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

Digestive System-Gastrointestinal
Inpatient Hospital

The patient is a previously healthy male who presented to the emergency department (ED) with a history of progressively worsening abdominal pain of 1 day duration. His evaluation included physical exam, labs, and computed tomography (CT) scan. He had a fever of 103 Fahrenheit (F) at the time of presentation. Other vital signs were normal. Lab data identified an elevated white blood cell (WBC) count of 11.9 thousand (K). CT scan yielded the diagnosis of acute appendicitis. Treatment was initiated with IV fluid and antibiotics. Surgical consultation was obtained on the day of presentation.
The patient underwent laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. The operative note describes an acute, non-perforated appendicitis. He was provided intravenous (IV) fluid and perioperative antibiotics. His vital signs remained normal throughout the hospitalization without recurrence of fever. He was discharged home.

The health plan's determination is upheld.

No. Inpatient stay  was not medically necessary for this patient. The care and treatment provided could have appropriately been rendered with a lower level of care status. The patient was clinically stable at the time of presentation and remained so during the course of care.
This patient was admitted to the hospital with abdominal pain. His evaluation with examination, lab data, and CT scan confirmed the diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, IV antibiotics and appendectomy. The early post-surgical course was uncomplicated, and the patient was clinically stable for discharge from the hospital later in the day.

In this case there is no documentation of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications. As such, the procedure (appendectomy) may be performed with a lower level of care status. In this case the patient tolerated oral hydration, diet and medication and pain was well controlled. A lower level of care status would have appropriately provided for presurgical assessment, laparoscopic appendectomy, and post-surgical monitoring. Inpatient care was not required or medically necessary in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #3 

This case involves a female currently diagnosed with Tarlov cyst disease.  The patient had subjective complaints of sacral, buttock, lower extremity, bowel and bladder symptoms, and painful intercourse.  The MRI of the pelvis without contrast indicated the patient had findings most compatible with Tarlov cyst at the sacrum, which was previously seen.  The MRI of the lumbar spine revealed mild degenerative changes in the lumbar spine.  There was a mild disc bulging at L3-4 level.  There was mild bilateral foraminal narrowing at L3-4 level.  There was a stable smoothly marginated cystic structure in the central aspect of the sacrum at S2 and S3 levels.  The appearance was most typical for Tarlov cyst and it was stable from the previous examination.  The symptoms were noted to be a sacral radiculopathy pattern that resulted from sacral nerve root compression within the sacral spinal canal.  The physician letter indicated the surgery was the most appropriate service and would render more effective treatment methods.  It was further noted that there was no alternative treatment that would be appropriate. 

The scientific evidence in peer-reviewed literature does not support the result of improvement in health outcomes.  There are no large long-term studies showing clinical efficacy to sacral reconstruction for Tarlov cyst treatment.  More studies are needed prior to making this surgery the standard of care.  Dowsett, et. al. (2018) noted that Tarlov cyst removal does help significantly but there is no clear indication that extensive sacral reconstruction is needed.  Dowsett, et. al. (2018) also noted, "The evidence suggests that surgery for symptomatic Tarlov cysts may be an effective option for partially or completely relieving symptoms.  Contrary to previous findings larger cysts were not associated with completely relieving symptoms."  Thus, more studies are needed.

The American Association of Neurosurgical Surgeons note with regard to surgery for Tarlov cyst, "Although some patients have noted a considerable decrease in pain, the most common negative outcome is the failure of the surgery to eliminate the symptoms.  In some cases, the surgery may cause an existing symptom to worsen or it may cause a new one." 
The above surgery is not well studied. Thus, this patient is not a good candidate for this surgery.  A search of Pubmed on the surgical technique used revealed no publications.  A sacral laminar reconstructive surgery/spinal surgery is not the best available treatment for this patient at this time.  The surgery has not been well studied and long-term outcomes are not clearly noted.  Other treatment options such as interventional radiology (IR) drainage of cysts and surgical removal without reconstruction have been noted.

The above is not likely to be more beneficial in contrast to alternative treatments such as cyst resection or IR drainage.

