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

Diagnosis: Nephrolithiasis  and a urinary tract infection
 
Treatment: Inpatient admission

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

This patient is a female with no significant past medical history presented to the Emergency Department with complaint of left flank pain radiating to the abdominal area.  Emergency Room (ER) triage vitals were temperature 98.70F, blood pressure 123/64, and respiratory rate 18.  CT scan revealed mild to moderate left hydronephrosis due to a 6.2 x 2.9 mm stone (elongated) with the proximal left ureter.  The patient was admitted from ER with diagnosis of nephrolithiasis  and a urinary tract infection.  Urology was consulted.  The patient received intravenous (IV) fluids, IV antibiotics and pain medication.  After admission, the patient improved significantly and was asymptomatic.  She was discharged home the day after admission with prescription for Cipro and outpatient urology follow-up.  The patient also was advised to follow-up with gynecology regarding an incidental lesion in her left breast found on imaging.

This insurer has denied coverage for the inpatient admission. According to MCG Health (22nd Edition) Renal Colic & Kidney Stones, inpatient admission is recommended if a patient has hemodynamically instability, acute renal failure, bilateral obstruction, obstruction with single functioning kidney, transplanted kidney with obstruction, severe pain requiring acute inpatient management, vomiting that is severe or persistent, urinary tract infection, need for IV hydration support despite observation care treatment, or stone removal procedure needed requiring inpatient admission. However, this patient was hemodynamically stable. The patient's renal function was normal (i.e. non-elevated creatinine), the patient did not have vomiting, and the patient did not fail observation care treatment. The patient was afebrile, and thus, urology did not recommend intervention (i.e. stone removal or stent placement). The patient's pyuria and suspicion for urinary tract infection could have been monitored and treated at observation status. Thus inpatient admission was not medically necessary to treat this patient's medical condition. 

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: Medical necessity
Decision: Upheld

Diagnosis: Elevated blood pressure 

Treatment: Inpatient hospital admission

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

This patient is a female G1 P0 at 31 weeks 4 days gestation who was admitted with elevated blood pressure (100-140/50-70). The patient denied headache, vision changes, shortness of breath, chest pain, right upper quadrant pain, nausea or vomiting.  Her blood pressure normalized in the observation area.  The patient was admitted for 24-hour urine collection, betamethasone and blood pressure control. Her laboratory evaluation was within normal limits.  The patient's blood pressure remained stable during her stay and no antihypertensive medications were required. The patient was seen by Cardiology prior to being discharged home.

The patient presented with elevated blood pressure, no vaginal bleeding, no uterine contractions and no ruptured membranes. There was no evidence of fetal compromise. 

Preeclampsia refers to the new onset of hypertension and proteinuria or hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation in a previously normotensive woman.  So based on this patient's presentation, she did not have preeclampsia, but uncontrolled hypertension.

According to MCG: Indications for admission include:

1) Severe preeclampsia or eclampsia 
2) Onset of seizures
3) Fetal compromise 
4) Hemodynamic instability
5) Hypertension and acute end organ damage.

This patient did not have any of the above. This patient presented with some blood pressure elevation that normalized by itself.  Laboratory evaluation was normal and there was no evidence of preeclampsia.  A 24-hour urine collection does not require hospital admission.

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

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

Alcohol Abuse Addiction
Substance Abuse /Inpatient

The patient  who presented for inpatient detoxification and substance-related services. The patient has a history of severe substance use disorders with alcohol, stimulants (crack cocaine), and cannabis (marijuana) class substances of abuse. The patient  has a history of prior substance use disorder treatment including detoxification and rehabilitation treatment with relapse. The patient was using large quantities of alcohol on a continuous daily basis with up to one liter or pint of liquor together with  crack cocaine and intermittent use of marijuana once to twice weekly.The health plans determination is overturned in whole.
Yes, the requested health service/treatment of inpatient detoxification treatment and withdrawal management and monitoring and other medical services,  was medically necessary for this patient, appropriate, and warranted, and therefore the admission and the continued inpatient level treatment through discharge could not have been safely or effectively provided with lower level services, especially in view or the clinical factors, treatment dimensions, and psychosocial aspects of this case. 
The inpatient detoxification stay could not have been safely or effectively provided at a lower level of care in this case scenario, The patient in this case was using large quantities of alcohol on a daily continuous basis together with other substances of abuse that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms (tremor, sweats, anxiety, irritability, restlessness and insomnia) which were being effectively addressed with Librium and comfort medications and with supportive measures that included seizure precautions. The patient had associated clinical features that included lack of sober supports and limited insight, impaired judgment and poor control of impulses.
Medical necessity was met in this case, consistent with prevailing standards of professional practice, published practice guidelines, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, including the application of NY OASAS LOCADTR 3.0 Criteria/Guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain

Treatment:  Inpatient admission

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

This patient is a female who presented to the Emergency Department (ED) with complaints of abdominal pain.  She was 13.3 weeks pregnant.  Her abdominal examination was benign.  White blood cell (WBCs) counts were normal for a pregnant woman, and vital signs were stable.  Ultrasound and MRI showed low suspicion for appendicitis.  The patient had a fibroid which was thought to be the cause of her pain.  The patient was admitted and managed for her pain.  Her symptoms gradually resolved, and she was discharged home.

Acute appendicitis is the most common general surgical problem encountered during pregnancy.  The clinical manifestations of appendicitis in pregnancy are similar to those in nonpregnant individuals; however, the following points should be noted: 1) right lower quadrant pain is the most common symptom and occurs within a few centimeters of McBurney's point in most pregnant women, regardless of the stage of pregnancy; 2) mild leukocytosis can be a normal finding in pregnant women; the total leukocyte count may be as high as 16,900 cell/microL in the third trimester and 29,000 cells/microL during labor, so leukocytosis may or may not be a sign of appendicitis; 3) the clinical diagnosis should be strongly suspected in pregnant women with classic findings: abdominal pain that migrates to the right lower quadrant, right lower quadrant tenderness, nausea/vomiting, fever, and leukocytosis with left shift. 

This patient had abdominal pain, otherwise, she was asymptomatic.  Her examination did not show a surgical abdomen.  She was afebrile with stable vital signs.  She had mild elevation of her white blood cell count consistent with pregnancy and no left shift.  Both ultrasound and MRI were not suggestive of appendicitis.  The patient could have undergone a full evaluation in the Emergency Department (ED), including ultrasound MRI and surgical consul.  Once the provider ascertained that the odds of appendicitis were negligible, she could have been sent home.  Admission for evaluation of the pelvic pain was not medically necessary.  Admission for control of the pain is not medically necessary, either.  Once the provider ascertained that there was no acute issue, the patient could have been sent home on oral analgesics. 

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

2) The inpatient hospital admission was not medically necessary.

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

Diagnosis: left renal colic
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

This female was admitted with left renal colic.  Vitals were 98.8-125/87-86.  The white blood cell (WBC) count was 11,700.  The creatinine was 0.9. Computed tomography (CT) imaging demonstrated an eight millimeter (mm) left proximal ureteral calculus with hydronephrosis.  Intravenous (IV) pain medications, nausea medications, IV antibiotics and IV fluids were administered.   

The next day, a left ureteral stent was placed.  The patient was discharged home.  She was afebrile and hemodynamically stable throughout the stay.

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.  The patient did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. She did not have bilateral obstruction, acute renal failure, severe vomiting.  Pain control, IV antibiotics and IVF followed by stent placement in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Digestive system/gastrointestinal (other)
Inpatient hospital

The patient is an ex-35 week premature infant who presented to the emergency department with fever, vomiting, diarrhea, and decreased oral intake. She was well until a few days prior to her presentation when she developed cold symptoms including vomiting, diarrhea, and decreased oral intake. She developed a fever up to 102 F and also had decreased urine output. She was given acetaminophen, and her fever went down to 101 F. She had not been able to eat or drink anything that day. She then had an accidental collision with her cousin where they banged their heads together. She had a change in behavior after that including babbling frequently and rolling her head. This prompted her mother to call for emergency services.

