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

This is female who presented to ER after being found unresponsive.  She was found to have evidence of benzodiazepine toxicity based on urine findings and subsequently complained of right upper extremity weakness.  A computed tomography (CT) scan and CT angiography performed on presentation were negative for acute changes or for hemodynamically significant stenosis.  A brain magnetic resonance imaging (MRI) revealed no stroke.  She also underwent a cervical spine MRI that revealed degenerative changes.  She noted that she took Valium prior to admission for treatment of dizziness but had no complaints of dizziness during the admission.  An electroencephalogram (EEG) was negative for seizures.  She apparently required a Foley catheter because of decreased voiding during her hospitalization.  During her hospitalization, she was also evaluated by physical and occupational therapy and was discharged to rehabilitation.  The health plan's determination of medical necessity is upheld.  Acute inpatient hospitalization was not medically necessary.  This is a patient who presented with a change in mental status.  This was believed due to benzodiazepines (diazepam).  Her symptoms resolved rapidly but because of the of right upper extremity complaints acute stroke and seizures required exclusion.  Acute stroke could have been ruled out at a lower level of care with a brain MRI.  Additionally, the EEG could have also been performed at a lower level of care to rule out seizures.  Once stroke and seizures were excluded, the patient could have been safely discharged.  There is, therefore, no specific indication for acute inpatient hospitalization given the lack of evidence of a stroke or seizure, and the patient otherwise did not require an acute level of care.  She did not require any intensive neurological, cardiac, hemodynamic, pulmonary or other medical monitoring.  She did not require any intravenous medications or hydration.  Once stroke and seizures were excluded, there was no anticipation of neurological deterioration requiring further monitoring.  The patient could have been safely discharged once acute stroke and seizures were ruled out, as there was no medical necessity for acute inpatient hospitalization.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency room with left forearm cellulitis and an abscess of the arm that was worsening despite oral antibiotics. A bedside incision and drainage was performed and the patient was admitted for intravenous antibiotics. The culture from the abscess resulted with methicillin-resistant staphylococcus aureus (MRSA). The health plan's determination is upheld. The patient was admitted on the basis that her cellulitis was worsening despite antibiotics, however, the patient had only been started on antibiotics the day before and therefore had not had sufficient time for the antibiotics to clear the infection. Second, there was an abscess that needed drainage. When a drainable abscess is present and not properly evacuated, the infection will not clear. It is not uncommon to treat abscesses with surrounding cellulitis with incision and drainage alone and no antibiotics. Inpatient admission for cellulitis is often not necessary.  Of all of the interventions that the patient had, the incision and drainage of the abscess was likely the most effective in clearing the abscess and associated cellulitis and this was a simple bedside procedure, not warranting admission.
Appeal type: Medical necessity
Decision: Upheld

Other
Inpatient Hospital Stay

This is a  patient with no past medical history (PMH) presenting with hives on the face, decreased breath sounds and wheezing after eating one cashew nut. The patient was given 3 teaspoons of Benadryl at home. This was the first time the patient consumed a cashew nut. Patient appeared lethargic initially and retractions were noted. Labs were essentially normal. Patient was treated with subcutaneous (SQ) epinephrine, IV steroids, and albuterol nebulizers. Patient was noted to still be tachycardic and the urticaria of the face was persistent. Hence the patient was given the second dose of epinephrine and admitted to the inpatient unit for continued treatment with steroids and Benadryl. The patient was later discharged.  The health plan's determination of medical necessity is upheld in whole. The inpatient stay was not medically necessary. After the patient was admitted to the floor, the patient did not have sustained tachycardia, hypotension, nor hypoxia. The patient did not require another epinephrine. Also there was no oxygen needed on the  floor. The patient's mental status remained alert and appropriate. The respiratory status improved in the ED. The retractions were not documented on the floor. In addition, after the first 4 to 8 hours the recurrence of anaphylaxis is miniscule, hence the patient was admitted to the floor rather than to the Intensive Care Unit (ICU).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Schizoaffective Disorder
 
Treatment: Inpatient Mental Health Treatment

The insurer denied the Inpatient Mental Health Treatment. The denial was upheld.

