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

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The inpatient admission was medically necessary.  

There are several issues of concern based on this patient's presentation that would require admission.  First, the patient had recently had a surgical procedure, during which a significant complication occurred, specifically a uterine perforation.  Depending on the location of the perforation, possible complications include hematoma, infected hematoma, pelvic abscess, and bowel or other visceral perforation with subsequent peritonitis and/or localized abscess formation.  This history combined with abdominal pain and leukocytosis is suspicious for a delayed complication that could be life-threatening. Admission for close observation is required.  

Secondly, the patient was found to be pregnant with a urinary tract infection with flank pain that could be suggestive of upper tract infection.  Pyelonephritis during pregnancy is much more dangerous than in the non-pregnant state and can lead to urosepsis, ARDS (acute respiratory distress syndrome), pregnancy loss, and maternal death.  It is recommended that pyelonephritis treatment in pregnancy be initiated on an inpatient basis with parenteral antibiotics.  

Therefore, for both of the reasons stated above, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Atrial Fibrillation, Cardiac Ablation

Treatment:  Inpatient Hospital Admission 

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

This is a middle aged female who presented to the hospital for a repeat cardiac ablation due to her persistent symptoms of fatigue, intermittent dizziness, and recurrent palpitations from atrial fibrillation, despite her use of amiodarone.  She had a past medical history of atrial fibrillation, and 2 prior ablations.  Upon presentation her electrocardiogram showed she was in atrial fibrillation; her vital signs were stable.  She had an ablation performed without complications.  She remained clinically stable during her hospitalization and was then discharged home with continued outpatient follow-up.  

The inpatient admission was not medically necessary.  The patient underwent an uneventful electrophysiology study and ablation of atrial fibrillation with no complications, remained hemodynamically stable, was ambulatory, and was tolerating oral intake.  There were no hemodynamic or clinical complications or concerns noted.  Per MCG 22nd Edition Guideline for Electrophysiologic Study and Intracardiac Catheter Ablation, this procedure is an outpatient procedure, with allowance of one night in the hospital at observational status. 

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

This patient is requesting an upper endoscopy as a screening evaluation prior to a sleeve gastrectomy.  Comorbid health conditions include diabetes, hyperlipidemia, hypertension, and sleep apnea.  A presurgical upper endoscopy is requested as a screening study prior to bariatric surgery.  The health plan's determination of medical necessity is overturned.

Obesity is an important risk factor for several digestive diseases, such as gastroesophageal reflux disease, erosive esophagitis, hiatal hernia (HH), Barrett's esophagus, esophageal adenocarcinoma, Helicobacter pylori infection, non-alcoholic fatty liver disease (NAFLD), cirrhosis, and hepatocellular carcinoma.  Most of these diseases are observed up to 2-3 times more frequently in obese patients than in normal weight individuals and may be asymptomatic.  Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery.  There is evidence that the chosen procedure might be changed, if specific pathological upper gastrointestinal (GI) findings, such as a large hiatal hernia (HH) or Barrett's esophagus, are detected preoperatively.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Post-procedure Percutaneous Coronary Intervention monitoring
 
Treatment: Inpatient admission, monitoring

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

The patient was a woman with a past medical history of coronary artery disease, hypertension, hyperlipidemia, diabetes mellitus, and recent myocardial infarction. She presented for an elective cardiac catheterization. The patient received a staged intervention to the left anterior descending artery with placement of a drug-eluting stent. There were no procedural complications, and the patient was then admitted for further monitoring. She remained hemodynamically stable, was ambulatory, and was tolerating oral intake. There were no vascular access complications. The patient was subsequently discharged home after an uneventful, brief overnight hospital stay. 

The inpatient admission status is not medically necessary for this patient. Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is designated as an outpatient procedure. The clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization and attempted angioplasty. 

