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

Diagnosis: Trauma/Injuries. 

Treatment: Inpatient Hospital Admission.

The insurer denied coverage for the Inpatient Hospital Admission.

The denial is upheld. 

This is a male patient who presented to the Emergency Department (ED) with gunshot wounds. The patient was shot in the right upper extremity, had an abrasion on the right chest, and a laceration of the left lower extremity in the tibia-fibula region. The patient was hemodynamically stable, but appeared to be in severe distress. Although there did not appear to be any breathing abnormalities, and the patient was hemodynamically stable, due to the right chest abrasion, there still was concern for an intra-thoracic injury. Multiple radiologic studies were done. There was gunshot residue along the track of the shot through the patient's arm from entry to exit wound. There was no injury to the humerus. The patient's computed tomography angiography (CTA) ruled out vascular injury. The patient's white blood cell (WBC) count was 12.2, and the patient was slightly hypothermic with a transient period of increased pulse rate.

As per literature review, it was reasonable to keep the patient for observation due to concerns for further injury and risk for infection. However, the patient's needs could have been met at a 23-hour observation level of care. There did not appear to be further indication of potential hemodynamic instability that warranted inpatient level of care. Providing pain control for patient also could have been done at this lower level of care, observation level. If further concern had arisen during this period of observation stay, the patient could have then been admitted to inpatient level of care. In this case, the patient did not develop complications that required inpatient admission.

Inpatient hospital admission was not medically necessary for this patient.

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

The medical necessity for the Inpatient Hospital Admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine fibroids.

Treatment: Laparoscopic surgery ablation for uterine fibroids (CPT code 58674).

The insurer denied coverage for laparoscopic surgery ablation for uterine fibroids (CPT code 58674).

The denial is upheld. 

This is a female patient with a diagnosis of symptomatic fibroid uterus.  A transvaginal ultrasound determined the patient has a large solid posterior upper uterine body mass suggestive of a large fibroid with submucosal component.  Treatment options were discussed with the patient, and she is interested in pursuing the Acessa procedure to treat her condition (CPT code 58674).  The patient desires future fertility.

Laparoscopic radiofrequency ablation (Lap-RFA), known as the Acessa procedure is used to treat women with symptomatic myomas not interested in future fertility.  It was approved by the United States (US) Food and Drug Administration (FDA) in 2012.

Based on a randomized, prospective study, compared to myomectomy, Lap-RFA is associated with significantly lesser intraoperative blood loss, shorter procedure and hospitalization times, lesser consumption/use of disposable and reusable surgery equipment, reduced health care resource utilization, and faster return to work through 3 months post treatment.

A meta-analysis of 8 studies showed that all subscales of quality of life improved significantly, and most of the changes remained stable in long-term follow-up.  The overall reintervention rate was 4.39% and the median uterine volume reduction was 69.17 cm3.  The overall procedure-related adverse events rate was 1.78% and patients missed an average of 4.35 days of work.  In conclusion, laparoscopic radiofrequency ablation therapy is an efficacious way to treat small-sized and non-pedunculated symptomatic uterine fibroids, providing stable long-term symptom relief and quality of life improvement with a low risk of adverse events and re-intervention and just a few days of missed work. 

However, this patient has a large fibroid with a submucosal component.  In addition, this patient is interested in future fertility.  The safety of the Acessa procedure in women interested in conceiving remains under study.  The standard of care for such patients is to do a myomectomy. 

In summary, this patient is not a good candidate for the Acessa procedure.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.  Laparoscopic surgery ablation for uterine fibroids (CPT code 58674) has final approval from the appropriate regulatory bodies for this diagnosis.  This patient is not a good candidate for laparoscopic surgery ablation for uterine fibroids (CPT code 58674).  Laparoscopic surgery ablation for uterine fibroids (CPT code 58674) 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.

The carrier's denial of coverage for laparoscopic surgery ablation for uterine fibroids (CPT code 58674) should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine fibroids.

Treatment: Laparoscopic surgery ablation for uterine fibroids (CPT code 58674).

The insurer denied coverage for laparoscopic surgery ablation for uterine fibroids (CPT code 58674).

The denial is overturned. 

This is a female patient diagnosed with menorrhagia with her monthly menses and uterine leiomyoma.  A transvaginal ultrasound revealed a large posterior uterine body mass suggesting a large fibroid with submucosal component.  The provider noted the patient's uterus was enlarged and was measuring 10.64 centimeters (cm) and her largest fibroid measured 4.9 to 4 cm.  She was having prolonged bleeding and heavy cramping and bleeding after intercourse.  It was noted, the bleeding was so heavy the patient had to change her tampon every 30 minutes and had severe cramping.  She had been taking birth control to help with symptoms but she was still having heavy bleeding.  Her strong preferences were to preserve her uterus, achieve sustained symptomatic relief and noted that she needed to get back on her feet rapidly.  The request was made for the Acessa procedure.