This is a female patient who presented to the emergency department with complaints of suicidal and homicidal thoughts.  She has a history of depression, anxiety, seizure disorder, schizoaffective disorder, alcohol and opioid abuse, a pituitary microadenoma, and asthma.  The patient was consulted by psychiatry.  She was treated with escitalopram, carbamazepine, ziprasidone, and fluphenazine.  The patient reported feeling better, and that she was no longer having hallucinations or audible disturbances. She was described to be appropriate and less distracted.  She was discharged home on anti-psychotic medication.
 
Based upon the information available, the patient did not medically require continued acute inpatient psychiatric treatment.  As of a certain date the patient had no indication of suicidal or homicidal ideation or intent, no psychosis, and no severely disorganized behavior.  She had no other medical symptoms that either alone or combined with her Schizoaffective Disorder required acute hospital treatment.  She could have received safe and effective care in an outpatient setting as of a certain date.   

This finding is consistent with the general standards of psychiatric care and the American Psychiatric Association (APA) Guidelines for the Treatment of Patients with Schizophrenia.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in their determination to deny coverage for inpatient psychiatric care.  

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

Diagnosis: Chest pain

Treatment: Inpatient admission, diagnostic testing, evaluation, and treatment

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

The patient presented to the emergency department with chest pain. He has a past medical history of coronary artery disease (CAD) with percutaneous coronary intervention (PCI) years ago and was no longer on Plavix. He also has a past medical history of diabetes mellitus, hyperlipidemia and hypertension. He presented with intermittent chest pain and shortness of breath with exertion for one week. The patient also noted that his heart was beating fast when walking. He denied diaphoresis and leg swelling. His review of systems is negative except what has been mentioned above. His physical examination described him as being in no apparent distress and no abnormalities are described. Home medications include aspirin atorvastatin, enoxaparin and insulin. A rhythm strip done at 14:32 described a supraventricular tachycardia at 151 bpm. An EKG done the next day shows a supraventricular tachycardiac at 146- beats per minute. A note written on the third day states that adenosine 12 mg was given IV. An EKG done on the second day at 14:42 showed normal sinus rhythm at 87 bpm with first-degree AV block. The EKG was otherwise within normal limits. A nuclear stress test was negative with no evidence of ischemia after IV medication. The study was thought to be of good technical quality. The left ventricle (LV) was normal in size, normal myocardial function with no evidence of abnormal function or inducible ischemia. Wall motion analysis was performed and shows normal wall motion with left ventricular ejection fraction (LVEF) of 54%.Echocardiogram was done on the second day and conclusions include normal LV internal dimensions, wall thickness, normal left ventricular systolic function, normal right ventricular size and function and trace mitral regurgitation (MR). The patient was seen by Cardiology who recommended telemetry monitoring, echocardiogram, stress test to rule out ischemia and use of a beta blocker. A note written on the third day states the patient was on telemetry to rule out acute coronary syndrome (ACS) which was in fact ruled out. 

This patient's EKG, chest x-ray, nuclear stress test and echocardiogram did not show any evidence of myocardial injury or ischemia. This patient was placed in a monitored unit at the time of his admission. Monitoring was medically necessary. The literature also recognizes the use of an observation unit for this type of patient. However, a monitored level of care or telemetry unit is not the same thing and the literature cited shows that a monitored inpatient level of care in an acute care hospital for this patient was not necessary or appropriate. 

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

Diagnosis: Pre-Gestational Diabetes
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.

This is a female patient who is 33.5 weeks gestation who presented to the Emergency Department (ED) for glycemic control. She was admitted for observation and glucose monitoring. While hospitalized the patient was consulted by Maternal Fetal Medicine who performed a fetal non stress test which was reactive. The patient had laboratory work up, dietary control, and insulin management. The patient was discharged home when her glucose balance was achieved. She was instructed to follow up with aftercare for continued medication compliance.

The patient had pre-gestational diabetes. She was stable, not ketoacidotic or in any danger, and the fetus was not in any jeopardy. The patient's blood sugar could have been easily controlled as an outpatient. Sugar control and diabetic teaching are done routinely as an outpatient. Nutritional counseling does not require admission. Note that this patient has been diabetic for many years, and it is expected that she is familiar with nutritional facts and glucose control.

