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

Diagnosis: Eating disorder and depression 
Issue under review: Intensive outpatient mental health services 

Determination: The Intensive outpatient mental health services were not medically necessary. 

The patient is a teen-aged female. She was admitted to this program for treatment of an eating disorder and depression. The patient previously had intensive outpatient treatment at a different program. Prior to that, she was in an inpatient facility. Precipitating reasons for these admissions are not described. 

The patient's treatment plan at the time of admission to the current program included 31 authorized sessions. At that time, the patient was described as being ambivalent about recovery. She became angry during a family session. Staff reported that she was not completing her meals and needed supplements, which she often did not take. Her parents were concerned about the patient going away to college in the fall. Authorization was given for some additional sessions. The program planned a discharge date. 

At no time was the patient in any acute medical distress. Her weight varied from approximately 122 pounds to 127 pounds, which for her height of 63 inches placed her within several pounds of her ideal body weight. 

The patient reported smoking marijuana three times weekly and did not plan to discontinue it. One note reports a history of substance-abuse and three "overdoses," but no details were provided regarding these episodes or use of other drugs except for mention of possible past use of cocaine, benzodiazepines, and psychedelics. The patient did not want to attend AA/NA (Alcoholics Anonymous/Narcotics Anonymous) meetings or disclose her drug use to her parents. 

She was provided cognitive behavioral therapy, dialectical behavioral therapy, group therapy, family therapy, meal support, and exposure therapy for three hours daily, four days a week. Her medications included fluoxetine 10 mg daily and quetiapine 75 mg at bedtime. 

The documentation reviewed does not reflect any significant medical or psychiatric distress. The patient made conscious choices about weight loss and continued substance use. While these choices may not have been in her ultimate best interest, they did not place her in immediate or significant danger and there was no evidence of any health consequences. They could have been appropriately addressed in a less intensive mental health outpatient setting for the dates of service under review.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute-on-chronic gout

Treatment: Inpatient Admission  

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

This is a male patient with a history of gout, chronic kidney disease (CKD), asthma, eczema, methicillin-resistant staphylococcus aureus (MRSA) infection and panic attacks. He presented to the Emergency Department (ED) with complaints of left and right arm swelling and palpitations. It was reported that several days prior to his presentation his right 1st metatarsophalangeal (MTP) joint was swollen and drained white material. His physical exam revealed swelling in the right knee and right 1st Metatarsophalangeal (MTP) joint and he was experiencing difficulty while ambulating. An x-ray of his wrist, knee and ankle were done that showed no acute changes. Laboratory work up was performed revealing white blood cell (WBC) count was 6.59, creatinine was 2.23, lactate was 1.9, and Troponin T, High Sensitivity was 18 (normal <6-14ng/L). The patient was consulted by rheumatology. The clinical impression for this patient's medical condition was acute-on-chronic gout. The patient's symptoms resolved and he was discharged. 

According to MCG Musculoskeletal Disease guidelines, gout is normally treated as outpatient. The patient had no fever, had normal white blood cell (WBC) count and the patient's pain involved multiple joints, which all made septic joint unlikely. The patient complained of palpitations but had normal electrocardiogram (EKG) and telemetry monitoring. The patient's elevated creatinine improved, and the patient did not exhibit any uremic signs or symptoms.

Due to this patient's complaint of palpitations along with borderline troponin and Creatinine, further monitoring was needed. However, the severity of illness of this patient's clinical presentation did not support the need for acute inpatient admission. The patient's Troponin T, High Sensitivity result of 18 ng/L was in the indeterminate level for acute myocardial injury. In view of the lack of ischemic symptoms and normal ECG, this was almost certainly related to AKI which is seen particularly with TnT. 

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

The carrier denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems
Dental/Orthodontic Procedure

The patient in question is a female with a Class I malocclusion and anterior crossbite of tooth # (number) 7. Tooth #27 is showing some recession. She is treatment planned for 24-30 months of orthodontics with extraction of teeth 5, 12, 21, and 28 to correct her malocclusion. Under review: Braces: Comprehensive Orthodontic Treatment.

