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

Diagnosis: Abdominal pain
Treatment: Inpatient admission

The acute inpatient stay for the management of this patient was not appropriate and medically necessary for the management of this patient's condition. 

The patient is a female with h/o (history of) cholecystectomy for gall stones 10 years ago. She was seen by her surgeon in his office for upper abdominal pain with radiation to the back associated with nausea and vomiting. She had no fever or chills. She had similar episodes of abdominal pain off and on in the recent past when she was visiting Jamaica. She underwent US (ultrasound) of the abdomen in his office, and it revealed dilated common bile duct measuring approximately 2cm in size and possible sludge/stones in the common bile duct. She was sent to ED, where she was evaluated.

In the ED, the patient was hemodynamically stable and afebrile. Her labs revealed normal CBC (complete blood count) with normal Hb/HCT (hemoglobin/hematocrit) and WBC (white blood count). The Chem panel revealed normal lytes, BUN/Cr (blood urea nitrogen/creatinine), and normal liver function tests. The ultrasound of the abdomen done in the ED revealed dilated common bile duct measuring 1.1cm in size. 

The patient was evaluated by GI (gastroenterology) and General Surgery. The GI recommended ERCP (endoscopic retrograde cholangiopancreatography) for the management of the common bile duct stones. She underwent ERCP and Common bile duct measured approximately 1.2cm in size and it revealed multiple stones. The biliary sphincterotomy was performed, and copious amount of stones and sludge were removed with balloon extraction. Biliary stent was placed after the duct was cleared of stones. 

The patient tolerated the procedure well. She was started on clear liquid diet and sent to the medical floor. The plan was to repeat the ERCP in six to eight weeks for biliary stent removal. The next day, she was discharged home and with outpatient follow-up with GI.

The patient had a history of cholecystectomy for gall stones about 10 years back and presented to the her Surgeon's office with upper abdominal pain nausea and vomiting (biliary colic). She was found to have choledocholithiasis on the ultrasound of the abdomen. She was sent to the hospital for further management of choledocholithiasis. She was evaluated by GI and underwent ERCP, sphincterotomy, stone extraction and biliary stent placement for the management of choledocholithiasis. She did well after the procedure and observed overnight and discharged home the next day. Given this clinical scenario and clinical course, the patient could have been safely managed under lower level of care. Acute level inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory problems
Inpatient Hospital

The patient is a woman with a prior deep vein thrombosis (DVT), transient ischemic attack (TIA), and gastroesophageal reflux disease (GERD) who presented with severe chest pain. She was admitted to the hospital.
The initial vital signs including blood pressure, heart rate, and respiratory rate were normal. Laboratory testing revealed a hemoglobin of 8.3. The electrocardiogram (ECG) demonstrated sinus rhythm with a rate of 63 beats per minute (bpm). The inpatient stay is under review. 

The health plan's determination is upheld. The requested health service/treatment of Inpatient Hospital Stay is not medically necessary for this patient. The patient had both a primary diagnosis of chest pain and dizziness. Milliman Care Guidelines (MCG) support an inpatient admission for suspected angina including evidence of a myocardial infarct based on ECG or abnormal cardiac enzymes, symptoms that require necessitating intervention due to unstable pattern, hemodynamic instability, refractory symptoms, and other comorbid medical histories.
There was no evidence of a cerebral event, infection, or vascular problem that would require surgery. There were no abnormal cardiac conditions such as hemodynamic instability or abnormal heart rhythms as well as new neurologic finding as manifested by papilledema, cerebral edema, and a central nervous system (CNS) mass or bleed.

