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

Diagnosis: Left lower leg cellulitis

Treatment: Inpatient admission

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

This patient is a male with past medical history significant for chronic obstructive pulmonary disease (COPD), asthma, diabetes mellitus, and hyperlipidemia who presented to the emergency department with complaints of bilateral lower extremity pain and swelling. Vitals on presentation included: Temperature 36.5 C, blood pressure 129/79, pulse 100, respiratory rate 16, and oxygen saturation 97% on room air. Laboratory values were notable for the following: WBC-9.83, Hgb-10.1, Hct-32.9, creatinine-0.79, glucose-108, CRP-18.11, ESR>130.

The patient was admitted for a left lower leg cellulitis. He was empirically started on intravenous antibiotics (vancomycin). Ultrasound of the lower extremity was negative for deep vein treatment (DVT). Infectious Diseases consulted for cellulitis and penicillin allergy. Of note, patient developed swelling in left side of face, cheek, and lips suspected to be an allergic reaction to Levaquin. He responded to IV Benadryl. The patient was seen by an Allergist consult who recommended antibiotic options. Vascular Surgery also evaluated patient for peripheral vascular disease. All cultures were negative. The patient remained afebrile, hemodynamically and clinically stable. The patient had a midline catheter placement for home intravenous antibiotic infusion (vancomycin).

According to documentation, patient was admitted for a left lower extremity cellulitis. He was otherwise afebrile, hemodynamically stable with unremarkable laboratory findings including a normal WBC. Although ESR and CRPs were noted to be increased, these non-specific findings likely reflected chronic inflammation. The patient had a localized infection with no failure of outpatient intervention and he did not require surgical intervention. He had an allergic reaction to Levaquin as a result of his hospital stay. Based on above findings, patient did not meet criteria for acute inpatient admission.

