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

Diagnosis: fracture at the base of the first metacarpal

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld. 

This male patient has a history of diabetes and hypercholesterolemia.

As noted in MCG Health Guidelines General recovery care 25th Edition: Musculoskeletal surgery or procedure GRG: ORG: SG-MS (ISC GRG) notes that the Operative Status Criteria is ambulatory for procedures such as: Closed or open reduction of simple fractures; Simple internal fixations; Simple external fixations; Simple wound repairs; Plastic operations on tendon or joints; Bone biopsies; Removal of most orthopedic devices. 
Thus, using these guidelines the patient did not require inpatient admission but rather a 23 hour observation. As per the progress notes the surgery was planned for several days after the patient's arrival, without any indication for the reason for the delay. He did require care, but this could have been done with a 23 hour observation status and not an acute inpatient admission.
It should be noted that the patient was sent home on the same day that he had surgery . Thus, he could have been discharged with a 23 hour observation and not an inpatient admission. There was no indication of need for inpatient admission as noted by MCG guidelines as the care should have been given in an ambulatory/observation status.

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: Elevated blood pressure
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is female with two pregnancies and two birth (G2 P2) who presented to the hospital five days postpartum with reported blood pressures of 147/102 and 142/101.  She denied any symptoms of preeclampsia with severe features.  

On initial presentation to the hospital, blood pressure was 139/85.  Laboratory workup was significant for protein to creatinine (P:C) ratio higher than 0.3 but otherwise negative and there were not laboratory abnormalities diagnostic of severe preeclampsia.  The patient was admitted to the hospital and treated with magnesium sulfate.  At no point in her hospitalization was there evidence of severe preeclampsia.  She was discharged home on hospital day #1 on a low dose of antihypertensive medication (labetalol 100 milligrams [mg] twice daily [bid]).  

The health plan contends that the admission was not medically necessary due to absence of severe range blood pressures, symptoms of severe preeclampsia, seizures, or other complications and that the care could have been given in the emergency room or observation area.  It cites MCG (Milliman Care Guidelines) 24th edition Hypertensive Disorders of Pregnancy ORG: M-285 (ISC).  The facility contends that the hospitalization was medically necessary because the patient had hypertension due to preeclampsia in the postpartum period and that there was no feasible way to discharge the patient, and that there was a risk of worsening to the point of severe hypertensive emergency in which death could occur.  It cites MCG (Milliman Care Guidelines) guidelines for Obstetric and Gynecologic Disease and Hypertension.

No, the proposed treatment, hospital admission, was not medically necessary.
The patient met the diagnostic criteria for postpartum preeclampsia without severe features with minimally elevated blood pressure and elevated protein to creatinine ratio.  There was no evidence of severe features at initial presentation nor at any point in the hospitalization.  Hospitalization is not required for preeclampsia without severe features in either the antepartum or the postpartum period as the risk of life-threatening complications is low in the absence of progression to severe features.  These patients can be safely followed up as outpatients with serial laboratory and clinical assessments to determine if progression to severe features occurs.

Hospitalization was not required for the patient's condition based on national practice standards and she could be safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epilepticus. 
Treatment: Inpatient hospital. 

The insurer denied coverage for inpatient hospital. 

The denial is overturned. 

The patient was brought to the emergency room by emergency medical services.  The patient had 4 different seizures on the date of presentation to the emergency room with the last 3 occurring within 20 minutes.  The patient's mother mentioned that the patient returned to baseline between seizures.  With the second seizure, the patient fell off the bed (5 inches off the floor), hit his head, and had swelling on his forehead afterward.  The patient had no chills, abdominal pain, nausea, vomiting, or changes to stool or urination.  The patient had a tactile fever on the morning of presentation.  The patient had been taking his medications after his last stay in the hospital.  The Keppra dosing was increased with a prior hospital stay.  The patient underwent a computed tomography (CT) scan of the head that was normal. The examination revealed the pupils were equal, round, and reactive to light.  There was a 2 cm (centimeters) hematoma to the mid forehead. The patient was given intravenous (IV) Keppra and IV lorazepam and was admitted to the Pediatric floor with status epilepticus. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital admission is considered medically necessary for this patient. 

