabetes and a burn injury made the admission medically necessary according to standard of care. Diabetic patients are at increased risk of pseudomonas infections, as are patients with burns. Given the allergy to penicillin, relatively few antibiotics were available to treat. And thus, at the time of admission when there was a concern for cellulitis and a burn-related infection, it was reasonable and standard of care to admit and treat with IV antibiotics.  Thus, this admission was warranted, supported by standard of care. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Male to female transgender
Treatment: Bilateral mammoplasty, augmentation with prosthetic implant 19325-50
The 19325-50 - bilateral mammoplasty, augmentation with prosthetic implant was not medically necessary.

Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person's gender identity and that person's sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). Treatment is available to assist people with such distress to explore their gender identity and find a gender role that is comfortable for them. Medical treatment options include, for example, feminization or masculinization of the body through hormone therapy and/or surgery.

Clinical documentation provided includes a letter from a LCSW and psychiatrist, a letter from the Legal Aid Society, and clinical notes from the treating surgeon including operative report. No clinical photographs are provided.

The documentation states the patient is a 38 B bra size in regards to breast size and wishes to be a "large C" or "small D." The operative report states the implants placed were 650 cubic centimeters (cc) in size. There is no mention of Tanner scale in regards to breast development. Based on this clinical information, there is inadequate clinical information regarding the lack of breast development necessitating breast augmentation since the patient is already a B cup. In addition, there are no photographs demonstrating incongruency of body appearance in associated with breast volume and shape that would require breast augmentation.

Based on the clinical information reviewed, there is inadequate documentation regarding evidence of clinically significant distress in social, occupational, or other areas of functioning. There are two letters of attestation which are brief and general in description. No actual clinical notes are present describing clinically significant functional issues secondary to distress that would necessitate breast augmentation.

Therefore, based on the clinical documentation provided, and the medical literature reviewed, adequate documentation of a presurgical medical necessity regarding breast augmentation has not been established. Therefore, medical necessity has not been established for augmentation mammoplasty. The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of abdominal pain for one week, more on the right rib cage and lumbar area. Per the patient, the pain was excruciating. He has never had similar pain in the past. There were no urinary complaints. He denied vomiting and there was no trauma. This was associated with nausea. He had been going to school with the pain. It had been worsening and he was taking Motrin to reduce the pain. The health plan's determination of medical necessity is upheld.
The patient was treated with intravenous (IV)IV Toradol and Morphine with good result. The pain was 3/10 by the time he was admitted. There is no documentation of any other IV analgesic given after the doses administered in the ER. He was seen by a surgeon and urologist. No further studies or procedures were performed after those ordered in the ER. He remained hemodynamically stable throughout. He did not require any highly skilled or technical care during his stay.