The carrier's denial of coverage for sacral laminar reconstructive surgery/spinal surgery (CPT code 64999) should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #2

This patient is a female who reports a three year history of coccygodynia, bladder and bowel dysfunction, inguinal pain, dyspareunia, numbness of the dorsal part of the right foot, tinnitus, pressure headaches with nausea and dizziness, and buttock pain that radiates to her right hip.  The patient has decreased right plantar flexion and toe walking, and there is decreased sensation in the left posterior and medial thigh.  The patient is stated to have a rare condition called Tarlov Cyst Disease with bone erosion.  A specialist stated that the patient was a candidate for Sacral Laminar Reconstructive surgery.  A MRI lumbar confirmed "Tarlov cyst incidentally noted in mid sacrum which resulted in mild erosive changes in mid sacrum."  Mild lateral recess narrowing was noted L2-3, L3-4, L4-5.

The specialist noted the patient has had back pain for 3 years and she has right buttock pain that radiates into the right hip; she has numbness of the dorsal right foot and reported constipation and pain during intercourse; on exam he noted normocephalic findings and dysfunction in the motor exam with decreased right plantar flexion and toe walking.  He confirmed MRI findings of large sacral cyst and he noted that there is "blatant compression of adjacent sacral nerve roots."  He recommended sacral cyst removal and sacral laminar reconstruction.

Reconstruction of the sacral lamina is required in order to prevent nerve compression and chronic pain; without reconstruction of the sacral lamina the nerves will be exposed to further injury and dysfunction.  The sacral laminar reconstructive surgery/spinal surgery is the best available treatment for this patient at this time.  Since Cyst removal is necessary, and that it would be dangerous to leave the sacrum not reconstructed as it would lead to pressure on the nerves, and cause possible further damage.

"In the general population, it has been estimated that 1.5% of people have 1 Tarlov cysts, with about 13% of those being symptomatic.  Despite a range of options for treatment, there is debate about when, and how to optimally treat individuals with Tarlov cysts among clinicians, and among policy decision makers. In total, 31 studies were included in this systematic review; all were case series.  Among the 646 participants included in these 31 studies, 210 experienced complete resolution of symptoms (32%), 327 had partial resolution (50%), 106 did not have any improvement or worsening of symptoms (16%), and 3 had their symptoms worsen after surgery (0.4%).

As noted by the treating providers the treatment of the Tarlov cyst is likely to be more beneficial, and based on the persistent severe symptoms, and the failure to improve with non-surgical care over time.                                                    

The carrier's denial of coverage for sacral laminar reconstructive surgery/spinal surgery (CPT code 64999) should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious disease
Secondary: Viral illness
This is the case of a patient with a past medical history of breast cancer status post lumpectomy and currently on chemotherapy, hypertension (HTN), chronic obstructive pulmonary disease (COPD), hyperlipidemia (HLP), asthma, and transient ischemic attack (TIA), who presented with shortness of breath, a non-productive cough, rhinorrhea, nausea, vomiting and non-bloody diarrhea x 2-3 days. Patient  reported a sick contact with grandchild at daycare ill with upper respiratory infection (URI) symptoms. The patient was subsequently brought into the hospital with assessment that patient  had nausea, vomiting and diarrhea that was improving with plans for intravenous fluids (IVF), electrolyte repletion, symptomatic treatment, and monitoring of the ability to take  (PO).
Overnight, the patient remained hemodynamically stable without fever, hypotension, tachycardia or other acute events. Patient was discharged home. The health plan's determination is upheld in whole. This is a patient with breast cancer on active chemotherapy who presented with shortness of breath, nausea, vomiting, and diarrhea in the setting of her grandchild being ill. This patient was noted to have mild hypokalemia and hypomagnesemia on presentation, but was otherwise hemodynamically stable, without acute kidney injury, and without abdominal exam that was suggestive of rebound, guarding, distention, or process requiring a naso-gastric (NG) tube or surgical intervention. The diarrhea furthermore was not associated with significant anemia and reported to be non-bloody without concern for a gastrointestinal (GI) bleed. patient  had leukocytosis but this was in the setting of just having received Neulasta. Given  electrolyte abnormalities and immunocompromised status on chemotherapy, this patient was certainly appropriate for a lower level of care, but it is unclear in the absence of an acute kidney injury (AKI), hemodynamic instability, concerning abdominal exam, and with the patient's symptoms already noted to be improving in the admission history & physical (H&P) from the ER, why this patient would not have been expected to improve quickly and could not safely be cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain 
Treatment: Inpatient stay 
The Inpatient admission  was medically necessary.