The health plan's determination is overturned. The inpatient stay was medically necessary. This is an infant who presented with fever, vomiting, diarrhea, and decreased oral intake. She also had a closed head injury. Her urine sample findings were consistent with urinary tract infection, and she had fever and tachycardia at the time of presentation. Inpatient care for urinary tract infection is needed for children with vomiting or inability to tolerate oral medication. She required inpatient admission for the administration of intravenous antibiotics to treat her infection and intravenous fluids to maintain her hydration status, along with close monitoring with additional therapies as needed.
The decision making at the time of admission for this patient was consistent with her very young age, the presence of fever, vomiting and decreased oral intake in the setting of a presumed urinary tract infection, and the need for parenteral therapies and intravenous fluids with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteomyelitis

Treatment: Inpatient Admission

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

This is a male patient with a history of diabetes mellitus, venous stasis, chronic osteomyelitis with left toe amputation, and polysubstance abuse on methadone. He presented to the Emergency Department with complaints of left foot pain. A left foot x-ray was performed that revealed possibility of osteomyelitis at distal fibula. Wound cultures were obtained that grew MRSA and vancomycin-resistant enterococcus faecalis (VRE). A peripherally inserted central catheter (PICC) line was inserted for intravenous (IV) antibiotic therapy. The patient was started on Suboxone and monitored for alcohol withdrawal. The patient signed out against medical advice (AMA). The PICC line was removed prior to his departure. 

According to documentation, the patient returned to the ED for management of left foot osteomyelitis. Although the patient was afebrile, the patient was tachycardic and possibly in withdrawal from active substance abuse. Laboratory results showed low WBC, as well as anemia (low Hgb and Hct). The patient had signed out AMA on several previous occasions before an appropriate treatment plan for a serious bone infection (osteomyelitis) could be established. Imaging studies and cultures results (MRSA, VRE) were consistent with acute osteomyelitis. Based on above abnormalities in a high-risk homeless patient with active substance abuse, hospital admission was unavoidable and medically necessary. 

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

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

Diagnosis: Chest pain
Treatment: Inpatient admission
The inpatient level of care was not medically necessary.

This patient is a female with diabetes, cerebral vascular accident (CVA), hypertension along with recent left atrial (LA) clipping, mitral valve replacement (MVR) and coronary artery bypass grafting (CABG) three weeks prior who presented with mid sternal chest discomfort. Symptoms resolved with Tylenol. Electrocardiogram (EKG) was normal, enzymes were mildly elevated and trend was flat (recent open heart surgery). Per chart note, admission was "to observe for further chest pain and trending troponins". The patient remained pain free and was discharged on her usual medications. 

This patient had recent open heart surgery less than a month prior to this admission. Pain was relieved with Tylenol and she was pain free from then on. There were no EKG changes and the trending of troponins was flat. The mild elevation of troponin is consistent with recent surgery. The patient was seen by Cardiology services and discharged without intervention. The note stated that admission was "to observe for further chest pain and trending troponins". No intervention, testing or new treatment was deemed necessary. 

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome (ACS). Exam and cardiac findings were normal. EKG showed no evidence of acute ischemia. Echocardiogram was unremarkable. The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for ACS such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG).   

The letter of appeal was carefully considered but offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. By the treating physician's own statements, the patient was admitted for monitoring. Subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of active CAD.  While there is always a potential for an adverse event, one did not happen and no actual treatment was added. All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

Milliman criteria requirements for admission were not fulfilled as there was never any evidence of ACS present nor was any care given that required a higher level of acuity. The appeal reference to a 24 hour stay is not relevant for consideration of level of care.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Abscess

Treatment: Inpatient Hospital

The insurer denied the inpatient hospital. The denial was reversed.   

This is a female patient with a history of opioid abuse who presented to the Emergency Department (ED) with complaints of a sinus headache and tooth ache for two weeks. Laboratory work up was performed that revealed white blood cell (WBC) count 12.1. An electrocardiogram (EKG) was performed that showed sinus tachycardia with possible left atrial enlargement. Intravenous (IV) fluids and antibiotics were administered. The patient underwent an extraction of her #7 tooth. She experienced no complications and was then discharged home.  