The patient did not require ongoing IV medication and was not pregnant. The patient could have been cared for at a lower level of care with serial cardiac enzymes and workup for chest pain which may have included an exercise treadmill test. After administering IV fluid and confirming no abnormalities on head CT scan the patient could have been discharged with further outpatient evaluation.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient Hospital

The patient who presented to the emergency department (ED) with a history of progressively worsening abdominal pain and a syncopal episode at home. The  evaluation included physical exam, labs, and computed tomography (CT) scan of the head and CT of the abdomen and pelvis. The patient  was without fever at the time of presentation. The heart rate was 80/minute. Lab data identified a white blood cell (WBC) count of 8.4 K. Blood glucose was elevated at 278. CT scan yielded the diagnosis of acute appendicitis without perforation. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was obtained. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This patient presented 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. The patient  was stable for discharge from the hospital. The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient required urgent surgical intervention for acute appendicitis and treatment for hyperglycemia secondary to diabetes, however, a lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care. There was no documentation of hemodynamic instability, intra- or peri-operative complications, severe pain, or unstable comorbidities. The patient tolerated oral hydration, diet and medication. Pain was well controlled.
The care and treatment provided could have appropriately been rendered at a lower level of care. The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care would have still provided for presurgical assessment, operative treatment and post-surgical monitoring. This lower level of care would have also allowed for overnight monitoring.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Advanced Imaging Services

The patient is a female under evaluation for anorexia and weight loss. The patient underwent upper endoscopy and colonoscopy which were unremarkable. The patient lost approximately 25 pounds over 8 weeks. A computed tomography (CT) of the abdomen with oral but no intravenous (IV) contrast was normal. Labs showed mild normocytic anemia with borderline low iron saturation.

The patient's provider requested approval for a magnetic resonance imaging (MRI) of the abdomen with and without contrast.

The subject under review is the medical necessity for the imaging.

The health plan's determination is upheld.

The patient has no localizing symptoms referable to the abdomen such as nausea, vomiting or persistent abdominal pain. There are no labs suggesting a possible inflammatory, obstructive or neoplastic process such as elevated liver function tests or elevated pancreatic enzymes. A prior esophagogastroduodenoscopy (EGD), colonoscopy, and CT of the abdomen demonstrated no significant abnormalities. Other causes of anorexia and weight loss such as medication side effects, depression, endocrinopathies, and others are far more likely and should be evaluated based on the standard of care.
Appeal type: Medical necessity
Decision: Overturned

GERD
Inpatient hospital

This patient is a male with a history of gastroesophageal reflux disease (GERD), hypertension (HTN), diabetes mellitus (DM) and HLD (hyperlipidemia). The patient underwent a laparoscopic fundoplication. The procedure was uncomplicated. Post op, the patient had some desaturations and required 3 liters nasal cannula (NC) oxygen on postoperative day (POD) #0. A NGT (nasogastric tube) was left and the patient was supported with intravenous fluids (IVF) and underwent an upper gastrointestinal (UGI) on POD#1 which was normal and the patient was started on clear liquids. Post op, the patient developed hyperglycemia and required endocrine consult for normalization of hyperglycemia. The patient had stable vital signs and tolerated po (by mouth) and pain controlled with po medication on POD#2 and was discharged home.

The health plan's determination is overturned. The inpatient stay was medically necessary. This patient underwent a laparoscopic fundoplication but was kept nothing by mouth (NPO) with NGT in place and supported with IVF on POD#0. Postoperatively, the patient required supplemental oxygen for normal oxygenation and endocrine consultation for management of uncontrolled BS (blood sugar). The patient underwent diagnostic study on POD#1 which was normal and then the patient was initiated on liquids and then advanced to regular diet on POD#2 at which time the patient met standard discharge criteria and was released. The patient was not able to meet standard discharge criteria within an ambulatory or observation < 23* period of time. The inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary. While the care was medically appropriate, the level at which the care was provided was not medically necessary.

The patient is a male. He had a medical history of diverticulosis and anxiety. The patient had presented to the emergency department of the facility filing the appeal after developing sudden shortness of breath. He had used a new CBD (cannabidiol)-filled vape instrument. He also complained of abdominal pain and diarrhea.

His shortness of breath resolved with treatment in the ED. The patient had tachycardia and diffuse tenderness in the lower abdomen. The white count was elevated at 24 with a left shift and an elevated lactic acid level. The patient refused a CT scan and was admitted with the clinical diagnosis of diverticulitis. The patient was rendered NPO (nothing by mouth). The patient received IV antibiotics and supportive care. With improvement, the patient was discharged.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had presumed diverticulitis; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for prolonged NPO status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such, the care in its entirety could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Alcohol Abuse/Addiction
Inpatient hospital

The patient with a past medical history significant for substance abuse, anxiety, and hyperlipidemia who presented to the emergency department after  found on the pavement being unresponsive and hypotensive. It was reported that at the time that Emergency Medical Services (EMS) found the patient he was hot to touch. Upon arrival to the emergency department, the patient received treatment with intravenous fluids and Acetaminophen, in addition to the placement of ice packs on the neck and groin areas. After receiving 2 L of intravenous fluids, the patient became more alert and was able to communicate with the emergency department staff. The patient was unable to remember what happened after he drank alcohol with friends.

