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

Diagnosis: Respiratory syncytial virus (RSV) and bronchiolitis

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a male child with a past medical history of ex-39 weeks gestation and admission to the Neonatal Intensive Care Unit for respiratory distress, neonatal jaundice and hypoglycemia. The patient presented to the Pediatric Emergency Department (ED) with shortness of breath and coughing. His vital signs included a temperature of 37.5C, a heart rate of 128, a respiratory rate of 44, and a pulse oximetry of 100% in room air. His mother stated that the patient had decreased appetite (breastfeeding only), grunting while feeding, difficulty with latching, spitting up, and a decrease in wet diapers (from 5 to now 2 diaper changes). He was taken to another facility's ED the previous day and received a nebulizer treatment. The mother felt the baby was not improving and took him to the Pediatrician's office. They advised her to take the baby to this facility's ED because the brother is also sick with upper respiratory symptoms. On exam, the patient was noted to have nasal congestion and an unproductive cough. No retractions, nasal flaring, grunting or head bobbing were observed. Bilateral lung sounds were clear to auscultation. The patient was alert, active, and maintaining eye contact. The impression was respiratory syncytial virus (RSV) and bronchiolitis.

The infant was not in distress. If one were to assess one of the time tested objective measures of bronchiolitis versus RDAI (Respiratory Distress Assessment Inventory), the score would have been at the most 2 or less, which indicates that the patient could have been managed as an outpatient or in observational status. As per the American Academy of Pediatrics (AAP) guidelines/policy statement regarding the Respiratory Syncytial Virus (RSV) and Admission, AAP recommends admission if the patient is dehydrated or oxygen saturation is < 90 %. The infant does not have any of the above. Furthermore, there is no history of cyanotic congenital heart disease or chronic lung disease or congenital neuromuscular disease. These risk factors pose significant morbidity in RSV infection. The infant did not have any of these.

RSV infection in premature infants can cause central apneas in premature infants and infants less than 42 weeks post conceptual age. However, based on this patient's post conceptual age, this could not portend central apnea in this child. Furthermore, there was no clinical or lab values that indicated the patient needed continuous intravenous (IV) fluids. Taking everything into account, this patient could have been managed as observational or in an outpatient status. 

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

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

Appendicitis
Inpatient Hospital

The patient is a female who presented to the emergency department (ED) with a history of progressively worsening abdominal pain, vomiting, and diarrhea of 1-weeks duration. Her evaluation included physical exam, labs, and computed tomography (CT) scan. She was without fever at the time of presentation. The heart rate was 85/minute. Lab data identified a white blood cell (WBC) count of 10.8 thousand (K). CT scan yielded the diagnosis of acute appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was obtained.
The patient underwent laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. The operative note describes an acute, non-perforated, appendicitis. She was provided IV fluid and perioperative antibiotics. The vital signs remained normal following surgery. She tolerated a diet and was discharged from the hospital.

The health plan's determination is upheld, in whole.

Inpatient admission was not medically necessary for this patient.
This patient presented with abdominal pain. The evaluation with examination, lab data, and CT scan confirmed the diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, IV antibiotics and appendectomy. The early post-surgical course was uncomplicated and the patient was clinically stable. She was stable for discharge from the hospital the following day.
The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient required urgent surgical intervention for acute appendicitis, however, a lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care. There was no documentation of hemodynamic instability, intra- or peri-operative complications, severe pain, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or unstable comorbidities. The patient tolerated oral hydration, diet and medication. Pain was well controlled.
The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care designation would have provided for pre-surgical assessment, operative treatment and post-surgical monitoring. This would have also allowed for overnight monitoring.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered mental status
Issue under review: Inpatient admission

Determination:
The inpatient admission was medically necessary.

This is an adult female with a past medical history pertinent for allergic sinusitis, asthma and vasovagal syncope who presented to the ER for further evaluation/management of altered mental status after exhibiting seizure like activity and becoming unresponsive. EMS reported that the patient vomited five times en route to the ER and was given Narcan x 2 with improvement in respiration and mental status. 

EKG revealed evidence of long QT interval of 477 ms. The patient was admitted to the inpatient medical service where she received extensive evaluation including 2D Echocardiogram, chest x-ray, EEG testing, serum toxicology screening and continuous cardiac monitoring. In addition, she received supportive care with IV fluids. This extensive evaluation and level of treatment intensity can only be offered in the inpatient setting. 