Laparoscopic Radiofrequency ablation (RFA) has been shown to reliably be performed on an outpatient basis with a return to normal activity within one week.  In peer-reviewed studies it has been shown to decrease the fibroid volume, increase the quality of life and decrease fibroid-related symptoms.  It is Food and Drug Administration (FDA) approved for the treatment of fibroids.
 
This patient is a good candidate for laparoscopic surgery ablation for uterine fibroids (CPT code 58674), as long as she has been properly counseled.  The patient expressed a desire to maintain fertility and in patients desiring future pregnancy, RFA should be used with caution since pregnancy data are limited because most studies have excluded patients planning a pregnancy.  Small case series have shown reasonably good results in women who became pregnant after undergoing this procedure.  However, further studies are needed to determine if RFA is appropriate for patients who desire future fertility.
 
Laparoscopic RFA offers the advantage of quick recovery, treatment of symptoms, and preservation of the uterus.  Laparoscopic RFA has the disadvantage of not being well studied in women desiring future pregnancy. 

Alternatively, a laparoscopic or open myomectomy is more invasive in nature, has a slower recovery but offers a similar reduction in symptoms.  It also has more data regarding pregnancy outcomes and although there are issues in pregnancy with prior myomectomies that were extensive, it is a well-described risk.
 
The carrier's denial of coverage for laparoscopic surgery ablation for uterine fibroids (CPT code 58674) should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Dizziness. 

Treatment: Code 92548- Computerized dynamic posturography sensory organization test (CPD-SOT), 6 Conditions (i.e., eyes open, eyes closed, visual sway, platform sway, eyes closed platform sway, platform, and visual sway), including interpretation report.

The insurer denied coverage for code 92548- Computerized dynamic posturography sensory organization test (CPD-SOT), 6 Conditions (i.e., eyes open, eyes closed, visual sway, platform sway, eyes closed platform sway, platform, and visual sway), including interpretation report.

The denial is overturned. 

This is a female patient with a past medical history of obstructive sleep apnea (OSA), atrial fibrillation, arthritis, cataracts, Crohn's disease, end-stage liver disease, gastroesophageal reflux disease (GERD), hyperlipidemia, hypertension, hypothyroidism, migraines, and unspecified amblyopia. The patient presented for the evaluation of dizziness/imbalance with associated aural fullness/pressure in the left ear and pulsatile tinnitus in the right ear. The patient reported ear symptoms for about two years including left ear fullness and dizzy spells. Whenever her ear would feel full, the patient would have days where she would feel like she could not walk steady and had to hold onto stationary objects. The patient was seeing a neurologist who suspected Meniere's disease or vestibular migraines. When the patient saw the neurologist, it was recommended that she come in for vestibular testing. The patient underwent a vestibular evaluation with vestibular testing. The central vestibular evoked myogenic potential (VEMP) amplitude on the right was large, suggesting a possible third window effect.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes. Code 92548 - computerized posturography testing has final approval from the appropriate regulatory bodies for this diagnosis, and this patient is a good candidate for code 92548. As per literature review, this sensory test is clinically useful, especially in peripheral lesions, which this patient may have based on abnormal vestibular evoked myogenic potential (VEMP) on the right side of the ear. The requested Code 92548 is the best available treatment for this patient at this time. This test can be used for diagnostic purposes and to rule out malingering; it can also be used to guide vestibular rehabilitation in treating the patient.

The code 92548- Computerized dynamic posturography sensory organization test (CPD-SOT), 6 Conditions (i.e., eyes open, eyes closed, visual sway, platform sway, eyes closed platform sway, platform, and visual sway), including interpretation report is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of code 92548- Computerized dynamic posturography sensory organization test (CPD-SOT), 6 Conditions (i.e., eyes open, eyes closed, visual sway, platform sway, eyes closed platform sway, platform, and visual sway), including interpretation report should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Displaced oblique fracture to humeral shaft. 
Treatment: Inpatient admission. 

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

The patient is a female who experienced a slip and fall. She sustained injury to her left arm. She was diagnosed with a displaced oblique fracture to her humeral shaft. She was status post total shoulder replacement left. Her physician performed a closed manipulation and applied a coaptation splint. She then underwent ORIF (open reduction internal fixation) to the left humeral shaft two days later. 