Summary:
The patient is a female with history of back pain. She was admitted to the hospital. She presented from emergency department for back pain. 

The patient presented to the ED with severe intractable pain and was not able to be discharged because of the level of pain. There was also a question of bowel/bladder issues during this time. The imaging showed a significant compression in the lumbar spine, which correlated with the imaging. Therefore, the initial date was appropriate for admission to manage pain control. The second day was appropriate because the patient underwent surgery and was monitored in the post-operative setting for neurological complications associated with this. The final date was also medically necessary, because the patient was discharged on this date.
Appeal type: Medical necessity
Decision: Upheld

Trauma/injuries: other
Inpatient hospital

The patient is a girl who fell and hit her face, suffered a nose fracture, bilateral orbital roof fractures with some rectus muscle swelling, and minimally displaced frontal bone fracture but no intra cranial air. No intra cranial bleed was seen. The patient was seen by the appropriate consultants and then was appropriately observed overnight to make sure concussive symptoms were ok and no ocular symptoms declared themselves. She remained stable and was on regular floor monitoring (q4 hours). There is no specific mention of frequency of neuro checks but it appears to be at q4h (every 4 hours). She did not develop any concerning symptoms and was discharged next day to address her injuries as an outpatient with specialists.

The health plan's determination is upheld. The inpatient stay was not medically necessary. Observation for this patient was appropriate. An inpatient level of care was not medically necessary. The patient's injuries do not meet criteria for an inpatient level.
Given the patient's injuries and lack of intra cranial bleed, this patient would have been appropriately managed at a lower level. This patient did not need, nor receive q1h neuro checks, nor intensive care monitoring. Nondisplaced injuries to the pediatric frontal bone typically do not require operative intervention. In as far as the orbital roof fractures, it is rare that they require surgical intervention and routinely can be managed as outpatient.
"In children, the most common fracture pattern extends along the frontal bone through the supraorbital foramen, and then progresses to involve the orbital roof/anterior cranial base. Generally these craniofacial fractures do not require open reduction and internal fixation (ORIF) unless a significant displacement is observed"
Given the concern for rectus muscle swelling, appropriate observation for 12-24h is reasonable but does not equate to needing inpatient status. The same goes for post concussive symptoms, and they can be appropriately managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bipolar disorder
Treatment: Continued inpatient admission

The continued inpatient admission was medically necessary.  

The patient has a history of mental illness including diagnosis with bipolar disorder.  There is a history of medical issues including type II diabetes mellitus (DM), hyperlipidemia, coronary artery disease (CAD), appendectomy, and mild dementia.  He takes aspirin, atorvastatin, metformin, and Lexapro with which he was non-compliant. There is a history of alcohol abuse and tobacco abuse.

The patient represented an acutely elevated risk of dangerous behaviors and there was no less-restrictive treatment environment appropriate.  The acute risk factors of depression with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were he to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.  

The patient represented an elevated risk of dangerous behaviors including self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained depressed.  The patient had multiple static risk factors for potentially dangerous behaviors including serious mental illness, substance abuse, and medical illness.  Therefore the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained anxious and depressed, as well as with ongoing medication changes, were acute risk factors for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pleuritic chest pain
Treatment: Inpatient admission

The proposed treatment, inpatient admission, was medically necessary.  

The patient is a G4P3 pregnant patient at 14 week's gestation who was transferred for new onset pleuritic chest pain described as substernal, persistent, worsening with inhalation, and associated with dizziness.  Despite concern for venous thromboembolism she had declined chest computed tomography (CT) due to concern about radiation exposure.  

On arrival, the patient was being treated empirically with subcutaneous enoxaparin.  She was afebrile with tachycardia to 106 and was saturating 100% on room air. She was admitted to the hospital for workup and treatment with presumptive diagnosis of pulmonary embolism.  Lower extremity Dopplers and troponins were negative.  A transthoracic maternal echocardiogram was performed which was normal with an ejection fraction (EF) of 55%.  Prior to completion of her workup she left the hospital against medical advice prior to definitive diagnosis and treatment.  

Based on the clinical severity of her presentation definitive treatment for pulmonary embolism had already been initiated prior to admission.  Although the workup had not been completed at the time of the patient's leaving the hospital against medical advice so that a definitive diagnosis could be determined, a presumptive diagnosis of pulmonary embolism had already been made and treatment begun.  Because of the associated co-morbidity of possible respiratory complications, hospitalization would be indicated for initial treatment of pulmonary embolism in this patient.  Therefore the hospitalization was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee cellulitis
Treatment: Inpatient admission
The acute inpatient admission was not medically necessary.