According to the guidelines provided by the Milliman Guidelines, the acuity of this case is considered to have required admission as this patient presented with status epilepticus. The patient sustained a fall and there was concern for potential intracranial bleed. The patient required imaging and close monitoring with treatment using IV Keppra. The patient was recently admitted and has high risk of recurrence, so admission was necessary to ensure adequate return to baseline and treatment initiation prior to discharge. 

The current literature indicates a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe persistent or there is evidence of hemodynamic instability. Within the documentation, it was noted the patient presented with breakthrough seizures with concerning alteration in mental status after a fall. The submitted documentation does warrant hospitalization at an appropriate level of care. 

The insurer's denial of coverage for the inpatient hospital admission is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female with a prior history of extensive abdominal surgeries, depression, DM (diabetes mellitus), HTN (hypertension), and CAD (coronary artery disease). The patient had presented to the Emergency Department (ED) with the complaints of abdominal pain. The patient noted intermittent, sharp right sided flank pain which radiated to the entire abdomen. This was associated nausea and relieved by Aleve. The patient related that she had been having the same pain for approximately six months; however, the pain had become progressively worse for the week prior to presentation. The patient was unable to tolerate any solids or liquids besides water. The patient had previously been evaluated at the same emergency department with the same complaint. At that time, the laboratory values were within normal limits.  An ultrasound was normal for both the renal and biliary systems.  The patient was also seen by surgery.

It was recommended that the patient be admitted for pain control and an EGD (esophagogastroduodenoscopy), but the patient had declined. On examination, the patient was evidenced to be in no acute distress. Her vital signs were BP (blood pressure) 149/84, HR (heart rate) 94, RR (respiration rate) 19, SpO2 (pulse oximetry) 98%, and Temperature 97.3 Fahrenheit. On physical examination, the patient was found to have generalized abdominal tenderness. Initial laboratory studies were remarkable for leukocytosis of 11.6, elevated absolute neutrophil count, direct hyperbilirubinemia, and hyperkalemia. An Electrocardiogram (ECG) was normal. A chest radiograph was unremarkable.

In  the  emergency  department, the patient was  administered  Pepcid,  Carafate,  and  Maalox,  in  addition  to  continual  reassessment.

No, the Inpatient admission was not medically necessary.
The care as provided was medically appropriate; however, the level at which the care was rendered was 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 had an infection; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (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.  Indeed, despite the report that the patient had intractable pain, the patient was observed as not being in any acute distress. As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sinus Congestion. 

Treatment: Tessalon Perles 100 milligram capsules. 

The insurer denied coverage for Tessalon Perles 100 milligram capsules. 

The denial is upheld. 

The patient has a past medical history of sinus congestion, congestion of lungs, and cough. She was prescribed Tessalon Perles 100milligram (mg) capsules by her medical provider. 

According to the provider she had obtained relief with Tessalon Perles but not the generic form of the medication. Generic Benzoate 100 mg is available through multiple generic manufacturers and other generic formulations could be tried. 

The patient was previously prescribed Benzonate (The generic drug for Tessalon Perles). She reportedly did not tolerate it. However, there are no medical records provided to document the specific problem / adverse side effects. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient, as a generic form of the drug Tessalon Perles is available. There are no specific contraindications or reaction noted to support medical necessity of Tessalon Perles. 

The insurer's denial of coverage for the medication Tessalon Perles 100 milligram capsules is upheld. 

Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left renal colic
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This male was admitted with left renal colic. He had an abdominal aortic aneurism (AAA) repair several days prior to this admission.

The patient's vital signs were temperature 36.4, pulse 74, and blood pressure 182/71 mmHg (millimeters of mercury). The white blood cell (WBC) count was 9200. The creatinine was 1.3. Computed tomography (CT) imaging demonstrated a six millimeter left proximal ureteral calculus with hydronephrosis. Intravenous pain medications, nausea medications, intravenous Rocephin and intravenous fluids (IVF) were administered. A cystoscopy with left ureteral stent placement was performed.