The health plan's determination is overturned. The inpatient stay was medically necessary. Based on the clinical signs and laboratory evaluation, this patient had rhabdomyolysis as a result of the mechanical trauma from laying on the pavement. If it remains untreated, rhabdomyolysis is associated with an increased incidence of acute kidney failure that is reported in 15-50 percent of rhabdomyolysis cases. The presence of dehydration in conjunction with rhabdomyolysis is associated with a higher incidence of acute kidney failure.
As it was reported in this clinical case, the patient had a significant elevation of the CPK level, which was consistent with rhabdomyolysis. Unfortunately, despite several boluses of intravenous fluids, the CPK level continued to grow. Taking into consideration these facts, treatment with continuous administration of intravenous fluids and close monitoring of kidney function and CPK level is usually warranted in similar clinical situations.
Considering the circumstances, the most effective way to provide the care was at the acute inpatient level. Unfortunately, the patient decided to leave the hospital AMA, but that still did not diminish the severity of his condition and the need for an inpatient stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion, anterior crowding, open bite, and overjet 

Treatment: Braces (D8080)

The insurer denied coverage for Braces (D8080). The denial was reversed.

This patient is a female who presented for evaluation for orthodontic care. The orthodontist identified Class I malocclusion, anterior crowding, open bite and overjet and has recommended orthodontics. She has completed the HLD index attaining 28 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements having attained a score of 17 points on the HLD index. 

It is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/ dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used, utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 28 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining a total of 28 points on the HLD index (9 overjet, 12 openbite, 5 anterior crowding, 2 labiolingual spread) which is at the threshold of 26 points to support orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies (listed as references).

Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

The determination is to reverse the denial as the clinical circumstance as presented does meet and substantiates the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval.

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

Based on the above, the medical necessity for Braces (D8080) is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Retroperitoneal hematoma

Treatment: Inpatient hospital services 

The insurer denied coverage for inpatient hospital services. The denial reversed.

This patient is a female with a history of hypertension. The documentation detailed that she presented to the Emergency Department complaining of severe pain to the left groin and hip.  The documentation detailed that the patient had an angiogram around midday; however, when she returned home she had severe pain and bloody vomitus during triage.  The physical exam revealed the patient was in no apparent distress.  She had a right groin wound without active bleeding or hematoma.  There was mild tenderness to palpation to the left groin.  The patient's vital signs revealed a temperature 99.5 with oxygen saturation at 99%.  The patient had a heart rate of 105 bpm with a blood pressure of 139/93.  The physician recommended multiple laboratory and diagnostic studies.  It was also recommended to begin intravenous (IV) fluids.  

The documentation detailed that the patient was recommended for admission.  The physician detailed that the patient had complaints of nausea on discharge from the Emergency Department.  She received fentanyl and Toradol; however, she continued to complain of pain.  She was admitted with a diagnosis of retroperitoneal hematoma, as well as anemia and postsurgical complication.  She was also infused with one unit of packed red blood cells.  The patient did undergo a cardiac consultation the following day. The consultant recommended continued monitoring.  The patient also underwent additional consultations from Vascular Surgery. The patient underwent a coil embolization of the iliac artery. There were no complications during the procedure.  The patient did not have any further complications.  She was noted to have a decrease in pain.  She continued with monitoring and it was noted that she was stable for discharge. The patient was discharged with instruction to follow-up.

The inpatient stay is appropriate.  The patient had a serious/severe complication after an angiogram resulting in a left-sided retroperitoneal hematoma due to iliac artery injury that required coil embolization. The medical record documentation for this admission included clinical signs of left hip/groin pain, a CT scan documentation of left retroperitoneal hemorrhage, a confirmatory angiogram revealing the site of injury to the left iliac artery, as well as a blood transfusion given and a scheduled procedure of coil embolization.