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

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: Upheld

This is a patient with a history significant for chronic thrombocytopenia with a baseline platelet count in the 90s and nasal septum deviation, who presented to the emergency department with complaints of intermittent midsternal chest pain that was not radiating, described as nonexertional, which lasted for an hour at a time.  The chest pain was associated with shortness of breath.  The patient described the pain as pressure-like, with no radiation or modifying factors.  The pain was intermittent and lasted for approximately 1 hour.  At the time of admission, the patient denied any sick contacts or long-distance travel.  The patient noticed some exacerbation of the chronic nasal congestion in the last several days preceding the day of admission.  She denied headaches, fever, cough, sputum production, neck stiffness, or photophobia.
The patient was not in acute distress, appeared anxious, head, eyes, ears, neck, throat (HEENT) exam was unremarkable.  The cardiac exam was within normal limits.  At the same time, the patient had mild chest wall tenderness that was reproducible.  The rest of the physical exam was unremarkable.
The patient had an abdominal ultrasound that was interpreted as an unremarkable study without hepatosplenomegaly.
An electrocardiogram (EKG) did not demonstrate any evidence of acute coronary syndrome.
The patient was admitted to the hospital with a diagnosis of chest pain and no risk factors for coronary artery disease.  It was mentioned in the history and physical exam note that the patient had no EKG changes and had a normal troponin.  It was also mentioned that the patient was not hypoxic.  The admitting physician suspected that the patient had a viral illness.
Another admitting diagnosis was non-anion gap metabolic acidosis that was improving; further monitoring of the laboratory results was planned at the time of admission.
The health plan's determination is upheld.
This patient presented to the hospital with complaints of chest pain.  The chest pain was atypical, reproducible on physical exam, and not related to cardiac origin. The patient was hemodynamically stable, had a normal troponin level, and her chest x-ray was normal.  There was a low probability of venous thromboembolism because of the lack of risk factors and a normal D-dimer level.  Even though the patient's platelet count was lower than the baseline, there was no mention that the patient had active bleeding or any other clinical manifestations of thrombocytopenia.
The reason for the non-anion gap metabolic acidosis was not clear, but it improved quickly, and there were no clinical manifestations associated with this condition.  There were no additional diagnostic tests or procedures required for the treatment of this condition.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history of hypertension (HTN) and coronary artery disease (CAD), who presented to the emergency room (ER) with elevated blood pressure. He had associated occasional headache and dizziness. His blood pressure had been poorly controlled for 2-3 weeks, with outpatient medication adjustments being made. He had no shortness of breath, chest pain, palpitations, or visual changes. He was in no acute distress. The patient was admitted for blood pressure control. He was given a dose of hydralazine and then continued on chlorthalidone, carvedilol, and nifedipine. Hydralazine was ordered as needed. Troponin was normal and electrocardiogram (EKG) without ischemic changes. His blood pressure remained controlled and he was discharged on an oral regimen.
His initial blood pressure (BP) was 196/92 (improved to 174/92 without any intervention). Lab results were significant for: hypokalemia (K 3.1)
An electrocardiogram (EKG) showed sinus bradycardia.
The health plan's determination is upheld. The patient's blood pressure came down without intervention, and he did not require intravenous (IV) drip medications to control blood pressure. He did not have chest pain, shortness of breath, renal failure. Although he had intermittent headache and dizziness, neurologic exam was non focal and no head imaging was performed.
According to the Milliman Care Guidelines, for hypertension, the patient did not meet inpatient criteria. The patient also did not meet  InterQual Level of Care Criteria for inpatient admission for Hypertension.
Although he had an initial systolic blood pressure (SBP) greater than (>) 180, he did not have any evidence of acute end organ damage. He did not have a severe headache at time of presentation or visual changes, no acute kidney injury, aortic aneurysm or dissection, heart failure, abdominal/back pain, chest pain, dyspnea, mental status change, nausea/vomiting.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department (ED) complaining of chest pain and dyspnea that had been going on for several months but had worsened in severity. A stress test with perfusion imaging had showed evidence of reversible ischemia and the patient had been scheduled for an elective cardiac catheterization the following week. In the emergency department (ED), her blood pressure was 146/64 millimeters of mercury (mmHg) with a heart rate of 85 beats/minute. Her respiratory rate was 18/minute. Her physical exam was remarkable for obesity; her cardiopulmonary exam was normal. Her troponin level was normal. Her electrocardiogram showed sinus rhythm without acute changes. A cardiac catheterization was performed. This showed normal coronary arteries and a normal left ventricular ejection fraction. The patient's left ventricular end diastolic pressure was elevated at 19 mmHg. The procedure was uncomplicated. The health plan's determination is upheld.
This patient presented with chest pain and dyspnea after having had an abnormal myocardial perfusion study several days prior. Given the suspicion for ischemic heart disease, monitoring until acute coronary syndrome could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease
Treatment: Inpatient stay

Summary:
The patient is female. She has a past medical history significant for hypertension, diabetes mellitus, dyslipidemia and CAD (coronary artery disease). She presented for evaluation of chest with a coronary CT significant for severely elevated calcium score of 1300. The patient underwent a coronary angiogram, revealing severely calcified obstructive LAD (left anterior descending) lesions. Rotablator-assisted PCI (percutaneous coronary intervention) was performed of the mid and proximal LAD lesions. 

The patient was hemodynamically stable. Her post PCI course was complicated by right femoral hematoma, which was managed with manual compression. The patient remained stable and was discharged home with a plan for outpatient follow-up.


The Inpatient admission was medically necessary. The patient presented for management of angina, in the setting of abnormal coronary CT scan. She was noted to have obstructive disease of the proximal and mid LAD on cardiac catheterization. A coronary intervention with rotational atherectomy and stent placement was performed on a calcified lesion in the LAD, which is considered a complex PCI. Post PCI course was complicated by access site hematoma, requiring manual compression. Patients such as this one were excluded from the studies of outpatient PCI. It would be consistent with the current standard of care that this patient, after this complex PCI with the use of rotational atherectomy, be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