The patient was discharged home the following day. He was afebrile and hemodynamically stable throughout the stay.

No, the proposed inpatient hospital admission was not medically necessary.

An acute inpatient level of care was not medically necessary. Care could have been provided at a lower level of care. The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis. Following admission, there were no unstable vital signs reported. He did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, or severe vomiting. Pain control, intravenous antibiotics and intravenous fluids followed by stent placement in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Surgery to repair cleft palate and myringotomy
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a female with a diagnosis of a cleft palate who underwent repair of the cleft palate along with a myringotomy procedure.  The patient was admitted to an inpatient acute care hospital admission.  The inpatient hospital admission is under review.  

The patient's medical history is complicated by a possibility of oculoauriculovertebral spectrum/Goldenhar syndrome which includes hemifacial microsomia, right upper and lower eyelid coloboma and right ear malformation.  The procedure was performed without any complications as documented by the operative note and progress.  However, the treating surgeon desired postoperative monitoring overnight prior to discharge.

Yes, the proposed treatment was medically necessary and medically indicated for the clinical scenario presented.
Based on, and in review of the clinical information provided and comparison with the medical policy which is consistent with clinical practice standards and peer-reviewed literature established by the relevant medical community, the request for approval for the acute inpatient hospitalization is approved as being medically necessary and indicated for this patient.  

The Milliman Care Guidelines (MCG) do state that standards of care established by the relevant medical community should apply when determining medical necessity.  In this clinical situation, the decision to keep the patient as inpatient for two days was necessary and indicated based on the comorbid conditions including but not limited to Goldenhar syndrome which includes hemifacial microsomia.  The clinical implication of Goldenhar syndrome and hemifacial microsomia poses increased risk for delayed airway compromise when navigating the cleft palate.  Although most typical patient's undergoing a cleft palate repair can be managed on an outpatient basis, patients who have an atypical narrowing of the airway are predisposed to complicated airway management as late as one to three days postoperatively.  Due to the narrowing of the airway, and airway compromise in patients with hemifacial microsomia or Pierre Robin sequence can occur several days after the original surgery.  Admitting the patients with these risk factors to an acute care facility to monitor the airway is prudent because if the airway is compromised, the patient can decompensate quickly.  Therefore, the inpatient hospital admission is approved as being medically necessary and indicated for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and monthly visits
The insurer denied braces and monthly visits.
The determination is overturned.

The patient has an anterior and bilateral unilateral crossbite on the left. She has mild crowding. She is treatment planned for orthodontics to correct her bite. At issue is the medical necessity of braces and monthly visits.

The patient has anterior and posterior crossbites. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3)

If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. The requested orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism, chronic lung disease, primary pulmonary hypertension, dependence on gastrostomy tube feedings. 
Treatment: Private Duty Nursing. 

The insurer denied the Private Duty Nursing. 
The denial is overturned. 

The patient is a male child with medical history significant for autism, chronic lung disease, primary pulmonary hypertension, dependence on gastrostomy tube feedings, gastroesophageal reflux disease, strabismus, cleft lip deformity, and global developmental delay. He receives three bolus gastrostomy tube feedings daily with water flush. He is incontinent of bowel and bladder, working on toilet-training. He is monitored via pulse oximetry, with supplemental oxygen available as needed. He receives albuterol as needed with chest physiotherapy. He does not sleep through the night according to a sleep log, waking up nightly for several hours. And per his mother, he is a flight risk. 

He lives with his mother, his primary caregiver. No specifics regarding her schedule, outside responsibilities, or health concerns were included. There were no details regarding other family members in the home. There were no details regarding school attendance either. 