The health plan's determination is overturned. Braces: Comprehensive Orthodontic Treatment are medically necessary for this patient.
The patient has significant maxillary anterior crowding with tooth #7 in crossbite. This tooth has a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Tooth #27 already has slight recession, and further movement of tooth #27 will likely lead to the need for future for periodontal grafting on this tooth. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons, the orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented with fracture lines and bone loss on tooth number (#) 14. Crown and core build-up are being requested at this time. At issue is the medical necessity of the crown and core buildup for tooth #14.
The health plan's determination is upheld.
According to the provided radiographs, tooth #14 has extensive bone recession and furcation involvement that has resulted in more than 50% bone level loss. Placing a crown on a tooth with severe bone loss will result in poor prognosis and failure. Due to the extent of bone loss and furcation involvement, this tooth is non-restorable.
Appeal type: Medical necessity
Decision: Upheld

Chest pain
Inpatient stay

The patient has a history of hypertension, diabetes, coronary artery disease with a myocardial infarction (MI), severe left ventricular dysfunction (ejection fraction (EF) 20%), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), asthma, and an opioid addiction who presented to the emergency department (ED)  with chest pain. Lab studies showed an elevated creatinine 1.92, blood urea nitrogen (BUN) 42 mg/dL, and blood sugar of 240 mg/dL. The potassium was 6.1. The patient was admitted. The patient was hydrated, calcium gluconate given for hyperkalemia, and MI ruled out by serial troponins. Patient was discharged the following day. The health plan's determination of medical necessity is upheld in whole. The patient had multiple problems requiring medical attention. The patient required prolonged observation to rule out MI. Additionally patient required treatment for hyperkalemia, and likely an element of dehydration, producing worsened renal function. These conditions could have been treated at a lower level of care with the ability to admit this patient to inpatient level of care if not resolved within 24 hours.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: IDDM, Dementia
Treatment: Increase in Consumer and Self-Directed Personal Assistance Services to eight hours/day, five days/week, for a total of 40 hours/week 

The increase in consumer and self-directed personal assistance services to eight hours/day, five days/week, for a total of 40 hours/week is deemed medically necessary. 

The patient is a female with a history of insulin-dependent diabetes mellitus (IDDM) and dementia. Due to these conditions, she requires assistance with the majority of her activities of daily living (ADLs). An appeal review requested for potential approval of an increase in Consumer and Self-Directed Personal Assistance Services to eight hours/day, five days/week, for a total of 40 hours/week to offer increased assistance with the patient's ADLs. The health plan has currently approved a schedule of 30 hours/week.

This is a female with a history of insulin-dependent diabetes mellitus and dementia. Due to these conditions, she requires assistance with the majority of her activities of daily living (ADLs). Per documentation from the patient's Attending Physician; the patient is demonstrating overall decline in her functional and cognitive status due to the progressive nature of her conditions. Furthermore, she oftentimes forgets to take her medications or check her fingerstick glucose readings, oftentimes leading to glucose levels frequently over 300 mg/dL with resultant diabetic nephropathy. For these reasons, the currently approved plan of 30 hours/week consumer and self-directed personal assistance services is not sufficient to meet the patient's current needs. Hence, the proposed treatment of an increase in consumer and self-directed personal assistance services to eight hours/day, five days/week, for a total of 40 hours/week to offer increased assistance with the patient's ADLs is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission
The Inpatient admission was medically necessary.

The patient is a male.  He has a past medical history significant for HTN (hypertension), systolic CHF (congestive heart failure) with EF (ejection fraction) depressed to 35-40%, subsequently improved to 8%, homeless, and shelter resident. He presented for evaluation of chest pain. 

The patient was hemodynamically stable. ECG (electrocardiogram) revealed inferior-lateral T-wave inversions. Troponin was mildly elevated. The patient was admitted for suspected ACS (acute coronary syndrome). Cardiac catheterization was planned, however the patient refused the procedure. Stress test was offered as an alternative, however the patient declined that as well. He was continued on medical therapy for suspected CAD (coronary artery disease). The patient was discharged with a planned outpatient clinic follow-up.

The patient presented with new onset chest pain, suspicious for unstable angina. The patient had multiple risk factors for CAD. ECG was abnormal, with T-wave changes suspicious for ischemia. Troponin was abnormal, suggestive of myocardial injury. There was a high index of suspicion for an ACS, and a cardiac catheterization was recommended, however the patient refused the procedure. He was treated medically for suspected CAD. Given the presentation, abnormal ECG and troponin, as well as clinical suspicion for an acute coronary syndrome/unstable angina, he would not be an appropriate candidate for an ED chest pain observation unit. It would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Leg pain; discoloration 
Issue under review: Inpatient admission 

Determination: The inpatient admission was medically necessary.