No, the Inpatient admission was not medically necessary. 

The records showed an isolated injury to the patient's left arm. It was of low energy with no open wound. Her neurovascular status was intact. Her operation was without problem. The surgical approach was direct with limited blood loss. She did not have problems with her wound. There was no evidence of bleeding nor infection. She was able to tolerate oral medications. She did not require treatment for an underlying medical condition, nor did she need special imaging. 

There is no documented reason why services provided would not be considered Observation level. There were no extenuating circumstances to substantiate admission at an acute level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental Health-Other-Confusion/dementia.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This patient has a past medical history of bipolar disorder, dementia, pulmonary embolism on oral anticoagulation(OAC), hypertension and diabetes mellitus type 2 who was admitted after her husband witnessed the patient taking 2-3 extra pills of gabapentin and progressively worsening altered mental status (AMS) since prior hospital discharge. Patient denied suicidal ideation/homicidal ideation. Vital signs were unremarkable. Physical exam was notable for ecchymosis of abdomen and lower extremities and oriented times 2. Labs significant for creatinine 1.6, blood urea nitrogen 70, creatine phosphokinase (CPK) 1120, urine drug screening positive for Benzodiazepines. Imaging studies, computed tomography (CT) scan of the head showed no acute pathology, chest x-ray showed no acute disease, abdominal radiograph showed no free air, CT scan of the chest showed no acute disease, transthoracic echocardiogram showed normal left ventricular ejection fraction. An electrocardiogram (EKG) showed normal sinus rhythm. The patient was diagnosed with AMS and treated with intravenous (IV) fluids, anti-emetics and continued oral anticoagulation. Of note, the patient experienced bright red blood per rectum (BRBPR) and underwent a flexible sigmoidoscopy, which found ulcerated and friable mucosa at the anorectal verge for which heparin was recommended in lieu of OAC. 

The hospital stay was not medically necessary at an acute inpatient level of care. This patient with a known history of dementia presented to the emergency department after the husband witnessed the patient taking a few extra gabapentin pills and complaining of five months duration of worsening mental status, after a family member was killed and coinciding with non-compliance with psychiatric medications. The patient was seen taking 2-3 additional tablets of gabapentin for her abdominal pain, but the husband expressed an inability to care for the patient at home any longer. The extensive radiological work-up was negative for acute pathology. She was hemodynamically stable, there was no hypoxia, respiratory failure or distress, apnea, intentional overdose/exposure, disruptive/uncooperative behavior, other acute co-existing illness, fever, significant trauma, or unstable vital signs. While the patient did have an episode of BRBPR for which the gastrointestinal (GI) service was consulted and sigmoidoscopy was received, it is documented that the amount of blood was non-significant and there was not a significant hemoglobin drop. She received observation, supportive care, IV fluids and psychiatry/neurology/GI evaluation. This could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a woman. Her medical history included tobacco-use. Her surgical history included appendectomy and C-section(Cesarean delivery). She presented to an emergency department with acute-on-chronic (four-days/four-months) epigastric and left-upper-quadrant abdominal pain, nausea, vomiting, anorexia, and diarrhea.

The patient's vitals were temperature 98.0, pulse 86, blood pressure 127/92, respirations 18, and oxygenation 99%.

The patient's physical examination demonstrated tenderness-to-palpation in the epigastrium and left-upper-quadrant of the abdomen, as well as a Murphy's Sign. Serum laboratories demonstrated normal white blood cell count (7.6); elevated total bilirubin (1.2); elevated liver enzymes (ALT [alanine aminotransferase] 387, AST [aspartate aminotransferase] 515); and elevated lipase (311). Abdominal ultrasound demonstrated "Hepatomegaly and hepatic steatosis." Computed tomography of the abdomen and pelvis demonstrated a "Contracted gallbladder."

The patient was admitted at an acute inpatient level-of-care with a diagnosis of "cholelithiasis vs choledocolithiasis." It was presumed she had passed a gallstone and had residual/resolving pancreatitis. She was made nil per os [NPO]; and provided with intravenous fluids, antibiotics, and analgesics.

The patient underwent laparoscopic cholecystectomy. Surgery and recovery were uncomplicated.

Having returned to her baseline health and function, the patient was discharged home in good and stable condition with prescriptions for oral analgesics and stool softeners, and outpatient surgical follow-up.

No, the Inpatient admission was not medically necessary.

