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

Diagnosis: Status asthmaticus. 
Treatment: Inpatient stay. 

The insurer denied coverage for the inpatient stay. 

The denial is overturned. 

This patient is a female child with a history of asthma. She developed a cough, a runny nose and red eyes. She was taken to Urgent Care when her cough persisted and she was having post-tussive vomiting. She was noted to be wheezing and was treated with albuterol and Decadron with recommendation to continue treatment for asthma at home with albuterol. The next day she had significant wheezing and increased work of breathing and her pulse oximeter was noted to be low at 89-90%. The patient's mother administered albuterol at home and then immediately brought her to the Emergency Room (ER) when her wheezing and increased work of breathing persisted. 

In the ER the patient was noted to have respiratory distress with retractions and evidence of increased work of breathing. She was tachypneic with a respiratory rate recorded at 55 breaths per minute. On physical examination she was noted to have retractions and expiratory wheezing. She was treated with steroids, several doses of albuterol and Atrovent. Her pulse oximeter was low at 88% and she was started on 2 liters of oxygen supplementation. A respiratory viral panel was positive for rhinovirus. She then was treated with continuous nebulization treatment with albuterol for 1 hour. When her respiratory symptoms did not improve with treatment in the ER the decision was made to admit her with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 2 hours. 

The patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. She had been seen in Urgent Care the day prior to the admission and she failed outpatient treatment with Decadron and albuterol given both in the Urgent Care center and in the home. She had evidence of increased work of breathing and hypoxemia which required treatment with oxygen and continuous albuterol. When there was ongoing respiratory distress with persistent wheezing and increased work of breathing, it was appropriate and consistent with the standard of care to admit her to the hospital for ongoing treatment with albuterol every 2 hours and oxygen supplementation. The patient had failed outpatient management of her asthma. She was at risk for respiratory failure and not stable enough to be sent home. 

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

The inpatient stay is considered medically necessary for this patient. 

The insurer's denial of coverage for the inpatient stay is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low Blood Sugar (Hypoglycemia)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

This patient is a male with type II diabetes, human immunodeficiency virus (HIV), and hepatitis B who presented with symptomatic hypoglycemia with dizziness and sweating after insulin administration. His glucose was 47 milligrams per deciliter (mg/dL). He was given glucose tablets and food by Emergency Medical Response (EMS). 

The patient's glucose upon arrival to Emergency Department was 51 milligrams per deciliter. Pulse was 91, respiratory rate was 19, oxygen saturation was 100%, blood pressure (BP) was 151/79, and temperature was  96.0. The patient had taken Basaglar 80 units instead of 23 units. He was discharged three days prior for pneumonia and sepsis. Insulin was held and he received 50% dextrose (D50) push and 10% dextrose (D10) infusion. Glucose was 31 milligrams per deciliter. Repeat glucose after D50 was 186 milligrams per deciliter. Glucose was 61 milligrams per deciliter and he was started on D10 drip. Glucose was 59 milligrams per deciliter. Glucose was 77 milligrams per deciliter. He was seen by endocrinology. 

Yes, the proposed inpatient stay was medically necessary.
This patient was admitted with symptomatic hypoglycemia after taking an excessive dose of long-acting insulin. He had profound hypoglycemia with a glucose level of 31 milligrams per deciliter. He subsequently had repeated hypoglycemic levels. He had a glucose 61 milligrams per deciliter, which prompted the initiation of a 10% dextrose infusion, and a glucose of 59 milligrams per deciliter. His glucose was borderline at 77 milligrams per deciliter. Therefore his inpatient stay was medically necessary to monitor and treat his persistent hypoglycemia in the setting of an excessive dose of long-acting insulin.

The requested inpatient stay was medically necessary due to persistent hypoglycemia and should not have been denied.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right patella tendon rupture

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admission.

The denial is upheld. 

This female patient has a history of right patella tendon rupture, osteoporosis, osteomyelitis, osteopenia, hypertension, and hyperlipidemia. The patient presented to the hospital for a right knee patella tendon repair. The procedure was performed without complications. The patient had failed overnight crutch training due to drowsiness. The patient was admitted for postoperative care. The plan was to have a physical therapy (PT) evaluation, keep the patient non weight-bearing (NWB) on the right lower extremity (RLE), maintain a regular diet, administer heparin as ordered for deep vein thrombosis (DVT) prophylaxis, maintain a regular diet, and administer analgesics as needed (PRN). The patient was given Percocet, Tylenol, atorvastatin, and intravenous (IV) Zofran. The patient was discharged with instructions to follow-up with orthopedic surgery within 2 weeks. The patient would have home physical therapy (PT). 

Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient. The records show that the patient underwent an elective procedure which was non-complicated. The surgical times were 16:33 to 18:34. The records showed that the patient's post-surgical vital signs were stable. There were no problems with the patient's wound. There was no evidence of bleeding or infection. There were no issues with regard to the patient's pain. The patient did not require treatment for an underlying medical condition or require special imaging. There were no factors present to substantiate the acute level of service provided. "Failed crutch training" is not included as a medical condition to warrant the admission. The records show that the patient was able to use a walker and walk 10 steps. The patient was also placed in a knee immobilizer to protect the repair. The patient was not elderly and did not have underlying comorbidities. A lower level of care would have been applicable.

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

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

Diagnosis: Atrial fibrillation.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This female patient has a past medical history of hypertension, hyperlipidemia, obstructive sleep apnea, and a prior gastric sleeve surgery. The patient presented from a city physician for evaluation of pre-syncope while at work.  She reported she had been having a mild  frontal headache for 2 weeks and on the date of evaluation she went to work and felt lightheaded after getting up from her chair.  She denied loss of consciousness but noted she collapsed and her coworkers were there to help her so there was no head trauma.  There was no chest pain but she reported feeling that her heartbeat felt "different".  The patient was brought in by ambulance for near-syncopal episode with a new onset of atrial fibrillation with a complaint of headache.  The physical examination revealed a blood pressure of 141/90.  Her cardiovascular rhythm was irregular.  Her lungs were clear. She was ambulatory in the Emergency Department with a steady gait.  Labs showed a normal Tn (troponin) and BNP (brain natriuretic peptide). chest x-ray showed clear lungs.  She was to be admitted to telemetry for observation given her pre-syncope symptoms.  Her rate was controlled in the ED (emergency department).  She was started on a betablocker.  Her CHADSvasc score was 2 and she was to be started on Eliquis.  She was to undergo a transthoracic echocardiogram and an electrophysiologic evaluation. Notes subsequently indicate she converted to sinus rhythm.   No new medications were started as her rate was in the 50s-60s.  She remained hemodynamically stable.  The transthoracic echocardiogram revealed normal left ventricular contraction and suspected pulmonary hypertension.  She indicated that she recently had an  outpatient stress test a report of which revealed a moderate amount of anterior wall ischemia with a left ventricular ejection fraction estimated to be 59%.  The patient was discharged in stable condition and she was to undergo outpatient portable cardiac monitoring for evaluation. 

The inpatient stay is not considered medically necessary for this patient.  She presented with new onset atrial fibrillation with dizziness and near syncope that converted to sinus rhythm after initial treatment. In the ED she was hemodynamically stable with no evidence of an acute ischemia event. She did not require ongoing therapy. She could have been observed and once initial evaluation revealed no acute process, further management did not need acute inpatient status. 

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

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

Diagnosis: Intracranial hypertension

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admission.

The denial is upheld. 

This female patient has a history of migraines and hypertension.  She presented with complaints of worsening frontal headaches associated with bilateral peripheral blurred vision, vertigo, nausea, and tinnitus.  The patient had presented to the ophthalmologist and papilledema was noted.  The patient's computed tomography (CT) scan was done in the Emergency Department (ED) at that time and it revealed bilateral small ventricles, and a lumbar puncture was attempted and was unsuccessful.  The patient was referred by neurology for a lumbar puncture under interventional radiation guidance and for brain magnetic resonance imaging (MRI).  The impression was headache likely secondary to idiopathic intracranial hypertension.  The treatment plan included a MRI of the brain, magnetic resonance venography (MRV), acetazolamide (Diamox), and neuroradiology consult for guidance for the lumbar puncture (LP).  The patient was admitted to the inpatient status.  The patient was started on acetazolamide. The patient's MRV and MRI were performed which showed narrowing of the left transverse sinus.  Neurology was called and they recommended an interventional radiation guided LP and repeat imaging.  On the second hospital day, the repeat LP was done.  There was 30 millimeters (mm) of clear cerebrospinal fluid obtained and the patient reported severe headaches.  The patient was started on Fiorinal.  The patient reported improvement in symptoms.  Repeat imaging showed significant stenosis at the junction of the transverse-sigmoid sinus and the patient was advised to have close follow-up with neurology and ophthalmology as an outpatient.  On the third day of admission, the patient reported a minimal headache and had been stable overnight.  The patient's cerebrospinal fluid (CSF) studies were unremarkable, and she was deemed fit for discharge.