Per Plewa MC, Tadi P, Gupta M. (2017), "Cavernous sinus thrombosis (CST) is a rare, life-threatening disorder that can complicate facial infection, sinusitis, orbital cellulitis, pharyngitis, or otitis or following traumatic injury or surgery, especially in the setting of a thrombophilic disorder. Early recognition of cavernous sinus thrombosis which, often presents with fever, headache, eye findings such as periorbital swelling, and ophthalmoplegia, is critical for good outcome. Despite modern treatment with antibiotics and anticoagulation, the risk of long-term sequelae, such as vision, diplopia, and stroke, remains significant."

Branson SV1. (2019), "Early diagnostic imaging with contrast-enhanced CT or MRI should be initiated in patients with risk factors and ocular symptoms concerning for cavernous sinus thrombosis.  Treatment entails early administration of broad-spectrum intravenous antibiotics, anticoagulation, and surgical drainage when applicable."
                                                    
The treatment rendered in South Nassau Communities Hospital was within standard of care and the proper diagnosis and subsequent treatment.  The concern for infection, potential panfacial involvement to include pansinusitis, cavernous sinus thrombosis, and brain abscess are all reasons for admission and surgical intervention.  The ED documentation clinically and radiographically supports treatment rendered.      

The surgical intervention is the standard of care to alleviate great infectious spread of all the adjacent areas to include Cavernous Sinus Thrombosis, Orbital Cellulitis or Brain Abscess.  The incision and drainage and eventually the enucleation and the extraction/curettage with gram stain/cultures of the purulence is appropriate and medically necessary. The patient was treated subsequently with Augmentin.  Therefore, the inpatient hospital services are considered medically necessary for this patient.

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

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

Diagnosis: Partial Rotator Cuff Tear

Treatment: Shoulder Surgery, Procedure Codes 29827

The insurer denied Shoulder Surgery, Procedure Codes 29827. The denial was upheld.   

This is a female patient with a history of obstructive sleep apnea, hypertension, hypothyroidism, diabetes mellitus, sciatica and arthritis. She presented to the hospital for a planned surgery for a rotator cuff repair. The patient underwent surgery under regional anesthesia; the surgery was uncomplicated. The patient remained medically stable and was discharged home. 

According to literature, the clinical indications for shoulder surgery require definition of pathology and likelihood of improvement with operative intervention. In order to justify the need for surgical intervention, literature support that there should be documentation that the patient is experiencing functional loss despite conservative treatment, and that this conservative treatment should include a course of physical therapy and/or cortisone injection.  However, this patient's records do not provide clinical evidence, such as clinical history, subjective complaint, and objective findings on physical examination or imaging that support this patient's need for shoulder surgery. The records provided do not indicate duration or effect of conservative treatment, such as physical therapy and/or anti-inflammatory (i.e. cortisone) injections to treat this patient's medical condition.  

Based on the AIM Clinical Guidelines 2018, rotator cuff repair is recommended if all of the following are met: Pain >= 4 on the VAS scale which interferes with age-appropriate activities of daily living; Weakness of rotator cuff muscle(s) (less than grade 4/5 on manual muscle testing); Physical exam demonstrating a positive response to at least ONE of the following tests: Neer impingement test, Drop arm test, Hawkins Kennedy impingement test, Painful arc test full/empty can test; Recent advanced imaging confirming a partial thickness tear; Symptoms present for at least 3 months; Failure of at least 6 weeks of conservative management.  

Up to Date state "Surgical repair may be needed to control pain and preserve function in patients with chronic partial tears that are recalcitrant to conservative treatment [24]. Recalcitrant cases are generally defined by a failure to respond to up to three to six months of properly performed physical therapy and one or two glucocorticoid injections. Older patients may need longer treatment."

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

The carrier denial of coverage for shoulder surgery, procedure codes 29827 (arthroscopic rotator cuff repair), 29828 (arthroscopic biceps tenodesis), 29826 (arthroscopic subacromial decompression), 29823 (arthroscopic debridement extensive), and 29824 (arthroscopic distal clavicle excision) performed is upheld. The medical necessity is substantiated.