The patient is an adult female with reported s/p (status post) ORIF (open reduction internal fixation) left ankle and tibia fracture a month prior to admission.  She was brought to hospital by medics for emergency evaluation of pain and discoloration to her left leg.  Her vital signs were stable.  Her cardiogram was without acute change.  CT angiogram revealed pulmonary emboli.  She was admitted to hospital and received IV fluids and subcutaneous enoxaparin.  She had telemetry monitoring and was provided with several medications.  Additional studies were completed which revealed Doppler negative and repeat CT angiogram negative.  She reported improvement and was then discharged home.  Initial CT angiogram was suboptimal. 

Additional records denote that the patient underwent a peroneal tendon procedure, not ORIF.  She was ambulatory and complaint was discoloration behind the knee.  There was no description of shortness of breath or other pains. 

Diagnostic testing revealed a pulmonary embolus (PE).  The patient underwent two CTAs.  The first was markedly positive with second opinion confirmatory for pulmonary embolus.  Based upon solely diagnostic studies, admission would be warranted.  The patient had undergone surgery, which does increase her risk for PE.  She would be expected to have been immobilized and with limited ambulation.  These factors would increase her risk for PE, i.e., stasis and hyper coagulability. 

A physician treating such a person would have low threshold to admit with a positive CTA.  Although her clinical presentation was without significant positive findings, the initial CTA cannot be discounted.  An admission would be required for the diagnosis of PE.  Criteria had been met, as she had recent lower extremity surgery.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/circulatory problems
inpatient hospital

This case involves a female with a history of asthma and chronic obstructive pulmonary disease (COPD), who continues to smoke, and presents to the hospital with a 3 to 4-day history of intermittent chest pain, located on the left side radiating down the left arm. It was worse with exertion. The patient is also experiencing wheezing and a productive cough as well as shortness of breath for three weeks. Symptoms of shortness of breath got worse over the last 24 hours as the patient ran out of her home inhaler. The patient has a history of cardiac evaluations, most recently one year before this presentation, with a stress test that is reportedly inconclusive as the patient did not hit the target heart rate. There is a family history of heart disease. Under review is the inpatient hospital stay.

The health plan's determination is upheld. The inpatient hospital admission is not medically necessary for this patient. A lower level of care is appropriate. There is no clinical indication for admitting this patient to inpatient care. She has no prior history of mechanical ventilation or intubation. The peak expiratory flow was 17% of the personal best, and it improved significantly after treatment. There is no recent history of recurrent hospitalizations for asthma, inadequate access to medical care or medications, there is no evidence of severe hypoxemia, accessory muscle use, that persists. There is no evidence of hemodynamic instability; there is no evidence that the patient has altered mental status, is obtunded, and requires assistance with respiration. In conclusion, this patient's asthma exacerbation responded very well to appropriate medical therapy, treatment with corticosteroids, aggressive inhaled bronchodilator therapy, and placement on the appropriate medical regiment for control of asthma.
In regards to the chest pain, it is atypical for a prolonged duration and a routine cardiac workup within the past year. Serial cardiac enzymes were negative, and she has a normal echocardiogram within 24 hours of admission. There is no evidence of acute coronary syndrome, pulmonary embolism (PE), or dissection to warrant inpatient hospitalization.

In conclusion, the patient's presentation does not warrant an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Infectious Disease - Viral Infection
Inpatient Hospital

The patient is a young male who presented with 2 weeks of gradually worsening right neck swelling. Fifteen days prior to presentation he developed a fever to 105 and a sore throat that lasted 4 days. During that time they also noticed small right sided neck swelling. His symptoms were initially treated with Tylenol. Fevers resolved after 4 days but right sided neck swelling gradually continued to increase. He was seen by his primary care physician (PCP) 7 days prior to presentation and was started on Cefdinir. Despite antibiotics the swelling of the right side of the neck continued to enlarge. In the ER his vital signs were normal, with significant right sided neck swelling present. Nodes were tender to the touch. He received oral Decadron, IV Clindamycin and was admitted to pediatrics for IV antibiotics as he failed outpatient therapy. Once admitted the patient received 4 doses of Clindamycin IV. The patient had positive heterophile antibody and Epstein-Barr virus (EBV) was pending on the day of discharge but his lymphadenopathy was likely improving with the disease course and s/p Decadron. The health plan denied the inpatient stay as not medically necessary.