Based on the review of the medical record and literature, hospital admission is not considered medically necessary for this patient. Inpatient care rather than observation is required only if the patient's medical condition, safety or health would be significantly and directly threatened if care were not in an intensive setting. A patient must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be provide safely and effectively only on an inpatient basis.  After reviewing this case it is  felt that this patient's illness, intensity, or discharge criteria did not require an inpatient level of care or acuity.  

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

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

Diagnosis: Sacroiliac joint fusion

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admission.

The denial is upheld.

This male patient has a history of a back fracture, degenerative disk disease, a herniated cervical disk, gastroesophageal reflux disease (GERD), hyperlipidemia, hypertension, and seizures.  The patient had previously undergone lumbar laminectomy with fusion and developed bilateral sacroiliac (SI) joint dysfunction. The patient's physician opined the need for bilateral SI fusion.  The patient's American Society of Anesthesiology (ASA) score was 3. The patient presented to the hospital  for a scheduled bilateral sacroiliac joint fusion.  The patient was admitted through the ambulatory unit and underwent the procedure without complications. After surgery, the patient was given aspirin for deep vein thrombosis (DVT) prophylaxis.  The patient had physical therapy (PT), and was given intravenous (IV) and oral (PO) pain medications.  The hospital course was uneventful and the patient was discharged after a period of hemodynamic stability.  

Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient. The patient underwent a procedure which was not complex or extensive.  The patient's physician performed percutaneous operations to the right and left sacroiliac (SI) joint.  The placement of guidewires and implants were "percutaneous", meaning limited surgical incision and approach.  There was limited blood loss.  The duration of the anesthesia and procedure was from 08:09 to 09:23 with extubation at 09:24.  The patient left the recovery room at 10:27. The patient's vital signs were stable.  The patient had no evidence of bleeding.  There were no signs of infection. The patient was advised to weight-bear as tolerated.  The patient was able to tolerate oral pain medication. The patient did not require treatment for other medical conditions or required additional tests. These clinical findings do not substantiate necessity for inpatient admission.  This percutaneous procedure is performed in an Ambulatory Surgical Unit (ASU).  There were no extenuating circumstances to warrant the inpatient level of care provided. 

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

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

Diagnosis: Cancer. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied: Lenvima. 
The determination is overturned. 

The patient is a female with metastatic endometrial cancer. She was not a surgical candidate due to multiple comorbidities and has been treated systemically initially with carboplatin+paclitaxel and subsequently with tamoxifen, Doxil, and topotecan. The patient has experienced progression in her liver and does not have microsatellite instability-high (MSI-H) or deficient mismatch repair (dMMR) disease based on a next generation sequencing panel. Pembrolizumab+lenvatinib has been recommended; lenvatinib (Lenvima) is under review. 

The plan's determination is overturned. 

A randomized trial (Makker, et al.) evaluating pembrolizumab and lenvatinib versus treatment of physician's choice (doxorubicin and paclitaxel) was conducted in 827 patients with advanced endometrial cancer progressive on prior platinum-based chemotherapy (697 of whom had proficient mismatch repair (MMR) tumors and 130 of whom had dMMR tumors). Overall, pembrolizumab and lenvatinib resulted in statistically significant improvements in median progression free survival and overall survival with a favorable toxicity profile. 

Similar results were observed in a prior single-arm open-label trial (Makker V, et al.) including 94 patients with metastatic, pretreated endometrial cancer (EC) that was neither MSI-H, nor dMMR, in which the objective response rate (ORR) to pembrolizumab with lenvatinib was 36 percent, with a complete response rate of 2 percent. For those responding, the probability of having a response duration greater than or equal to (>=) 6 months was 85 percent. This patient's characteristics mirror those of the trial patients.
The provider has recommended lenvatinib in combination with pembrolizumab (although only lenvatinib is under review) and based on the data detailed above both the authors of UpToDate and the National Comprehensive Cancer Network (NCCN) Guidelines recommend the use of this agent in this clinical scenario. In the manner prescribed, this agent is not under ongoing investigation for efficacy or safety. For these reasons, criteria for medical necessity have been satisfied.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: left shoulder pain
	
Treatment: arthroscopic surgery

The insurer is denied coverage for arthroscopic surgery

The denial is overturned. 

