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

Diagnosis:  Abdominal pain and vomiting
Treatment:  Inpatient admission
The inpatient admission was not medically necessary.

The medical records and medical literature were thoroughly reviewed.  Pelvic inflammatory disease (PID) comprises a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.  Acute PID is difficult to diagnose because of the wide variation in symptoms and signs associated with this condition.  Many women with PID have subtle or nonspecific symptoms or are asymptomatic.  Delay in diagnosis and treatment may contribute to inflammatory sequelae in the upper reproductive tract.  Laparoscopy can be used to obtain a more accurate diagnosis of salpingitis and a more complete bacteriologic diagnosis.  However, this diagnostic tool frequently is not readily available, and its use is not easily justifiable when symptoms are mild or vague.  Moreover, laparoscopy will not detect endometritis and might not detect subtle inflammation of the fallopian tubes.  Consequently, a diagnosis of PID usually is based on imprecise clinical findings. 

Presumptive treatment for PID should be initiated in sexually active young women and other women at risk for sexually transmitted diseases (STDs), if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum clinical criteria are present on pelvic examination: cervical motion tenderness or uterine tenderness or adnexal tenderness.  The requirement that all three minimum criteria be present before the initiation of empiric treatment could result in insufficient sensitivity for the diagnosis of PID.  After deciding whether to initiate empiric treatment, clinicians should also consider the risk profile for STDs.  The Centers for Disease Control (CDC), in its Treatment Guidelines, states: 
"The decision of whether hospitalization is necessary should be based on provider judgment and whether the woman meets any of the following suggested criteria:
1) surgical emergencies (e.g., appendicitis) cannot be excluded; 2) tubo-ovarian abscess;
3) pregnancy; 4) severe illness, nausea and vomiting, or high fever; 5) unable to follow or tolerate an outpatient oral regimen; or 6) no clinical response to oral antimicrobial therapy."

The patient, as confirmed by the gynecologic consultant, did not meet criteria for inpatient admission for PID.  She did not have a surgical emergency, as she did not have an acute abdomen.  She did not have a tubo-ovarian abscess by imaging, was not pregnant, did not have a severe illness, persistent nausea and vomiting or high fever.  She could have been managed with IV antibiotics in a less than acute care setting rather than by inpatient admission.  Therefore, the admission was not medically necessary, and the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever and rash, Measles
Treatment: Inpatient admission 
No, the Inpatient admission was not medically necessary.

Summary:
The patient is a unvaccinated and previously healthy male child. He presented to the ED with one-week history of fever and rash. He was seen in the ED for evaluation of stridor, with plans for admission. However, he was able to take a bottle and was able to maintain his saturations above 90% while sleeping so was discharged home. Chest x-ray at that time was negative, and measles testing was positive. He was seen in the pediatrician's office on the day of presentation and was found to be tachypneic in respiratory distress with extensive oral lesions and not tolerating anything by mouth. He was also noted to have early otitis media. He was referred to the ED for evaluation.

This unvaccinated male infant contracted measles after exposure to his older brother who had measles. He developed significant oral lesions, was unable to drink sufficiently, and became dehydrated. He also had croupy cough and intermittent stridor with some tachypnea in the pediatrician's office. Following stabilization in the ED, it was reasonable and appropriate to provide continued monitoring with parenteral hydration pending adequate oral intake. However, he was overall hemodynamically stable, with no signs of shock or sepsis, no respiratory distress, no oxygen requirement, and no stridor. He did not require acute inpatient admission. He could have been safely managed at lower level of care, such as observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: Inpatient admission

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

This patient is a female who presented to the ED with complaints of fever, nausea and right lower quadrant pain (RLQ) pain since the day prior. The patient was afebrile with stable vital signs. Exam revealed RLQ tenderness. WBC was 17.6. CT of the abdomen revealed acute appendicitis. The patient was given IV antibiotics and made nothing by mouth (NPO). The patient was admitted and taken to the operating room and underwent laparoscopic appendectomy. Pathology results revealed acute suppurative appendicitis. The patient did well and was discharged to home.