The patient is a female whose inpatient stay is under review. She had left knee redness, but no pain. She was given one dose of Vancomycin in the ER the day prior. Her symptoms initially improved, but then started worsening according to the patient. Her PMD stated that the knee was improved compared to the day prior.

In the ER, the patient's vital signs were as follows: T (temperature) - 37.1, P (pulse) - 69, RR (respiration rate) - 16, BP (blood pressure) - 166/79. On general examination, the patient was found to be NAD (no acute distress). Examination of her CVS (cardiovascular system), chest, and abdomen were normal. Examination of her skin revealed minimally fluctuant, 3x4 cm area of erythema, tenderness over left anterior patella, minimal pointing and scattered faint erythema to the anterior left shin.

The patient's labs were as follows: WBC (white blood count) - 8.0, Hg (hemoglobin) - 13.4, Hct (hematocrit) - 39.5, Plt (platelets) - 249, Na (sodium) - 141, K (potassium) - 3.9, Cl (chloride) - 103, CO2 (carbon dioxide) - 31, BUN (blood urea nitrogen) - 16, Cr, (creatinine) - 0.62, Glucose- 102

U/S (ultrasound) of the patient's left knee revealed fluid collection lateral to patella, which may have a tract extending to skin. LE (lower extremity) duplex revealed no DVT (deep venous thrombosis).

The patient was seen in the ER and thought to have cellulitis. Of note, cellulitis was noted to be improved compared to the prior day. She was admitted and kept on IV vancomycin. The next day, she was discharged home on PO (oral) antibiotics.

The patient does not meet the initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (1), as she did not fail outpatient therapy, had no systemic signs of infection (fever, tachycardia, leucocytosis), and had no co-morbid conditions that were concerning (immunodeficiency or homelessness, for example).  Also, it was noted that she had already started to improve after one dose of antibiotics. Thus, this admission was not supported by IDSA guidelines. Therefore, the acute inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Creatinine 8 and dizziness, and displaced nephrostomy tube 
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient is an adult male with bladder Ca (cancer) and CKD (chronic kidney disease) stage 5. He is s/p (status post) cystectomy and prostatectomy, nephrostomy tube. He was admitted with Creatinine 8 and dizziness, and his nephrostomy tube had fallen out.

The admission was medically necessary, because the patient started with severe renal failure, and with the nephrostomy tube displaced, the patient would quickly become critically ill. The patient needed emergency treatment and close monitoring in the hospital to ensure that his renal function improved. Outpatient treatment and monitoring would not have been safe for this patient. As such, the Inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Cardiac/Circulatory Problems - Arrhythmia/Irregular Heart Rhythm
Inpatient Hospital

The patient is a female who presented to the emergency department complaining of palpitations and near syncope. She had experienced multiple similar episodes over the preceding several days and had had several in the past hour. Upon presentation to the emergency department her blood pressure was 93/65 millimeters of mercury (mmHg) with a heart rate of 200 beats/minute. The tachycardia terminated with vagal maneuvers but then recurred. An electrocardiogram showed a narrow complex tachycardia at 214 beats/minute. This was terminated with carotid sinus massage (CSM), recurred again and was again terminated with CSM. A continuous intravenous diltiazem infusion was started, and the patient was admitted to the hospital. An echocardiogram was performed and was normal. Oral atenolol was started, and the diltiazem was weaned off. The patient was discharged. Medical necessity for an inpatient admission is at issue.

The health plan's determination is overturned, in whole. 

An inpatient level of care was medically necessary. This patient presented with near syncope and very rapid supraventricular tachycardia (SVT). She had had several episodes in the hour prior to presentation and two recurrences after initial tachycardia termination in the emergency department (ED). Published studies show that the majority of patients who present to the ED with SVT can be safely discharged home with a 24-hour recurrence rate of less than 5%. However, this patient had two recurrences while still in the ED and required continuous infusion of intravenous diltiazem for rhythm control. Given the need for intravenous medication, her near syncope, relative hypotension and extremely rapid heart rate during tachycardia, an inpatient level of care was medically necessary.