This female patient has a history of left shoulder impingement and acromioclavicular (AC) joint arthritis. Orthopedic notes indicate she has been treated with injections and physical therapy. She has full range of motion with painful arc, positive Hawkins maneuver, and 5 out of 5 strength with rotator cuff testing. Her Orthopedist is now recommending arthroscopic surgery.

The medical record demonstrates consistency. The records show continued left shoulder pain and functional limitation. There are physical findings of decreased motion and positive provocative maneuvers. Imaging studies did not show pathology but the overall clinical presentation substantiates intra articular pathology as a pain generator. The woman has received several cortisone injection and physical therapy. She has not improved. The next step should be surgery. An arthroscopic evaluation will allow inspection, treatment, and likely improvement.

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

The carrier's denial of coverage for the arthroscopic surgery is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gout
Treatment: Uloric 80 milligrams (mg) tabs
The insurer is denied coverage for Uloric 80 milligrams (mg) tabs
The denial is upheld. 

This male patient has a history of gout. Per the office visit note from Internal Medicine the specialist , the patient has had good control of his gout with brand name Uloric. He has tried allopurinol and febuxostat.

The request for documentation of generic febuxostat failure/toxicity before approving branded Uloric is reasonable, given they are the same medication (although same benefit/toxicity is not automatically the case, so it is possible to do well on one and not the other).  The issue is whether there has been adequate documentation of generic febuxostat failure/toxicity before coverage of branded Uloric. Pharmacy records indicate Uloric was taken, given refills of Uloric are documented and there is no documentation febuxostat was filled. No pharmacy records/prescriptions were provided for review to support a trial of febuxostat.

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

The carrier's denial of coverage for Uloric 80 milligrams (mg) tabs is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: vision (cataract)
Treatment: eye surgery to remove cataract from the eye with the use of special equipment dye.
The insurer denied eye surgery to remove cataract from the eye with the use of special equipment dye. 
The denial was upheld in whole. 

The patient is a female scheduled for complex cataract surgery. The patient complains of difficulty with reading, watching television, and driving. Her vision is best corrected to 20/30 for the right eye (oculus dexter) (OD) and 20/40 for the left eye (OS). With brightness acuity testing, vision decreased to 20/70 for both eyes (OU). There were 2 plus (+) nuclear sclerotic cataracts noted bilaterally. Cataract surgery was schedule for the OS and for the OD. It was noted that, with a poor red reflex, trypan blue dye would be needed intraoperatively.
At issue is the medical necessity of eye surgery to remove cataract from the eye with the use of special equipment dye - left side.

The health plan's determination of medical necessity is upheld in whole.

The records provided for review support the medical necessity of standard cataract surgery (66984). However, the need for use of dye at the time of cataract surgery does not support complex cataract surgery (66982).
According to the American Academy of Ophthalmology, the primary indication for surgery is visual function that no longer meets the patient's needs and for which cataract surgery provides a reasonable likelihood of improved vision. [1]
According to general standards of care as reflected by Centers for Medicare and Medicaid Services (CMS) guidelines, cataract surgery is indicated when a patient experiences decreased ability to carry out activities of daily living such as reading, viewing television, driving, or meeting occupational or vocational expectations, and the patient has a best corrected visual acuity of 20/50 or worse at distant or near; or additional testing shows that either consensual light testing or glare testing decreased visual acuity by two lines. [2]
In this case, the patient complains of decreased vision impacting reading, watching tv, and driving. Vision was best corrected to 20/30 OD and 20/40 OS and decreased with brightness acuity testing to 20/70 OU.
Therefore, the medical necessity of standard cataract surgery (66984) is established per standard of care.
However, this request is for complex cataract surgery (66982) because of the need to use Trypan dye at time of surgery. In March 2016, CPT Assistant published, "the additional work of instilling and removing Trypan Blue dye from the anterior segment though an additional surgical step does not reach the threshold of physician time, work, or intensity necessary to report the complex cataract code." [3] Therefore, CPT 66982 is not established as medically necessary.