The health plan's determination is upheld. He did not have any fevers or significantly elevated inflammatory markers as his WBC, ESR and CRP were all within normal limits. CT scan did not demonstrate any drainable abscess or necrotic lymph nodes. In this scenario, invasive bacterial infection would be less likely. 
There was no airway compromise or signs of impending airway compromise. He did not have any difficulty breathing or difficulty tolerating diet. He responded quickly and well to steroid treatment and was found to be positive for mononucleosis. He did not require any highly skilled or technical care during his stay and he was discharged within 48 hours of admission. Testing and treatment with close follow up could have been safely accomplished without admission to inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hypertension, hepatitis C, hepatocellular carcinoma, end stage kidney disease status post-transplant, and depression who presented to the emergency department . He presented with a chief complaint of persistent cough, chest tightness and severe cold. He reported that his symptoms had improved previously but then worsened two days prior to presentation. He denied fevers, chills, palpitations, nausea and vomiting. Vital signs showed temperature 37.0 degrees Celsius, heart rate 72, blood pressure 127/78, and respiratory rate 18. On physical exam, his heart rate was regular, breath sounds were normal with no wheezing, and neck was supple. A chest x-ray showed left lower lobe patchy opacity. Lab results showed sodium 137, potassium 4.4, creatinine 2.37, glucose 160, calcium 9.5, magnesium 1.5, white blood cell count (WBC) 10.1, hemoglobin 13.8, and platelets 65. Troponin was negative. The patient was admitted for suspected pneumonia and an acute kidney injury. The plan of care included intravenous (IV) antibiotics, viral panel, pro calcitonin testing, kidney ultrasound, and continuing other home medications. He remained stable overnight and was discharged.

The health plan's determination is upheld. 

The patient presented with pneumonia but was hemodynamically stable, had no evidence of sepsis, had no evidence of respiratory failure, and had no other complicating factors at the time of presentation with the exception of mild acute kidney injury. He was at increased risk for an adverse outcome because of his transplant history but given his stability, he could have been safely managed at a lower level of care.
A patient who presents with pneumonia but does not have evidence of sepsis, respiratory failure, or significant failure of other organ systems does not need to be treated at the inpatient level of care. The patient's acute kidney injury represented a mild increase in creatinine from baseline.
Appeal type: Medical necessity
Decision: Overturned

Blood disorder: Other
Lab Work/Blood Tests

This is a female with a history of bruising and excessive bleeding. She also has a history of heavy menstrual bleeding (though she is now post-menopausal). She has been experiencing conjunctival hemorrhages, as well. The patient was suspected of having von Willibrands disease (vWD). A von Willibrands panel was obtained and is under review.

The health plan's determination is overturned. The Laboratory Testing Services were medically necessary for this patient. In this case, the patient was found to have type 2A, which involves loss of the platelet binding function of VWF and a reduction in the most functional high molecular weight (HMW) multimers. The loss of HMW multimers may be due to either decreased multimer assembly or to increased proteolysis. The ratio of VWF Activity to VWF Antigen is decreased. This subtype accounts for 10 to 15 percent of VWD cases and its treatment is distinct. Additionally, treatment is titrated based on response to therapy as measured by these assays.
The use of the testing under review is consistent with the literature and guideline recommendations; and not the subject of ongoing investigation. It is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Lung cancer
Cancer Testing

The patient is a male with stage IV adenocarcinoma of the lung whose oncologist ordered a "liquid biopsy" via Guardant Health to assist in treatment selection. Coverage for this testing has been denied by the patient's health care plan as not medically necessary. The health plan's determination is overturned. 

For patients who do not have a tumor(s) location amenable to percutaneous or surgical biopsy or in a situation where a patient may be progressing on an EGFR (epidermal growth factor receptor) TKI (tyrosine kinase inhibitors) based therapy, plasma based testing such as the Guardant 360 is an accepted standard of practice assay. Such testing is endorsed by the National Cancer Care Network (NCCN), who synthesizes data and generates recommendations free of commercial bias. Based on the information provided, the patient did exhibit such a situation, prompting the provider in the case to order this test. The testing ordered was an appropriate diagnostic step to assist the provider in their efforts to select the appropriate treatment option for this patient.