Based upon the records provided, this reviewer agrees with the insurer that the patient did not require acute level of care as the patient could have been cared for based upon an observation admission. The patient presented to the hospital and was admitted at approximately and underwent lap appendectomy. The patient was sent home and could have been cared for with a 23 hour observation and did not require an acute care admission but rather observation. There was no evidence of a complicated post op course requiring hospitalization. Thus, the patient should have had the appendectomy performed under an observation status without an inpatient admission.

MCG, the goal length of stay is ambulatory or 1 day postoperative. The operative status criteria include ambulatory for most patients and inpatient for patients with severe systemic illness (e.g., sepsis), poorly controlled co morbidities (e.g., COPD, chronic heart failure), or complications from procedure (e.g., infection, bleeding) that require more than 24 hours of postoperative care. Milliman notes that most patients can be treated on an ambulatory basis. Extended stay may be indicated and defined as Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days).  This patient did not have any factors that required hospitalization, or any other factors present that would have required prolonged hospitalization (e.g. ileus, postop bleeding, and signs of peritonitis, wound infection or complication) and the patient should have been discharged within 23 hours and did not require acute inpatient setting.
  
To summarize, the acute level of care, inpatient admission was not medically necessary at the acute care level. The patient underwent an uneventful appendectomy and should have been cared for under an observation status following the appendectomy. She did not need acute care and thus as noted by MCG guidelines did not need acute admission.

The health plan acted reasonably with sound medical judgment in the best interest of the patient. Based on the above, the medical necessity for the inpatient admission not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pneumonia

Treatment:  Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.  The denial is reversed.

This patient is a male child who had been sick for one week with a maximum fever of 104 degrees.  When his fever and cough did not respond to therapy in the home he was taken by his mother to the Emergency Room (ER).  He had not been feeding well, and the mother was concerned.  In the ER he was evaluated with a blood test, which indicated that he had a high white blood count of 24,000.  A chest x-ray documented the presence of right lower lobe pneumonia.  In the ER the staff noted that the child was not drinking or eating, and attempts to administer the oral antibiotic were unsuccessful.  Since the physicians determined that the child had a significant pneumonia and required ongoing intravenous (IV) antibiotics, the decision was made to admit the child to the hospital for ongoing care.  The child was treated in the hospital with intravenous fluids and antibiotics, and the next day when the child had improved clinically and was tolerating oral feeds and the antibiotic the child was discharged on a course of oral antibiotics.  The insurer has denied coverage for acute in-patient admission to the hospital.

The health plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  The inpatient admission was medically necessary.
The patient was treated appropriately in the ER for right lower lobe pneumonia and the inability to tolerate the antibiotics by mouth.  He received intravenous fluids and antibiotics in the hospital, and when the child's clinical condition improved he was discharged the next day.

The white blood count was significantly elevated confirming a bacterial infection, and the decision to admit to the hospital was consistent with the standard of care for treatment of pneumonia in a young child who was unable to tolerate liquids and oral antibiotics.  He could not have been safely discharged on antibiotics because he was not tolerating any fluids by mouth.  As per Up to Date, indications for admission in a child include "Dehydration, or inability to maintain hydration orally."

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

Hypertension
Inpatient Hospital

This is a patient  who was brought by paramedics to the emergency department with hypertension and a headache. Her headache was described as on and off, 6-7/10, frontal, especially behind her eyes, with no aggravating factor identified. Her past medical history (PMH) was remarkable for intentional weight loss, and she previously had right hip surgery and breast reduction. Her review of systems otherwise was unremarkable.
The patient was seen at the shelter where she resides for a routine visit, and her blood pressure (BP) was elevated (reportedly 180-200 systolic). The patient had persistent headaches and she was treated with acetaminophen and metoclopramide.
The patient was evaluated in the emergency department (ED) and her heart rate (HR) was 37-66. Her BP was 156/81 (the highest BP in the ED was 174/113). Her physical examination was unremarkable. Her electrocardiogram (ECG) revealed sinus bradycardia with HR 37 beats per minute (BPM). otherwise, it was normal.
The patient was admitted for further evaluation. She underwent lab tests, an ECG, chest x-ray (CXR) and a computed tomography (CT) scan of the head.
Her CXR was unremarkable.
The patient was admitted with the suspicion of pseudotumor cerebri and because of bradycardia. She was consulted by cardiology and neurology. Her condition was stable. Her BP was controlled with Nifedipine 30 milligrams (mg) by mouth (PO). She felt better. Her BP was normal and her HR was in the range of 50. Her serial troponin was normal. She was discharged. At issue is the medical necessity of an inpatient level of care.
The health plan's determination is upheld. The patient presented with an elevated blood pressure and slow heart rate. She had a headache, but no localized neurologic deficit. Her head CT scan was negative. She was treated with oral medications. Her lab results were unremarkable, troponin was normal and brain (or B-type) natriuretic peptide (BNP) was 48. Her echocardiogram revealed normal left ventricular (LV) function and LV size was 72%.  An x-ray of the cervical spine was done and there were no abnormalities. Her urine was positive for cannabinoid.
It was appropriate to observe the patient for high BP and slow HR, but there were no indications for inpatient admission. The patient was treated with oral medications and her condition improved. A lower level of care than inpatient would have been more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stage V chronic kidney disease 
Treatment: Inpatient stay 