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

The patient has a history of hypertension, hyperlipidemia, diabetes and a prior stroke. The patient presented to the hospital for a scheduled peripheral angiography for the evaluation of worsening claudication. Patient was hemodynamically stable with no evidence of acute limb ischemia. The angiography revealed significant peripheral vascular disease. A stent was placed in the right tibioperoneal trunk and balloon dilatation of the right peroneal artery was performed. The procedure was uncomplicated.  
Inpatient level of care was not medically necessary. Peripheral arterial interventions in stable patients with claudication are increasingly being performed in the outpatient setting, including office-based centers. If it was necessary to monitor this patient overnight, this could have been accomplished under a lower level of care. According to peer-reviewed literature, peripheral arterial intervention procedures that were performed at an outpatient catheterization laboratory for 1 years time concluded that performance of these procedures in an outpatient setting was safe and effective. The health plan's determination is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

The patient is a  woman who presented to the emergency department (ED) with abdominal pain and vomiting. She was known to have gallstones. She was evaluated with lab data, an abdominal ultrasound, computed tomography (CT) scan, and physical exam. This revealed a white blood cell (WBC) count of 7.2 K. The complete metabolic panel and lipase were normal. The gallbladder contained stones without gallbladder wall thickening or pericholecystic fluid by ultrasound. Vital signs were normal at the time of presentation.

She underwent laparoscopic cholecystectomy. The operative dictation describes a standard cholecystectomy procedure. Her post-surgical course was uncomplicated, and she was discharged from the hospital on the following day.

The health plan denied the inpatient admission as not medically necessary. The health plan's determination is upheld. 

There is no clinical documentation to support the need for inpatient admission for this patient. The patient remained hemodynamically stable throughout the perioperative period, there was no documented complication of surgery. The records include no documented comorbid medical condition that required an inpatient level of care [such as conversion to open procedure, intolerance of diet, complications of procedure, thromboembolic disease, care for comorbidities, advanced age/decompensated physiologic status]. This patient's clinical needs could have been satisfied with a lower level of care following the cholecystectomy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, hypertension 
Treatment:  Inpatient stay 

Summary:
The patient had abdominal pain with enteritis on computed tomography of the abdomen/pelvis but did not have bloody diarrhea, hemodynamic instability, fever, need for surgical intervention, or evidence of bowel perforation, acute pancreatitis, acute cholecystitis, bowel obstruction, or ileus.  This significantly elevated blood pressure on presentation had improved by the time of admission.  There was no evidence of end organ damage, such as acute heart failure, acute myocardial ischemia, hypertensive encephalopathy, or acute cerebral ischemia.  Renal function improved with intravenous fluid administration.  The blood pressure improved with oral antihypertensive agents and the patient did not require continuous infusion of antihypertensive medications.  Inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Overturned

The patient has a diagnosis of Major Depressive Disorder (MDD) and Anxiety. Case notes document that the patient has had no prior inpatient hospitalizations. The patient developed severe depressive symptoms with a suicidal plan to overdose and was prevented from overdose by family members who then referred the patient to the emergency department for evaluation. In the emergency room the patient was evaluated and her mental status examination noted severe depressive symptoms with suicidal ideation, anxiety, agitation, lack of will to live, hopelessness and helplessness. In addition to diagnoses of MDD and anxiety, the patient had significant medical symptoms including diabetes mellitus (DM), thrombocytopenic purpura, and morbid obesity with a body mass index (BMI) of 44.9. The patient was also documented to be a daily smoker. The patient had diminished social support due to being homeless. The treatment included individual and group therapy, and a combination of psychotropic medications including venlafaxine, aripiprazole, as well as benztropine as needed (prn) and lorazepam prn, and later Buspar. The patient initially required each (q) 15-minute checks for safety. Medical consultation was provided for her serious medical diagnoses.

The health plan's determination is overturned. the Inpatient Psychiatric Admission was medically necessary for this patient. The DOS through discharge were medically necessary for several reasons. This patient was globally distressed psychiatrically and medically. The patient suffered severe depressive symptoms that had not substantially abated and if discharged on that date would have a high probability of requiring readmission or would have an increased vulnerability to self-harm. The accompanying co-morbid anxiety worsened her depressive symptoms. The homelessness indicated a reduced support system. The case notes documented that the patient was still dysphoric, agitated at times, with intermittent anxiety. While the pateint was mildly improved from admission, she was not ready for discharge using good medical judgment. The patient's mental status still showed depression, anxiety, hopelessness, and a labile mood.The Buspar was increased to treat anxiety. The patient showed substantial improvement for the first time. The patient was cooperative, less anxious, less depressed, with organized thinking, and without suicidal ideation, as well as improved in insight and judgment. The patient could therefore be discharged with good medical judgment, in accord with current standards of best care, and in accord with the medical literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vertigo
 