The day after admission, the patient exhibited an episode of respiratory distress during which she had a significant coughing spell which requiring treatment with nebulized bronchodilator therapies. This represents an intensification of services during the patient's hospital stay. Hence, the patient's care could not have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. 

For the above reasons, the proposed treatment of Inpatient admission is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient  with a history of anxiety, asthma, irritable bowel syndrome, and a cholecystectomy who presented to the hospital with worsening epigastric abdominal pain. She described the pain as burning with improvement with calcium carbonate tablets. She also reported three episodes of dark vomiting and had subsequent episodes in the emergency department.  Lab results showed sodium 142, potassium 4.3, calcium 10.3, creatinine 0.63, hemoglobin 12.8, white blood cell count (WBC) 7.9, and platelets 397. A liver ultrasound was negative for acute findings but showed mild enlargement of the liver. The patient was admitted for suspected gastrointestinal (G.I.) bleeding. The plan of care included intravenous (IV) fluids, monitoring hemoglobin, a gastroenterology consult, IV proton pump inhibitor, no aspirin, and a plan for endoscopy. The endoscopy demonstrated gastritis and a hiatal hernia. Her hemoglobin remained stable. The health plan's determination is upheld. The patient did have a suspected G.I. bleed but she was hemodynamically stable, had a stable hemoglobin level, did not require a blood transfusion, was not anticoagulated, and there was no documentation that confirmed acute bleeding. She did need medical care because of symptomatic anemia, but could have been safely and effectively cared for in the hospital at a lower level of care. She had no significant, acute bleeding and no other acute abnormalities in laboratory or imaging beyond anemia. In addition, there was no evidence of hemodynamic instability, cardiac ischemia, angina, or unresponsive hypotension.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male who was brought in by ambulance from urgent care with chest pain/pressure. He had two episodes, associated with shortness of breath and nausea, occurred on ambulation, and resolved at rest. The pain was radiating to the upper neck. (The alternative history documented in the cardiology consultation reported chest pain at rest, right sided, no radiation, lasted for 20 min, without shortness of breath). Another episode while driving was noted. In the emergency department (ED) the pain was at rest, substernal and without radiation.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented with atypical chest pain. He has history of CAD and multiple coronary risk factors. His BP was elevated during admission, but otherwise he was stable. His physical examination was unremarkable. His cardiac enzymes, ECG and stress test, as well as echocardiogram were unremarkable. He was treated with oral medications. This patient's condition and management did not meet inpatient admission criteria. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Decay, Root Involvement
Dental /Orthodontic Procedure 

The patient who presented to the dental office of the  provider for the evaluation and treatment of teeth #5 and 29. Provided for review are a narrative from the dental provider explaining radiographic opening under current restoration for #5 and 29 along with recurrent decay, full mouth radiographic images from 05/02/18, bite-wing images from 07/09/19, panoramic radiographs from 05/02/18, and American Dental Association (ADA) Dental Claim Forms.
In question is the medical necessity of the planned treatment of (2751) porcelain crown and (2954) prefabricated post and core for teeth #5 and 29.
The health plans determination of medical necessity is upheld in whole .
Based on the provided documentation there is no evidence of decay radiographically nor clinically to support the need for the requested treatment of (2751) porcelain crown and (2954) pre-fabricated post and core for teeth #5 and 29.The current documentation does not support the presence of decay at the margins of #5 and 29 neither clinically nor radiographically, hence removing any rationale for the replacement of the current crowns on those teeth. Because there is not a medical necessity need for the porcelain crowns, there is also not the need for post core and buildup for either teeth. Without evidence of decay radiographically or clinically to support the need for the planned treatment of porcelain crown and prefabricated post and core for teeth #5 and #29,  medical necessity cannot be established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia.
Treatment:  Personal care assistance; 24 hours/day, 7 days/week live-in

This is a female with a history of dementia.  Due to cognitive impairment related to this condition, she requires assistance with completion of the majority of her activities of daily living (ADLs).  Documentation from the patient's Attending Physician indicates that the patient is demonstrating significant, progressive functional decline and worsening cognitive impairment.  For these reasons, the currently approved plan of PCA, Level II, 10 hours/day, 7 days/week is no longer sufficient to meet the patient's needs.  Hence, the proposed treatment of an increase in Personal care assistance hours to 24 hours/day, 7 days/week live-in is deemed medically necessary for increased assistance with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Teeth Spacing Problem
Treatment:  Dental/Orthodontic Procedure

The patient in question is a male.  He has a Class 1 malocclusion with protrusive maxillary incisors.  Teeth 6 and 11 are in anterior crossbite.  He is treatment planned for 24 months of orthodontics with extraction of teeth 5, 12, 21, and 28 to correct the crowding and protrusion.  This is the subject of this review.

