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

Diagnosis: Chest pain
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

This patient presented with atypical chest pain for a month and nausea for four days. While she had no evidence for ischemia (EKG changes were nonspecific and likely related to position), it was appropriate to rule out serious conditions for these symptoms. However, the testing performed and treatment given did not require an inpatient level of care. 

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. It is highlighted in the orders for care. 

In this case, the patient's symptoms were present for a month, atypical and unlikely to be representative of acute coronary syndrome. The exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. CXR was normal. Echocardiogram showed no wall motion abnormality. Stress echo showed good exercise tolerance, and no evidence of CAD. The physicians' treatment did not reflect any serious concern about the patient's cardiac condition. Orders did not include medical therapy for ACS, such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG (nitroglycerin).  Her discharge diagnosis was chest pain with no restrictions.

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care.  The statement that this patient could not be managed in an outpatient setting is not consistent with guidelines or usual community practice. This patient had no evidence of CAD. In fact, all tests showed absence of ischemia.  While there was always a potential for an adverse event (and in this case a low probability), one did not happen, and no actual treatment was added. There are no examples of care requiring inpatient level of care.

Milliman criteria requirements for admission for unstable angina were not fulfilled, as there was never any evidence of ACS present. Since all testing and therapy that were provided would have been appropriate, safe and guidelines-consistent in  a lower level of care, inpatient level of care was not medically necessary.

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

This is a patient who presented for coronary angiography. He had previously complained of episodes of chest "burning" with climbing stairs or walking 3 blocks, relieved with rest. Symptoms had been ongoing for approximately 2 months. Cardiac catheterization was performed on 1/29,  showing an obstructive lesion in the proximal left anterior descending. This lesion was successfully stented. He was monitored on telemetry overnight. No procedural complications were noted. The health plan's determination is upheld.  This patient had an elective, uncomplicated coronary stent placement to the left anterior descending. He was hemodynamically stable throughout the hospitalization and did not meet any of the other requirements for inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the hospital with abdominal pain. An ultrasound  showed gallstones. His past medical history is significant for no other chronic health conditions. At the time of presentation, the patient was without fever and vital signs were normal. He was tender in the right upper abdomen. The white blood cell (WBC) count was normal at 7.2 K. The complete metabolic panel was normal. An ultrasound showed gallstones. He was initially treated with intravenous (IV) fluids and IV antibiotics. He was treated with laparoscopic cholecystectomy. The operative dictation and the anesthetic record describe an uncomplicated cholecystectomy procedure. The pathology note describes cholecystitis and gallstones.  The health plan's determination is upheld. 

The inpatient admission was not medically necessary. The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation. The WBC count was normal and serum chemistries were normal at the time of presentation. Surgery was performed and the perioperative period was uncomplicated. Inpatient stay may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, complications of procedure. In this case a lower level of care would have satisfied the clinical needs. There is no documentation of hemodynamic, pulmonary, neurological or metabolic reason for an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and Shortness of Breath
Treatment: Inpatient admission
Inpatient level of care was not medically necessary.
This patient presented with atypical chest pain, dyspnea but no objective evidence of ischemia or hypoxia. While it was appropriate to rule out serious conditions for these symptoms, the testing performed and treatment given did not require an inpatient level of care. 
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. Biomarkers and EKG showed no evidence of acute ischemia. Chest x-ray (CXR) was normal. Echocardiogram showed no wall motion abnormality.  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 it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care.  The statement that this patient could not be "managed" in an outpatient setting is not consistent with guidelines or usual community practice. This patient had no evidence of CAD. All tests showed absence of ischemia.  While there is always a potential for an adverse event (and in this case a low probability), one did not happen and no actual treatment was added. There are no examples of care requiring inpatient level of care.
Milliman criteria requirements for admission for unstable angina were not fulfilled as there was never any evidence of ACS present. Since all testing and therapy would be appropriate, safe and guidelines consistent in a lower level of care, the inpatient level of care was not medically necessary.
The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Decision: Fever and fatigue.  She has a past medical history of migraines, polycystic ovarian syndrome, morbid obesity, hypertension, and depression

Treatment: Inpatient admission, evaluation, and medication management.