Skilled nursing needs include the following: gastrostomy tube care and feedings, maintenance of reflux and aspiration precautions, administration of respiratory medications and airway clearance as needed, monitoring of pulse oximetry with administration of supplemental oxygen as needed, administration of routine and as needed medications, maintenance of skin integrity, assistance with toilet training, monitoring to prevent elopement, and assistance with all activities of daily living. 

Yes, the requested skilled nursing hours are medically necessary. 

This child has a number of medical issues as a result of and in addition to his chronic lung disease and autism as detailed above. While it is not unreasonable to expect a trained layperson caregiver to manage his pulmonary needs and maintain adequate monitoring to prevent elopement throughout the day, it is neither safe nor reasonable to expect this level of constant supervision round-the-clock. The child does not sleep through the night, so he must also be monitored for respiratory difficulties, feeding difficulties, and possibility of elopement at night. Because of the continuous nature of his medical needs, the requested 48 hours per week of skilled nursing services are medically necessary and appropriate for the duration of time in question.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headaches

Treatment:  Facet joint injections, outpatient procedure codes 64490 x (times)1, 64491 x1, and 64492 x1

The insurer denied coverage for facet joint injections, outpatient procedure codes 64490 x1, 64491 x1, and 64492 x1

The denial is overturned.

This is a female with complaints of bilateral neck pain and headaches. She has a history of cervical spine surgery. The pain reportedly interferes with activities of daily living. She was advised by her treating cardiologist to avoid physical therapy due to concerns for COVID (coronavirus) infection. Currently, under review is the medical necessity of requested cervical facet (medial branch) injections.

The patient's neck pain and headache complaints are not associated with a particular diagnosis.  The requested cervical facet (medial branch) injections are reportedly for diagnostic purposes.  A preponderance of the evidence supports the existence of facet joint pain. However, the literature for facet injections as a treatment for non-radiating neck pain is hampered by small sample side, lack of case control, lack of placebo or prospective evaluation. Generally, it is prudent to require 3 months of physical therapy, medications and a home exercise program.  The medications and home exercise program have not been effective. In this case, physical therapy has been cautioned against by her treating cardiologist. Given the circumstances, there was sufficient evidence to support that the requested facet injections are clinically reasonable and medically necessary.

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient. Taken into consideration were the clinical standards of the plan, information provided concerning the patient, attending physician's recommendation and applicable generally-accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.

The insurer's denial of coverage for facet joint injections, outpatient procedure codes 64490 x1, 64491 x1, and 64492 x1 is reversed. Medical necessity is substantiated
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal reflux disease (GERD)

Treatment: transoral incisionless fundoplication (TIF) procedure using EsophyX (code 43210) and associated inpatient stay

The insurer denied coverage for transoral incisionless fundoplication (TIF) procedure using EsophyX (code 43210) and associated inpatient stay

The denial is upheld

The patient has a history of chronic reflux esophagitis. An endoscopy revealed a 3 cm (centimeter) hiatal hernia. A Bravo test was negative although there was reported to be good correlation with heartburn. The DeMeester score was 11.8.

The American Gastroenterological Association (AGA) has published a statement on Surgical options for GERD. This procedure has been shown to improve health outcomes, symptom relief, decrease in PPI (proton pump inhibitor) utilization, and improvement in esophageal pH (measure acidity). However, these benefits were found in patients who had a hiatal hernia of 2 cm or less. The device is indicated only for those with a hiatal hernia of 2 cm or less or for those who had a laparoscopic hiatal hernia repair to 2 cm or less.

This patient had GERD but was found to have a hiatal hernia of 3 cm. The scientific evidence has not shown an improvement in healthcare with TIF when there is a hiatal hernia greater than 2 cm. The TIF procedure has FDA (food and drug administration)-approval for patients with a hiatal hernia of 2 cm or less. This patient is not a good candidate for TIF due to the 3 cm hiatal hernia. It is not the less available treatment for this patient. The benefits of TIF have not been proven in the scientific literature for patients with a 3 cm hiatal hernia.

The carrier's denial of the transoral incisionless fundoplication (TIF) procedure using EsophyX (code 43210) and associated inpatient stay should be upheld.