The patient was brought to the emergency department (ED) with a fever and a worsening buttock abscess and surrounding cellulitis despite oral cephalexin that had been prescribed the day before. The skin infection had worsened over a period of about a week during which time the child had intermittent fevers. In the ED, the temperature was 101.1 degrees Fahrenheit. The white blood cell count (WBC) was 31.1, Erythrocyte sedimentation rate (ESR) 56, and C-reactive protein (CRP) 20. The patient was admitted, sedated with intravenous (IV) medication, and the abscess was drained of 10 ml of pus, using the loop technique . Post procedure, the baby was continued on IV vancomycin; the wound continued to drain. The baby was afebrile the following day and clinically improved, so was discharged the following day on oral antibiotics. The health plan denied the acute admission. At issue is the medical necessity of an inpatient stay.
The health plan's determination is overturned. The patient had a large and expanding abscess on the buttock with expanding cellulitis with systemic signs of fever, significant leukocytosis (31,000) and elevation of inflammatory markers (CRP and ESR). This patient had a white blood cell count greater than 15,000. Moreover, he had failed outpatient oral antibiotics, so both IV antibiotics along with the surgical incision and drainage (I&D) were medically necessary. Acute criteria were met and the one day inpatient hospitalization was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Feeding disorder and failure to thrive

Treatment: Speech therapy (92526) x 10 visits

The insurer denied coverage for speech therapy (92526) x 10 visits. The denial was reversed.

This patient is a male child diagnosed with a feeding disorder and failure to thrive.  The services in question include 10 speech pathology visits for a specified date range. This is a child with well-established and well-documented developmental deficits, including speech, oral motor, and feeding/swallowing per his speech pathology evaluation, behavioral feeding evaluation, physician notes, and recent plan of care.  He has not advanced to age-appropriate food items and/or self-feeding behaviors.  His deficits are documented as 80% delayed at this time.  As a result, the physician has documented a medical diagnosis of failure to thrive.  While the child's growth charts document weight/height at the low range of normal, the degree of effort and intervention required to maintain these measurements is not typical or acceptable for a typically developing child of this age with acknowledgement that failure to address the child's deficits will result in further functional declines, a poorer prognosis, and ultimately more medical services needed in the future to address the resulting outcomes.
 
According to the American Speech-Language-Hearing Association (ASHA) scope of practice and clinical documents, treatment of a child with a severe feeding disorder is considered within the scope of practice for speech pathologists and standard of care/best practice within the field. ASHA also states in regard to medical necessity within their Medical Review Guidelines that, "Speech-language pathology services are medically necessary to treat speech-language, swallowing, and cognitive-communication disorders.  Many of these disorders have a neurological basis..."
	
The severity of an individual's deficits determines treatment intensity and duration. While this child has reportedly received 45 visits of speech therapy, the pervasive nature of the child's deficits and the clinical impact of an inability to eat/drink appropriately warrant ongoing services. 

Further, the child has documented previous success in feeding therapy, good attendance, and good family support which demonstrate the effectiveness of the treatment being provided and demonstrates stimulability to make further gains. 

Given the above-indicated rationale, ongoing speech pathology services between the service dates in question would be considered medically necessary.   A re-evaluation would be indicated at the conclusion of the certification period prior to request of any additional services to document functional progress toward measurable goals, and to identify any ongoing deficits warranting medical necessity of ongoing intervention.

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 speech therapy (92526) x 10 visits is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Abdominal/Stomach Pain
Inpatient hospital

This is the case of a male with past medical history of hypertension (HTN), Afib (atrial fibrillation), colostomy placement, and hernia repair, who presented to the emergency room (ER) with nausea, repeated episodes of vomiting, abdominal pain, chest pain, constipation x1 week. He denied fevers, chills, shortness of breath (SOB), or other complaints. He was admitted to the hospital. 

The health plan's determination is overturned. The Inpatient Hospital Stay was medically necessary for this patient. This is a patient who presented with abdominal pain, nausea, and vomiting and acute renal failure with increase in his creatinine from 1.3 three days prior to 3.88 on admission in addition to leukocytosis to 23 with concern for urinary tract infection (UTI). His ARF with increase in creatinine 3x baseline was associated with concern for both a pre-renal component given vomiting in addition to obstruction secondary to enlarge prostate for which IVF, Foley catheter, and addition of Flomax were needed, in addition to work-up with Renal US and urine electrolytes. He was at risk given vomiting and severe constipation for ongoing renal injury. Though his creatinine improved, it was still not close to baseline, and the physicians treating the patient were concerned about ongoing kidney injury, encouraging the patient to remain in the hospital for further treatment. However, he decided to leave AMA. This patient required inpatient treatment for acute renal failure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations
Treatment: Inpatient admission

Summary:
The patient is a male. He has a past medical history significant for HTN (hypertension), GI (gastrointestinal) bleed, paroxysmal atrial fibrillation/flutter and gastric cancer, s/p (status post) resection. He, who presented to the ED for complaint of palpitations. 