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

The patient presented to the Emergency Room with fatigue.  She had a low grade fever and the vital signs were stable.  Lab results revealed potassium of 2.1.  She also had thrombocytopenia and elevated liver enzymes.  The following day after receiving KCl infusions, the potassium was 2.8.  The hypokalemia was felt to be related to taking Chlorthalidone.  She had a fever spike to 103.7.  Blood cultures were done.  She underwent a work-up for liver disease.  The INR was elevated at 1.4.  The fevers and hypokalemia resolved and the patient was referred for outpatient work-up of the liver disease.

Clinical Indications for Admission for Electrolyte Disorder: Common Complications and Conditions are listed in MCG CCC-007.  A potassium level less than 2.5 despite emergency treatment is an indication for admission.  However, in this case, after Emergency Room treatment the repeat potassium went up to 2.8.  The next day the potassium was normal.

Clinical indications for admission for Liver Disease Complications (M-570) include hepatic encephalopathy, hemodynamic instability, tachypnea infected ascites, an INR over 1.5, severe vomiting, and severe dehydration.  The patient did not have these conditions.

This patient had hypokalemia related to using Chlorthalidone.  She required potassium replacement.  This could have been done under observation status.  The potassium level responded to Emergency Room (ER) treatment.  The patient also had liver disease and required a liver work-up.  However, she was stable to have been managed with observation status.  She did not meet MCG criteria for admission for liver disease complications.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who was brought to the emergency department (ED)  with knee pain. Initially, the knee appeared normal to the parent, but that morning , it was swollen and red and he was refusing to bear weight. There was no history of trauma or broken skin, no fever, and no other illness. In the ED, his vital signs were normal and he appeared generally healthy. He had a swollen, warm, and tender left knee that also hurt with range of motion. The initial ED concern was for a septic arthritis or osteomyelitis, given the rapid onset, symptoms, and signs, despite the absence of fever. The health plan's determination is overturned.  The patient's condition required initial hospitalization for management and the potential worsening on the second night-manifested by fever-meant that he could not be discharged safely, but required a surgical procedure. The post-operative course was standard; he could not have been safely discharged sooner for this condition.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the hospital. The patient had a history of coronary artery disease (CAD), diabetes, hypertension, and hyperlipidemia, and  presented with chest pressure. The patient also reported right arm pain and stated that the symptoms started three days prior to presentation while the patient was walking home from a store. The symptoms improved with rest.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient was hemodynamically stable, had negative cardiac enzymes, no evidence of acute ischemia on EKG, and no evidence of other complicating factors such as aortic dissection or acute pulmonary embolus. Cardiac enzymes were negative, and the patient could have been managed at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

This patient has a history of an endometrial ablation in 2018. Pelvic ultrasound, transvaginal, demonstrated an anteverted uterus with anterior intramural fibroid and a 0.9 cm endometrium with internal flow. The patient was seen for a preoperative visit regarding complaints of abnormal bleeding, abdominal pain, constipation, and cramps.  The patient was described as premenopausal and not pregnant.  She described a heavy irregular bleeding, heavy periods, cramping, and passage of large clots.  The risks and benefits of ablation were discussed and the patient wished to proceed.   