A retroperitoneal hemorrhage after angiography is not an uncommon complication that could have devastating and potentially life-threatening complications.  It requires immediate admission; serial hemoglobin/hematocrit draws to document blood loss, imaging, and treatment if indicated.  All this requires inpatient admission until the situation is treated and stabilized. The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

The carrier's denial of coverage for the inpatient hospital services at the inpatient level of care is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath and cough
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The patient is a male. He has history of tuberculosis (TB) with worsening shortness of breath, and cough. He was found to have right upper lobe infiltrates, bronchiectasis as well as right pleural effusion. The patient was treated with oral antibiotics prior to presenting to the emergency room. Since the patient had history of TB, there was a concern for reactivation of TB, as well as bacterial pneumonia that failed outpatient therapy.  

The patient was admitted for IV antibiotics as well as isolation for active TB. The patient also underwent thoracentesis to rule out pleural tuberculosis. He also had three induced sputum for AFB (acid fast bacillus) stain. 

The patient was improving on IV antibiotics, and AFB stains were negative. The patient was discharged home on oral antibiotics.

The patient had failed outpatient therapy. The patient had abnormal chest x-ray and CT-chest performed in the emergency room, which showed right upper lobe cavitary infiltrates, bronchiectasis and right pleural effusion with concern for reactivation TB.  Since the patient had failed outpatient therapy and had worsening cough with dyspnea, the IV antibiotics were necessary. Due to high likelihood of reactivation TB, the in-patient isolation for TB rule out is the standard of care. The acute in hospital level of care was medically necessary. 

The patient likely had pneumonia as well as high risk for reactivation tuberculosis. He tried and failed outpatient therapy. Due to high likelihood of reactivation TB, the inpatient isolation for TB rule out is the standard of care. The acute in hospital level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Jaundice, vomiting, and diarrhea 

Treatment: Inpatient admission 

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

This patient is a male who presented with jaundice, vomiting, and diarrhea. He was afebrile and the vital signs were stable. The abdominal exam was benign. An abdominal ultrasound revealed gallbladder sludge. The bilirubin was 7.7. The INR was 1.02. He was able tolerate a diet. It was felt that the elevated bilirubin was due to a viral infection. Both, the jaundice and his symptoms improved.

MCG Clinical indications for admission for Liver Disease Complications (M-570) include hepatic encephalopathy, hemodynamic instability, and infected ascities. AST or ACT 15 times over the upper limit of normally INR over 1.5, and persistent vomiting or dehydration. The patient did not have these conditions.

This patient had jaundice. However, there was no evidence of liver failure. He did not have a coagulopathy. There was also no evidence of acute cholecystitis or biliary tract obstruction. The patient required an abdominal ultrasound and monitoring of the liver enzymes. However, this could have been done with observation status. He did not meet MCG Criteria for admission for liver disease complications. 

The healthcare plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

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

Diagnosis: Brain injury; dementia
Treatment: Personal care level II; 84 hours/week; 12 hours/day, 7 days/week

The increase in Personal care level II; to 84 hours/week; 12 hours/day, 7 days/week is deemed medically necessary. 

The patient is a male with a history of anoxic brain injury, dementia, atrial fibrillation, hyperlipidemia, hypertension and diabetes mellitus. For these reasons, he requires assistance with the majority of his activities of daily living (ADLs). An appeal review requested for potential approval of Personal care level II; 84 hours/week; 12 hours/day, 7 days/week for increased assistance with completion of the patient's ADLs.

This is a male with anoxic brain injury, dementia, atrial fibrillation, hyperlipidemia, hypertension and diabetes mellitus. For these reasons, he requires assistance with the majority of his activities of daily living (ADLs) including toileting, bathing, dressing, feeding, transfers and ambulation. For these reasons, the currently approved schedule of 56 hours/week is not sufficient to meet the patient's needs. For these reasons, the proposed treatment of an increase in Personal care level II; 84 hours/week; 12 hours/day, 7 days/week for increased assistance with completion of the patient's ADLs is deemed medically necessary.