Summary:
The patient is a female with stage V chronic kidney disease (baseline creatinine between 5.0-6.0), chronic methadone use, hypertension, and schizophrenia. She presented to the hospital with irrational behavior and paranoid visual delusions.  

The patient's behavioral change and delusions were not accompanied by a focal neurologic process such as acute cerebrovascular accident, loss of consciousness, seizure activity, or intracranial vasculitis.  QT prolongation on electrocardiogram was not accompanied by evidence of ventricular arrhythmia.  Renal function remained stable, with the creatinine being minimally greater than the patient's previous baseline creatinine.  Dialysis was not required, and the patient did not have hyperkalemia, pulmonary edema, acidosis, or uremia.  The patient remained hemodynamically stable and afebrile.  

In summary, 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: Upheld

Diagnosis:  Chest pain
Issue under review:  Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female.  She has a past medical history significant for migraine HA (headache), back pain, obesity, bipolar disorder, and NSTEMI (non-ST elevation myocardial infarction).  The patient had been admitted for chest pain approximately one month prior, and she had undergone a cardiac catheterization, which revealed no obstructive coronary disease.  She was admitted for complaints of chest pain and dizziness. 

The patient was hemodynamically stable. Her ECG (electrocardiogram) revealed sinus bradycardia, with minor voltage criteria for LVH (left ventricular hypertrophy) and non-specific T-wave change.  Her cardiac enzymes were negative. Her D-dimer was elevated and the patient underwent a CTA of the chest, which revealed no evidence of PE (pulmonary embolism).  Chest X-ray was negative for acute pulmonary disease. 

The patient was admitted to telemetry for monitoring.  Her recent echocardiogram revealed preserved LV (left ventricle) systolic function, LVH, mild to moderate mitral insufficiency.  On telemetry, the patient was noted to have sinus bradycardia in 40s, with increase in heart rate to 80s on movement.  Head CT was done due to episodes of dizziness, and was unremarkable.  No ischemic work-up was planned.  There was no plan for pacemaker placement, and the patient had a loop recorder placed for monitoring with a plan for outpatient follow-up with cardiology.

This patient presented for evaluation of chest pain.  The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. The patient had had a recent cardiac catheterization, which revealed patent coronaries, and no further ischemic work-up was planned.  CTA of the chest was done on admission and was negative for PE.  There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability.  Due to episodes of dizziness and sinus bradycardia, a loop recorder was placed to monitor the patient at home.  There was no plan for inpatient pacemaker placement, IV pressors.  There was no evidence of an acute neurological event, CVA (cerebrovascular accident), seizure, etc.  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: Upheld

Diagnosis: Renal calculi and acute bronchitis

Treatment: Inpatient admission 

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

This patient is a male with a past medical history of renal stones, hypertension and substance abuse who presented to the Emergency Room (ER) with complaints of chest pain and hematuria for three days.  ER triage revealed a temperature of 98.7, a blood pressure of 142/62 and a heart rate of 78.  The patient was admitted with diagnosis of renal calculi and acute bronchitis.  Intravenous fluids/intravenous antibiotics/analgesics were given.  A CT scan revealed left hydronephrosis due to an 8-9 mm left ureteral pelvic junction (UPJ) stone, as well as bilateral non-obstructing calculi.  The patient was managed conservatively and his pain and hematuria resolved.  The patient denied passing any stone.  He was discharged in stable condition with outpatient urology follow-up.  