According to American College of Obstetricians and Gynecologists (ACOG), treatment options for patients with abnormal uterine bleeding associated with ovulatory dysfunction, in whom endometrial and structural pathologies have been ruled out, include progestin-only contraception (i.e., levonorgestrel releasing intrauterine device [IUD; Mirena], medroxyprogesterone acetate [Provera], megestrol [Megace], norethindrone, and depot medroxyprogesterone acetate[Depo-Provera]) and combined hormonal contraception (e.g., transdermal patches, vaginal rings, oral contraceptives). If medical treatment fails, is contraindicated, or is not tolerated, or if the patient has concomitant significant intracavitary lesions, surgery may be an option. Endometrial ablation and hysterectomy are options; however, endometrial ablation is not considered a first-line option. If medical treatment fails, further investigation (e.g., imaging, hysteroscopy) is indicated. Hysteroscopy allows for visualization of the endometrial cavity and endocervix and can help diagnose focal lesions possibly missed by endometrial sampling. Saline infusion sonohysterography has a sensitivity of 96% to 100% and negative predictive value of 94% to 100% for assessing the uterus and endometrium for pathology. It can confirm whether intracavitary lesions are present, can determine the myometrial involvement with leiomyomas, and can provide more accurate assessment of the endometrium vs. transvaginal ultrasonography alone. 

The patient presented with menorrhagia despite unspecified hormonal therapy.  There were no structural abnormalities on transvaginal ultrasound.  However, based on the available documentation, an adequate work-up to determine the etiology of the abnormal bleeding was not completed prior to proceeding with endometrial ablation.  Therefore this was not the best available treatment for the patient. The patient is not a good candidate for the procedure, and this procedure is not likely to be more beneficial than any other standard treatment/procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

This patient was seen due to heavy menses/clots.  The patient states her periods were becoming longer and occurring more frequently.  The documentation does detail the patient was noted to be obese. The patient underwent an ultrasound revealing an anteverted uterus with anterior intramural fibroid.  She was then seen for a follow-up to discuss an ablation.  It was recommended at this visit that the patient follow-up. The physician detailed the patient had not responded to medical therapy and the patient was unable to tolerate bleeding.  The patient did undergo surgical intervention.  Appeal documentation indicated the patient did not want hormonal therapy and had a normal endometrial lining the endometrial biopsy was not necessary or warranted according to the physician.

According to medical literature, treatment for abnormal uterine bleeding should not be initiated until the etiology of the bleeding has been evaluated. Initial evaluation of uterine bleeding should include history and physical examination to look for obesity and hirsutism (manifestations of polycystic ovary syndrome), a pregnancy test, measurement of thyroid-stimulating hormone, and prolactin levels. An endometrial tissue assessment should be completed to rule out cancer. When the endometrial biopsy is normal a transvaginal ultrasonography or sonohysterography should be completed to rule out structural abnormalities. The goal of initial therapy is to control the bleeding, treat anemia (if present), and restore quality of life. Initial therapy is typically pharmacological to include oral contraceptives, levonorgestrel-releasing intrauterine device, and tranexamic acid. In cases in which the initial medical therapy is not effective, more invasive procedures such as myomectomy, endometrial ablation, uterine artery embolization, or hysterectomy are indicated. Specifically regarding this case, there is a lack of documentation supporting the patient had the appropriate work-up.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Irregular menses

Treatment: Endometrial ablation

The insurer denied endometrial ablation and associated services as experimental/investigational. The denial was upheld as three of three reviewers determined the services were not likely more beneficial than any other standard procedures/treatments.

The patient has a history of menorrhagia. Per the pre-op visit note dated 11/29/18, the patient had not responded to medical therapy and she was unable to tolerate bleeding. On 12/05/18 the patient had a hysteroscopy, dilation and curettage (D&C) and endometrial ablation. 

The provider stated that the patient has failed medical therapy, however, it is not clear what treatment she failed as the details are lacking. In women aged 40 years to menopause, abnormal uterine bleeding may be due to anovulatory bleeding, which represents normal physiology in response to declining ovarian function. It also may be due to endometrial hyperplasia or carcinoma, endometrial atrophy, and leiomyomas. Prior to performing an endometrial ablation, the structure and histology of the endometrial cavity should be thoroughly evaluated, both to assess for malignancy or endometrial hyperplasia and to ensure that the length and configuration is suitable for endometrial ablation. These parameters will vary depending on the technique or system used. 

According to American College of Gynecology (ACOG): "The endometrium of all candidates for endometrial ablation should be sampled, and histopathologic results should be reviewed before the procedure." 