Treatment: Inpatient admission, medication, monitoring

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

The patient is a male who presented to the emergency department (ED) from urgent care with intermittent dizziness for several days. He stated the symptoms started with the room spinning three prior and this worsened as he lay down or turned his head. The episodes lasted 15-60 seconds at a time. Pre-hospital EKG reportedly showed second-degree AV block at 45 beats per minute (bpm). He had a past medical history of syncope, hypertension, obesity, and an episode of vertigo 1.5 years prior. Initial vital signs were BP 146/94, temperature 97.7, heart rate 58, and respirations 20. The left pupil was noted to be sluggish. No nystagmus was noted. EKG showed sinus bradycardia with second-degree AV block and incomplete right bundle branch block (RBBB). CT of the head noted a 4mm calcification in the right parietal lobe medially. The patient was treated with intravenous normal saline and meclizine. He was admitted to telemetry with a diagnosis of second-degree AV block. The patient had no orthostatic changes and no neurologic defects noted on exam. His initial troponin was normal. Telemetry monitoring revealed sinus rhythm with first-degree AV block. EKGs were reviewed and only two tracings showed periods of Mobitz type I second-degree AV block. An MRI of the brain noted a 4mm calcification of the right parietal lobe medially. A physician's note stated that the patient had dizziness which was probably due to vertigo. 

This patient presented with symptoms that were typical of vertigo, since they were clearly related to the patient's head position. EKGs showed sinus bradycardia with first-degree AV block, which may have been related to intrinsic disease, beta blocker use or increase in autonomic tone. There was no definite evidence of second-degree AV block and his cardiac work-up was otherwise negative. His head CT and MRI were unrevealing and it is noted that he responded to treatment with IV fluids and meclizine. 

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

Diagnosis: Abdominal pain, nausea
Treatment: Inpatient stay 

Summary:
The Inpatient stay was not medically necessary. The patient is a male with a past medical history of alcohol abuse. He presented to the ED complaining of abdominal pain and nausea. He had been sick for one day. 

Following his ED evaluation, the patient was clinically stable. There was no evidence that his abdominal pain was caused by any acutely dangerous disease process. The patient had also presented with alcohol withdrawal. Following treatment in the ED, the CIWA score decreased to three. Vital signs had normalized. The patient was able to eat. The admission note for this patient indicates that he would be observed overnight and given oral Ativan as needed. It was expected he would be discharged home the following morning. No other treatment or consultations were planned for the patient.

In conclusion, an inpatient admission was not medically necessary for this patient. He could have safely been managed at a lower level of care. The Health Plan did act reasonably in denying coverage for an inpatient admission on this date.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis of knee
 
Treatment: Hyaluronic acid injection

The insurer denied the Hyaluronic acid injection. The denial was upheld.

This is a male with left knee pain. His physical examination was significant for swelling, tenderness, limited motion, crepitus and varum deformity.  His physician provided an injection of hyaluronan.  The records demonstrate a previous surgery many years ago and relief from prior injections. 

A review of the Clinical Practice Guideline by the American Association of Orthopedic Surgeons (AAOS) cites: the 2013 OA knee treatment CPG contains one significant recommendation change from the 2008 CPG, and this is with regard to the issue of viscosupplementation.  The 2008 OA knee CPG included an "inconclusive" recommendation regarding the use of intra-articular hyaluronic acid (HA) injections that was largely the motivating factor for the expedited update of the CPG. The second edition CPG recommendation reads "We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA of the knee," with a "Strong" rating, based on supporting evidence from 3 high-quality and 11 moderate-quality research studies that met the inclusion criteria.

The CPG's best evidence synthesis does not support the efficacy of viscosupplementation.  Although statistically significant outcomes were seen in some studies with higher molecular weight HA preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement (MCII). (For more information on MCII, see "The Importance of Clinical Significance in AAOS CPGs," AAOS Now, May 2013.)

The Orthopedic group reports "do not recommend use", therefore the use of these injections would thus not be medically necessary as per current Guidelines. The carrier's denial of coverage for hyaluronan injections is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart failure and high blood pressure 
Treatment: Inpatient admission
The proposed treatment was not medically necessary.
This patient presented for evaluation of dyspnea and was diagnosed with new onset diastolic dysfunction (HFpEF). The patient was hypertensive on admission and his BP responded to treatment provided in the ER. The diagnosis of an acute myocardial infarct (MI) was ruled out by cardiac enzymes, which were negative. There was no evidence of deep vein thrombosis (DVT). There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), renal failure, malignant arrhythmia or hemodynamic instability. The patient responded to treatment and was discharged after one day. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ankle tendinitis (plantar fasciitis)
Treatment: Custom shoe inserts
The L3020 - Custom shoe inserts are medically necessary.