The health plan's determination is overturned.  The braces are medically necessary for this patient.  There is strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma.  Extraction of four premolars combined with orthodontics will make his teeth less protrusive.  Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth.  For this reason, braces are medically necessary.  Teeth #8 and #9 are protruding forward within the dental arch.  This makes them more prone to trauma.  Additionally, 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.
Appeal type: Medical necessity
Decision: Overturned

This is a male patient with a long history of papillary thyroid cancer and soft tissue and bone lesions causing symptoms. This followed multiple previous therapies. Also, there are positron emission tomography (PET) avid metastatic lesions to the left sacral pelvic bone and latissimus dorsi; both to be targeted for therapy. Radio-frequency ablation of these targets is requested. Imaging notes PET avid areas at the right latissimus dorsi and left sacral ala. He also has recurrent lung and liver lesions.
Pertinent past medical records note also other cryoablation of lesions in early 2019 and hypothyroidism, gastroesophageal reflux disease (GERD) and vocal cord paralysis.
His past medical history includes radioactive iodine treatment (RAI), ablation of liver lesions, right modified neck dissection with lymph node dissection in early 2015 with tracheostomy after total thyroidectomy. He had concurrent chemotherapy. He is on Synthroid.
The current treatment plan is radiofrequency ablation performed under positron emission tomography (PET) /computed tomography (CT) guidance.
At issue is the medical necessity of radiofequency ablation.
The requested health service/treatment of radiofrequency ablation is medically necessary for this patient. These lesions have had previous radiotherapy via RAI. The best way to control local disease that is not appropriate for surgical resection is with heat ablation. This patient will have the best outcome with ongoing treatment of metastatic lesions to control disease and symptoms. Local tumor control of PET avid metastatic lesions is necessary for ongoing palliation of this patient.
The health plan's determination is overturned. Local tumor control is a viable goal for RFA. These 2 lesions were appropriate to be targeted.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hypertension. She presented to the emergency department complaining of left-sided chest pain and dyspnea. Her blood pressure was 140/88 millimeters of mercury (mmHg) with a heart rate of 119 beats/minute. Her respiratory rate was 20/minute. Her room air oxygen saturation was 100%. Her cardiovascular exam was unremarkable. She had chest wall tenderness. Her electrocardiogram showed sinus rhythm at 105 beats/minute with nonspecific T wave changes. Her troponin and brain (or B-type) natriuretic peptide (BNP) levels were normal. A chest computed tomography (CT) scan showed no evidence of pulmonary embolism. An echocardiogram showed a dilated left ventricle with normal systolic function. She was treated with aspirin, nitroglycerin and a statin and admitted to the hospital to rule out acute coronary syndrome. The health plan's determination is upheld.
This patient presented with atypical symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was reasonable and prudent. On the other hand, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. There is no indication in the records provided that other potentially life-threatening diagnoses were considered likely. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

This is the case of a male with past medical history significant for ethanol (EtOH) abuse, hypertension (HTN), and schizophrenia, who presented to the emergency department (ED) with chief complaint of hearing voices telling him to attack people. He was in the psych hallway of the ED and noted to have a fall at which point internal medicine was consulted to see the patient.
On evaluation, he was noted to be bradycardic with borderline HTN and unremarkable orthostatics. Exam otherwise noted no acute abnormalities. Labs noted complete blood count (CBC) within normal limits, basic metabolic panel (BMP) with bicarbonate (HCO3) of 30 but otherwise grossly normal, EtOH level of 244. Urinalysis (UA) was negative and urine drug screen (UDS) positive (+) for cannabis. Electrocardiogram (EKG) showed heart rate (HR) of 42 without concern for ischemia or heart block. Chest x-ray (CXR) and computed tomography (CT) head noted no acute findings. The patient was brought into the hospital with assessment that he should be worked up for syncope and plans for tele, intravenous fluids (IVF), troponin, transthoracic echocardiogram (TTE), consideration of neurology consult, and Ativan prn to prevent EtOH withdrawal.
The next day his bradycardia had resolved and work-up was otherwise unrevealing. He was deemed medically stable for discharge. Psychiatry saw the patient with assessment that he was psychiatrically stable and did not require inpatient psychiatric treatment. The patient was subsequently discharged.
The issue in question is whether this patient required care at the acute inpatient level of care.