The insurer has denied coverage for the inpatient admission as not medically necessary.

Per MCG Health (23rd Edition) Renal Colic and Kidney Stones, the patient fails to meet clinical indications for admission to inpatient care.  These include hemodynamic instability, acute renal failure, bilateral obstruction, obstruction in a single functioning kidney, etc.  Also, per MCG Health (23rd Edition) Urologic Disease GRG, the patient fails to meet clinical indications for admission to inpatient care under subsections: 

1) Gross hematuria requiring inpatient care.

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

The inpatient admission is not considered medically necessary for this patient. 

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

Diagnosis: Difficulty swallowing history of irritable bowel syndrome, gastroesophageal reflux disease and Type ll achalasia

Treatment: Peroral Endoscopic Myotomy

The insurer denied the procedure as experimental investigational. The denial was reversed.

Reviewer #3:

The patient presented with dysphasia. Esophageal motility testing revealed lack of esophageal peristalsis consistent with achalasia. A barium swallow was also done and was consistent with achalasia.

Up-To-Date has an article titled "Peroral Endoscopic Myotomy" which states that this procedure is indicated in patients with symptomatic achalasia. A review of 14 studies showed a clinical success rate of 82% in the short term. In another study of 80 patients who were followed for more than 2 years after POEM. The success rate was 78%.

The scientific literature does support the use of POEM for achalasia. POEM has been approved by the FDA. The patient has dysphagia and an abnormal motility study, making him a good candidate for the procedure. There are multiple options for the treatment of achalasia. However, POEM has been shown to be an effective procedure with minimal invasiveness and high cure rates. Five year follow-up of 36 patients demonstrated successful palliation of symptoms in the majority. Therefore, this procedure is likely to be more beneficial than any of the standard treatments/procedures for this patient.     

The carrier's denial of Peroral Endoscopic Myotomy (POEM CPT 43499) should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Difficulty swallowing history of irritable bowel syndrome, gastroesophageal reflux disease and Type ll achalasia

Treatment: Peroral Endoscopic Myotomy

The insurer denied the procedure as experimental investigational. The denial was reversed.

Reviewer #2:

The patient has a history of type II achalasia. He was advised to have a myotomy via a peroral approach. Peroral Endoscopic Myotomy (POEM CPT 43499) is considered more beneficial for this patient's diagnosis.

The per oral endoscopic myotomy has been FDA approved to treat achalasia and does not need final approval from the regulatory bodies.  The patient does appear to be a good candidate for this procedure (POEM CPT 43499).     

The peroral endoscopic myotomy is comparable to a Heller myotomy in regards to results of approval of swallowing function. The only drawback is some patients develop reflux symptoms after this type of procedure and may need antireflux surgery at a later date, but otherwise yes this is the best available treatment for this patient as this time.

"Short-term results show that POEM is more effective than LHM in relieving dysphagia, but it is associated with a very high incidence of pathologic reflux." (Schlottmann, F., Luckett, D., J., & Fine, J., et al., 2018).

"In 2008, a new treatment modality for esophageal achalasia was introduced-peroral endoscopic myotomy (POEM). POEM is a procedure performed endoscopically, which allows transection of the muscular fibers of the distal esophagus and of the lower esophageal sphincter. The procedure is therefore similar to a laparoscopic Heller myotomy without a fundoplication. Short-term studies have shown that POEM is very effective in relieving dysphagia and regurgitation, but concerns have been raised about the incidence of post-POEM gastroesophageal reflux. Prospective and randomized trials will be needed to determine the role of this new procedure in the treatment algorithm of esophageal achalasia." (Kroch, D. A., & Grimm, I. S., 2018).     

The main benefit for this procedure (POEM CPT 43499) is that it is minimally invasive, and can be done on an outpatient basis compared to the standard Heller myotomy. Therefore, this procedure is likely to be more beneficial than any of the standard treatments/procedures for this patient.     

The carrier's denial of Peroral Endoscopic Myotomy (POEM CPT 43499) should be reversed.