The patient is a female with bilateral ankle pain and stiffness. She had been diagnosed with bilateral posterior tibialis tendonitis. She had tried OTC (over the counter) orthotics without benefit. Custom orthotics were prescribed. 

The patient has bilateral posterior tibial tendonitis. She has ongoing pains with positive physical findings consistent with the diagnosis. She has a structural abnormality with pathology localized to medial aspect of her foot. She has plano valgus feet (collapsed arches). The initial management of this condition is structural support and PT (physical therapy) services. If standard OTC orthotics are not beneficial, the next step would be a custom orthotic. The medial aspect of hind and mid foot requires support. The contour of the foot is measured, and placement of custom orthotic can prevent necessity of surgery. A course of weight loss would also be suggested.

The patient had received conservative management. The next step should be use of the custom orthotic.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Jaundice, Elevated Bilirubin
 
Treatment:  Inpatient Admission

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

The is a female infant who was admitted to the hospital for phototherapy due to a bilirubin level of 19.2 mg/dl.  Repeat bilirubin level was done after one day of phototherapy with a decreased result of 12.6 mg/dl.  At the time of discharge the patient's bilirubin was 9.3 mg/dl. 

The cited MCG Guideline specifies: 

Admission is indicated for 1 or more of the following:  1)	 Total serum bilirubin (TSB) exceeding risk threshold for infant's age, gestational age, and clinical risk factors, or 
2) TSB greater than 20 mg/dL (342 micromoles/L) at 96 hours or more in lower-risk infants.

The payer has misapplied the above information.  First, MCG itself notes that its guidelines are not absolutes.  The difference of 19.6 mg/dl and 20 mg/dL is within the range of measurement error.  Second, had the infant not been admitted and treated, it is likely the bilirubin would have increased further, and admission would have still been indicated.  Third, and most importantly, the standard of care stems from the Academy of Pediatric Guideline: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation in PEDIATRICS Vol. 114 No. 1 July 2004 pp. 297-316. Accordingly, the guideline states: "These guidelines are based on limited evidence and the levels shown are approximations." 

Additionally, for practical purposes, many neonatologists use BiliTool TM, which has been adapted from the AAP Guideline and is available on-line.  It provides an easy to use "tool" to determine risk factors, level of risk, and treatment options.  Therein, for a "lower risk" infant "it is an option to provide conventional phototherapy in the hospital or at home at TSB levels 2-3 mg/dl (35-50 mol/L) below those shown."  

In view of the above, the provider met the standard of care in admitting the patient for phototherapy that was medically necessary.  The health plan did not act reasonably and with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mild Metabolic Anion Gap Acidosis, borderline hypoglycemia secondary to decreased PO, dehydration and diarrhea

Treatment: Inpatient Admission

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

This patient is a small child who presented to the Emergency Department (ED) with complaints of diarrhea the morning of the presentation to the ED, and three episodes of vomiting.  There was no fever, no pain.  Her mother reported decreased wet diapers. She did have a wet diaper that morning (and may have had some in diarrhea history of several episodes of non-bloody/ non-bilious vomiting x 1 day.)  The patient was still feeding orally with Pedialyte and was breast feeding.  Her physical exam was unremarkable with no focal findings (described as well developed, well nourished, well hydrated, no distress, actively trying to breastfeed from mom, clear chest and good breath sounds, good capillary refill).  It was noted that she had not voided since presentation to ED, intravenous fluids (IVF) NS Bolus was given.  The mother was also registered and evaluated in the ED for complaints of not feeling well.  After further evaluation the patient was admitted for hydration due to no oral intake or urine output. It was noted that the child did not required IVF hydration while in the hospital.  No further episodes of vomiting or diarrhea were documented in the ED.  

The medical records provided and reviewed do not show any severe problems as indicated by MCG 23rd edition criteria.  For example, severe fluid or blood loss, severe or persistent vomiting, altered mental status, metabolic acidosis with pH <7.35.  Vital signs were not abnormal.  Criteria for full hospital admission were not met and observation level of care could have been instituted.

The carrier's denial of coverage for the inpatient hospital services at the inpatient level of care is upheld.  The medical necessity is not substantiated.