The health plan's determination is upheld.

This is a patient with schizophrenia and EtOH abuse who presented to the ER actively intoxicated and with voices telling him to attack people. He was initially in the psych emergency room (ER), after which he was transferred to the medical unit when he had a fall and was noted to have bradycardia. He notably was not agitated in the ER or requiring repeated doses of intramuscular (IM) or intravenous (IV) psychiatric medications or restraints. Given his fall and bradycardia, he was certainly appropriate for monitoring on the medical unit and further monitoring of bradycardia. It is noteworthy, however, that his bradycardia was not associated with hypotension, concerns for heart block, or concern for QTc prolongation. As noted, with regards to his psychiatric symptoms, he was not noted to be agitated, requiring as needed (prn) IM or IV medications or restraints. He was appropriate for monitoring of his psychiatric symptoms to see if they persisted or improved after he was not intoxicated. Monitoring and syncope work-up with keeping an eye on psychiatric symptoms as the patient detoxed from EtOH was appropriate, but this did not require inpatient treatment. The patient could have been treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary embolism

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a female with a history of Hodgkin's Lymphoma status post chemotherapy and radiation therapy who presented to the Emergency Department (ED) with complaints of shortness of breath and chest pain of one day duration.  The patient had gone to an Urgent Care Center where an EKG and chest x-ray was normal.  The patient's labs revealed that her D Dimer was elevated; therefore, she was sent to the ED.  The patient had given birth four months prior to presentation and was now on oral contraceptive pills.

Vital signs at presentation to the ED included a temperature of 98.1F, a blood pressure of 110/73, a heart rate of 89, a respiratory rate of 20, and an oxygen saturation of 99% on room air. The patient's D Dimer was still elevated to 1227.  A CT angiogram revealed an acute sub segmental pulmonary embolism (PE) in the bilateral lower lobes.  An EKG showed normal sinus rhythm.  There were no acute changes.  The echocardiogram was unremarkable.  

As per the History & Physical, the patient was afebrile.  Her heart rate was 84, her respiratory rate was 18, her blood pressure was 103/72, and oxygen saturations were 100% on room air.  The patient was alert and oriented. She was in no acute distress.  Her lungs were clear and cardiovascular system (CVS) S1 S2 was normal.  Her abdomen was soft and non-tender.  There was no edema.  The patient had a normal neurological exam. The white blood cell (WBC) count was 8.7K and the hemoglobin was 12.1. Electrolytes and blood urea nitrogen (BUN)/creatinine levels were within normal limits. The patient was thought to have pulmonary embolism (PE) related to the use of OCP.  The patient was admitted to a medical floor and treated with Lovenox and Xarelto.  The patient remained stable after admission.  She was discharged home on Xarelto with outpatient follow-up in 1-2 weeks.

This patient did not need acute hospitalization.  She was stable to be placed in Observation status while diagnostic testing and treatment were initiated.  The patient was afebrile and hemodynamically stable.  She was not hypoxic.  Oxygen saturations were good on room air. Labs were unremarkable.  An EKG and echocardiogram were within normal limits.  There was no evidence of right (R) heart strain.  The patient was in no acute distress.  She was tolerating oral intake.  The physical exam was unremarkable.

This patient was switched to a non-vitamin K antagonist oral anticoagulant (NOAC) and was stable to be discharged on the NOAC after initial diagnostic testing was completed.  The patient could have been followed up closely in the outpatient setting after discharge.  The prior denial is upheld. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

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

Prostate Cancer
Cancer Screening 

The patient is a man with newly diagnosed prostate cancer. He has Gleason Grade Group 1 disease, clinical stage T1c, with a pre-treatment prostate-specific antigen (PSA) 7.0. The OncotypeDx testing was ordered. This is the subject of this review.

The health plan's determination is upheld. The cancer screening: OncotypeDx Prostate Cancer Assay is not medically necessary for this patient. The current guidelines of the American Urological Association and the National Comprehensive Cancer Network (NCCN) do not endorse the use of this test for this patient's type and extent of prostate cancer.
The OncotypeDX test is not supported by current standard of care and medical literature. According to Bostrom, " Greater understanding of the potential long-term benefits and limitations of these tests and their optimal use in clinical decision making is important."