According to UpToDate: "Endometrial sampling is performed in all women prior to endometrial ablation to exclude endometrial hyperplasia or cancer. Ideally, this should be performed with enough time to receive the results and cancel the procedure, if neoplasia is found." 

While endometrial ablation has final approval from the appropriate regulatory bodies for this diagnosis, and scientific evidence in peer-reviewed literature supports a result of improvement in health outcome, this patient is not a good candidate for endometrial ablation. Endometrial ablation is not the best available treatment for this patient at this time. The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.
Appeal type: Medical necessity
Decision: Upheld

The patient was receiving physical therapy for a four month period. It is noted that continued therapy for a three month period was denied due to lack of medical necessity. The health plan's determination is upheld.

In this case the submitted clinical documentation did not support the medical necessity for the units of each exercise billed. The provider did not document specific information such as exercises performed, repetitions, number of sets, time of each exercise or details indicating whether treatment was one-on-one with the therapist, and no details for the manual therapy he received (i.e. body part treated, modalities utilized). There is no time component included for either service. It should be noted that the only modalities that include times/duration were electrical stimulation, ultrasound phonophoresis, cryotherapy, and hot packs. 

It is standard of care for physical therapists to document details including amount of time spent on each procedure/modality, what body part was treated, and details indicating if this was one on one treatment or independently performed. Multiple dates of service are billed with no detailed documentation of times and specific activities/exercises completed. The physical therapist's documentation is insufficient in order to support the medical necessity of the services that were billed.
Appeal type: Medical necessity
Decision: Upheld

The patient was admitted from an emergency department for acute inpatient psychiatric services on due to worsening symptoms of depression and suicidal ideation.  The patient has a history of major depressive disorder and an unspecified eating disorder associated with restricted intake and purging that intensified following gastric sleeve surgery. Patient had undergone transcranial magnetic stimulation (TMS) treatments augmenting  psychotropic medication and therapy.  However, mood disturbance had worsened with continued disordered eating and onset of suicidal ideation. 
The patient was admitted to the acute inpatient psychiatric level of care treated with supportive measures and safety monitoring and antidepressant medication titrated as clinically appropriate.  Patient had opportunity to participate in psychotherapy, group activities, and participate in other milieu interventions.  Received dialectical and cognitive behavioral therapy (DBT & CBT), as well as nutritional supports with a meal plan and supplemental Ensure and vitamins.  Patient was referred to her community providers for follow-up.  The health plan determination is upheld in whole.  The patient did not continue to display suicidal ideation; did not have acute general medical complications or a co-occurring substance use disorder that would have warranted continued inpatient treatment.  The patient's mood disturbance and associated symptoms of anxiety and functional impairments had been addressed to the extent that she did not require continued acute inpatient level structure or 24-hour monitoring during the time interval under review.  There was no further risk for suicidal behaviors, as the patient denied active suicidal ideation or plan for suicide, and there were no further documented symptoms that would have required the continued assessment, safety monitoring and treatment in an acute inpatient setting for the requested time period.  The patient could have been safely and effectively been treated with intensive services in a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pericardial effusion

Treatment: Inpatient admission and evaluation

The insurer has denied inpatient admission. The denial is upheld.

This patient was sent to the Emergency Department (ED) by his primary care provider for "fluid around the heart" noted on echocardiography, which was done during a routine visit.  The patient denied dyspnea, chest discomfort or other symptoms.  Past medical history was remarkable for only hypertension treated with amlodipine/valsartan/ hydrochlorothiazide.  An EKG at 07:28 revealed only normal sinus rhythm and left axis deviation.  A chest x-ray was normal with an unremarkable cardiac silhouette.  An echocardiogram revealed a calcified trileaflet aortic valve with mild to moderate insufficiency, mitral annular calcium with minimal mitral regurgitation, normal right and left ventricular dimension and function, and a small circumferential pericardial effusion.  

There is no evidence that this patient required an acute inpatient level of care to evaluate the small circumferential pericardial effusion noted on echocardiogram done during a routine visit.  The evaluation could have been performed in an outpatient setting.