The patient has a known history of paroxysmal atrial fibrillation/flutter and presented with a recurrent episode of atrial flutter with RVR (rapid ventricular response). The patient's blood pressure was stable, there was no evidence of acute MI (myocardial infarction) or decompensated CHF (congestive heart failure). The echocardiogram was unremarkable. The patient was not anticoagulated previously due to his GI history, and there was no plan to start anticoagulation during this admission. There was no plan for cardioversion or ablation. The patient spontaneously converted to normal sinus rhythm with oral b-blocker. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at a lower level of care in the ED.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: braces [D8080] and monthly visit [D8670]

The insurer denied coverage for braces [D8080] and monthly visit [D8670]. The denial was upheld.

This patient is a male child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, maxillary and mandibular spacing, deep bite.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated (right maxillary canine #6).  

The insurer has denied coverage for orthodontic treatment as not medically necessary.

Upon review of the submitted documentation, 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, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index.  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 claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated.  This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care.  This reviewer concurs with the findings of the insurer of attaining 11 points on the HLD index (5 points overjet, 5 points overbite, 1 point labiolingual spread).

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.

Each of the 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.  

Uphold the denial as the clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.  The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient.

The braces (D8080) and monthly visit (D8670) are not considered medically necessary for this patient. The carrier's denial of coverage for the braces [D8080] and monthly visit [D8670] is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: GPA (granulomatosis with polyangiitis)

Treatment: Immunoglobulin, CPT J1561 x13 units

The insurer denied coverage for Immunoglobulin, CPT J1561 x13 units. The denial was reversed.

This patient is a man with GPA (granulomatosis with polyangiitis). There is a history of renal and lung disease. He also has low IgG, recently 511 but as low as 446 in the past. IgG1 and IgG2 are low. This latter problem pre-dated Rituxan therapy but was made worse by it. He has received plasmapheresis and Rituxan and is currently on Cytoxan and prednisone. GFR is 56. He has dyspnea and fatigue. Coverage for treatment with IVIG has been requested.

The insurer has determined that the patient does not have a condition (Churg-Strauss) for which treatment with IVIG is supported.
 
His medical doctor has noted that he needs treatment for his lungs and kidneys due to GPA, and that he also has immunoglobulin deficiency. He has recurrent relapsing GPA and recurrent infections. 

It should be noted that for this review the diagnosis of GPA is being used. Churg-Strauss is a relative of GPA and is referred to by patient, insurer, and the Allergist, but the Rheumatologist notes indicate GPA. The patient has had IgG levels as low as 446 and has had recurrent infections. His risk of infection is high due to the low IgG plus the additional immunosuppressive effects of the treatments for GPA. 

GPA is rare and the clinical picture of relapses on multiple immunosuppressives is even rarer. There is no realistic expectation of large studies comparing alternative treatments. As noted in UpToDate, Granulomatosis with polyangiitis and microscopic polyangiitis: Treatment of Resistant Disease, IVIG is an alternative in such a case. The evidence is weak but it is weak for the other recommended option, CellCept, as well. Also, in the face of low IgG and infections CellCept would be much riskier than IVIG. IVIG in this case addresses both the patient's conditions.

The health care plan did not assess the patient's medical condition accurately, thereby misinterpreting the information. Thus they did not act reasonably in the best interest of the patient.

As noted above, IVIG is a good choice for a patient requiring treatment for resistant relapsing GPA and low IgG levels with infections. 

Based on the above, the medical necessity for Immunoglobulin, CPT J1561 x13 units is substantiated.  The insurer's denial is reversed.