People with diabetes are usually admitted if they have the following:
1)	Life-threatening acute metabolic complications of diabetes
2)	Severe chronic complications of diabetes that require intensive treatment or other severe conditions unrelated to diabetes that significantly affect its control or are complicated by diabetes

This patient had none of the above.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Angina
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.

This is a male patient who presented to the emergency department with complaints of chest pain associated with diaphoresis and dizziness.  He had a history of hyperlipidemia and diabetes. He had an electrocardiogram that revealed normal sinus rhythm and a chest x-ray that was normal. An echocardiogram was performed that showed normal left and right ventricular function. His cardiac troponin levels were negative. The patient was 
discharged when he was deemed medically stable. 

The patient presented with chest pain, however, the initial evaluation in the ER was unremarkable, including negative cardiac troponin and a non-diagnostic EKG. Inpatient admission was not medically necessary for this patient. In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing. Further evaluation was warranted, however inpatient admission criteria was not met.  Although the patient had new onset symptoms, criteria were not met for any other additional extenuating circumstances. There were no other high-risk co-morbidities. 

Based on the above, the medical necessity for the inpatient hospital admission at the acute level of care is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, dizziness, shortness of breath
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

This patient presented with chest pain and no significant past medical history. Her pretest probability of coronary artery disease is low (Reference 1). Utilizing the HEART (History, EKG, Age, Risk factors, initial Troponin), score she was considered low risk (Reference 2). Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, she also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). 

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Heydayati et al. (Reference 3). Using the HEART score risk stratification schema, this patient would have a low 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. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. Although the patient was also complaining of dyspnea and leg swelling, her history and physical exam were not consistent with a significant risk of DVT or pulmonary embolism.  

In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Primary Diagnosis:  Plantar Fasciitis
Treatment:  Orthotics

The patient is a male who presented with right heel pain.  He also has flat feet, for which he has been wearing custom orthotics.  The provider has requested new custom orthotics, stating that the current orthotics are worn out.  The subject under review is the medical necessity of the orthotics.

The health plan's determination is upheld.

The requested custom orthotics are not medically necessary for this patient.  Based on the medical documentation, the provider is requesting the custom orthotics as initial treatment for plantar fasciitis.  While custom orthotics are considered an appropriate treatment for plantar fasciitis based on the standard of care, they are not considered first-line treatment.  There is no documentation of any appropriate first-line treatment that has been attempted, such as stretching, night splint, anti-inflammatory medication and home cryotherapy.  The plantar fasciitis is a new diagnosis; thus, the current orthotics that the patient has cannot be considered as evidence that they are medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Wearable Cardioverter Defibrillator (K0606)
The K0606 - Automatic external defibrillator with integrated electrocardiogram analysis, garment type was medically necessary.

The patient is a woman with non-ischemic systolic heart failure with reduced ejection fraction (LVEF [left ventricle ejection fraction] 25%). She presented to the hospital with chest pain.  

The patient's hospital work up included cardiac catheterization, which revealed an elevated left ventricular end diastolic pressure and no coronary artery obstruction.  While hospitalized, the patient was noted to have frequent runs of non-sustained ventricular tachycardia (NSVT) on telemetry monitoring.  This included an 18 beat run of NSVT associated with lightheadedness. She was treated with guideline-directed medical therapy and an external Lifevest defibrillator.

External Lifevest defibrillator for a patient presenting with newly diagnosed systolic congestive heart failure would not be considered unproven by the general medical community.  Such therapy is both safe and efficacious. The patient had clear evidence of recurrent non sustained ventricular arrhythmia that was associated with symptoms of lightheadedness.  These findings are consistent with a higher risk of sustained ventricular arrhythmia.  The SCD HFT trial clearly demonstrated that such patients have a significant risk of sudden cardiac death and benefit from ICD therapy. (Reference 1)  

Prior to implanting an ICD (implantable cardioverter defibrillator), patients must be treated with guideline-directed medical therapy for at least three months in an attempt to allow for ventricular remodeling and improve LVEF.  If medical therapy is effective, then patients often do not require device implantation. (Reference 2)  During this period of treatment, patients are at risk for sudden cardiac death and must be protected.  External Lifevest defibrillator therapy provides such protection. 