According to peer-reviewed reports, patients with mild gallstone pancreatitis can safely undergo "early cholecystectomy" [Aboulian et al.; Dubina et al.]; the median length-of-stay is three days. Therefore, this patient could have undergone surgery and observation at a lower level-of-care. If a complication were to have arisen, requiring intensive or prolonged evaluation and treatment, then the patient could have been transferred to a higher level-of-care.

In the absence of significant co-morbidities and physiologic derangements, according to peer-reviewed reports, patients with mild gallstone pancreatitis can undergo "early cholecystectomy." Post-operative evaluation and treatment does not require admission at an acute inpatient level of care; they could be achieved at a lower-of-care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Concern for bacterial superinfection.

Treatment: Inpatient Admission.

The insurer denied coverage for the Inpatient Admission.

The denial is upheld. 

This patient is a male child with a history of eczema. The patient was brought to the Emergency Room (ER) with complaints of a generalized worsening rash on the left leg for 2 weeks. The patient ate fish for the first time around the same time and there was initially lip swelling and a generalized erythematous rash. The patient was evaluated per the historian in another local hospital and was discharged. Benadryl was given at night without improvement. In the ER, the patient was afebrile with stable vital signs. The patient was well appearing, happy and playful. The patient was in no apparent distress. The physical examination revealed dry erythematous scaly lesions on the left lower leg with mild swelling. There was no warmth to area, no honey crusting, or any vesicles, discharge or pus. The patient's left upper arm also had a rash. The rash was described as most likely eczema with overlying bacterial infection. The patient's white blood cell (WBC) count was 8.8. The patient was given intravenous (IV) ceftriaxone, acyclovir, and clindamycin in the ER. Benadryl was also given. The patient tolerated the medications well.

 The patient was admitted with concern for a bacterial superinfection. The patient's intake and output were within normal limits. The patient did not need IV fluids. The patient's rash was most likely eczema flare up with concern for infection. Ceftriaxone and acyclovir were discontinued, and the patient was continued on IV clindamycin every 6 hours (Q6H). Aquaphor was used with gauze to treat broken skin. Triamcinolone was used to treat non-broken skin. Dermatology consulted over the case and they recommended outpatient follow-up. The patient remained afebrile and stable throughout the admission. The patient was discharged with instructions to continue mupirocin ointment and triamcinolone for eczematous patches. The patient was set up to establish care with a new primary care provider.    

Based on Milliman Care Guidelines (MCG) 25th edition, for Pediatric Cellulitis, this inpatient hospital stay was not medically necessary. At most, this patient's care could have been provided at the observation care stay. 

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

The carrier's denial of coverage for the Inpatient Admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain and Substance use. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is overturned. 

This is a male patient with a history of hypertension, diabetes, and asthma who presented to the hospital with palpitations and chest pain following cocaine use.  Upon presentation, the patient was hypertensive and tachycardic.  Other findings on physical examination were unremarkable.  The patient's electrocardiogram (EKG) revealed sinus tachycardia without acute ST or T wave abnormalities. The patient's serum troponin level was elevated.  The patient was admitted to the hospital for observation and treatment. 

Based on the review of the medical record and literature, inpatient hospital admission was medically necessary for this patient. This patient presented with chest pain and positive serum troponin.  The patient's pretest probability of coronary artery disease was intermediate 1.  Utilizing the History, Electrocardiogram, Age, Risk factors, and Troponin (HEART) score, the patient was considered intermediate risk 2. 

Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. These findings are concerning and warrant inpatient level of care and management. Cocaine use is associated with vasospasm, poorly controlled hypertension and myocardial infarction 4. In conclusion, given the patient's presentation and multiple cardiac risk factors in the setting of active cocaine use, inpatient hospital admission was medically necessary for this patient. 

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

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

Diagnosis: Fevers, chills, fatigue, and myalgias.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with recent coronavirus (COVID) infection who presented to emergency room with fevers, chills, fatigue, and myalgias. The patient was treated with intravenous (IV) fluids and Tylenol in the emergency room and was admitted to acute in-hospital level of care for dehydration and viral illness. The patient was found to have mono infection. The patient's condition improved and he was discharged home.

No, the proposed inpatient admission was not medically necessary.

The patient had viral infection which caused high fevers and poor intake. With intravenous (IV) fluid hydration and Tylenol, the patient's condition improved within 24 hours.  The patient improved significantly with emergency room treatment with IV fluids, IV steroids, and Tylenol.  At the time of admission, the patient was hemodynamically stable and not on supplemental oxygen. The patient was tolerating oral diet and could ambulate.  The acute in hospital level of care was not medically necessary, as the patient could have been safely and effectively treated at lower level of care.