Guideline statements from the Heart Rhythm Society/American Heart Association and the American College of Cardiology specify that external Lifevest defibrillator therapy should be utilized during periods when patients are at risk of sudden cardiac death and require further cardiac workup/treatment. (References 3-5) A recent real world study of patients treated with external Lifevest defibrillators, almost 5% of subjects received lifesaving therapy. (Reference 6). 

In conclusion, the K0606 - Automatic external defibrillator with integrated electrocardiogram analysis, garment type was medically necessary.  External Lifevest defibrillatory therapy is likely to be more beneficial for the patient than any available standard therapy.
Appeal type: Medical necessity
Decision: Upheld

Female Breast Disorder/Lump/Cyst
Surgical Services  (All)

This patient is a female with a diagnosis of breast hypoplasia secondary to ectodermal dysplasia. She also has breast asymmetry. Her surgeon recommends bilateral breast augmentation (CPT 19325-RT/LT). This is under review.

The health plan's determination is upheld. The CPT 19325-RT/LT: Mammaplasty, Augmentation, with Prosthetic Implant is not medically necessary for this patient.
Augmentation of the breasts is not medically necessary to treat a health problem in this patient. The patient has breast asymmetry and hypoplasia, but her breasts are not currently causing any health problems, and she will not suffer any adverse health consequences if plastic surgery on the breasts is not performed. In fact, breast augmentation puts the patient at risk for functional problems including difficulties with mammography, implant infection, implant exposure, anaplastic large cell lymphoma and capsular contracture. Moreover, because the size and position of her breasts will change with age and weight gain or loss, her breasts will likely become asymmetric again as she ages.
Appeal type: Medical necessity
Decision: Overturned

The patient has a Class II, crowded occlusion and a deep bite causing soft tissue damage on her palate. The planned treatment is for 24-30 months of orthodontics with extraction of four first premolars to correct the malocclusion, but the health plan denied the claim as not medically necessary. This is the subject of this review.

The health plan's determination is overturned. The braces are medically necessary for this patient. A deep bite on its own is not a reason to treat with orthodontics. However, the patient is already damaging the soft tissue of the palate. This will worsen with time if left untreated and can lead to periodontal problems in the future that will be more invasive to correct than the orthodontic problem she currently has. The patient's orthodontist has documented that the patient is damaging the soft tissue of the palate due to her deep overbite, and the cephalometric radiograph confirms this. Palatal tissue damage is a known side effect of deep bite malocclusions.
Appeal type: Medical necessity
Decision: Overturned

The patient is right handed with past medical history of mechanical valve on chronic anticoagulation, history of cerebrovascular accident (CVA) with mild aphasia, diabetes mellitus type 2, permanent pacemaker, coronary artery disease and hypertension who presented to the emergency department after injuring the right hand following a mechanical fall in her shower. The patient sustained laceration to the volar aspect of the right middle and ring finger with injury to FDP (flexor digitorum profundus) and FDS (flexor digitorum superficialis) tendons. The patient was seen urgently by orthopedics who recommended surgical repair due to the "devastating nature of injury". The patient had urgent cardiac clearance. The international normalized ratio (INR) was 2.1 in the ED and the patient was given 2 milligrams (mg) of vitamin K, with plan for fresh frozen plasma (FFP) if INR not < 1.7. The INR was acceptable for surgery and the patient went to the operating room (OR) and had I & D, wound exploration and right middle and ring finger tendon repair. The patient remained anticoagulated on Lovenox as it was necessary for the patient to be anticoagulated due to the mechanical valve. The patient was unable to administer Lovenox injections as she was right-handed. 

The health plan's determination is overturned. The inpatient stay is under review. The patient required close monitoring for bleeding and frequent neurologic checks of the affected extremity with urgent consultation with orthopedics and cardiology. The patient required urgent procedure to repair two tendons that were injured on the dominant hand. It is medically necessary for patient to remain anticoagulated given the mechanical valve, but the patient was not able to administer lovenox due to the injury to the dominant hand. Per Milliman Care Guidelines (MCG) guidelines for musculoskeletal surgery or procedure the patient meets inpatient criteria as she did have 1) fracture, dislocation or other skeletal injury requiring procedure of "other operative repair" as well as wound or soft tissue injury with repair needed for complex wound closure. In summary, the inpatient hospitalization was medically necessary for this patient.