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

Cardiac/Circulatory Problems
Inpatient Hospital

The patient is a male with a history of hypertension, hyperlipidemia, diabetes, morbid obesity, coronary artery disease, and multiple percutaneous coronary interventions (PCIs). He presented to the emergency department complaining of two weeks of worsening dyspnea and chest pain with minimal exertion. He had recently undergone PCIs. His cardiologist instructed him to report to the emergency department for admission for cardiac catheterization due to recurrent symptoms.

In the emergency department his blood pressure was 140/77 millimeters of mercury (mmHg) with a heart rate of 64 beats/minute. His room air oxygen saturation was 96%. His cardiac exam was unremarkable. His serum troponin level was normal. There were no acute electrocardiographic changes. Chest X-ray was unremarkable. Coronary angiography showed a 30% distal left main coronary artery stenosis, mild in-stent restenosis in the proximal left anterior descending coronary artery with patent stents in the mid and distal vessel, total in-stent restenosis in the diagonal artery that was noted on prior catheterization, luminal irregularities in the left circumflex artery and patent stents in the right coronary artery. No percutaneous intervention was warranted. The post-catheterization note  indicates that the patient could be discharged that day. He was discharged the next day. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld.

An inpatient stay was not medically necessary. This patient, with known coronary artery disease, presented with symptoms that were suspicious for unstable angina. He was hemodynamically stable, with a normal serum troponin level. He had no acute electrocardiographic changes. Urgent cardiac catheterization was performed and showed no acute lesions or critically stenosed lesions that required intervention. The procedure was uncomplicated. The post-procedure note indicates that same-day discharge would have been appropriate. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be both 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: Upheld

Cardiac/Circulatory Problems
Durable Medical Equipment (DME) (including Wearable Defibrillators)

Diagnosis: ventricular tachycardia 
Treatment: Zoll LifeVest. 
The insurer denied the Zoll Lifevest. The health plan's determination is upheld. 

The patient is a man with a history of hypertension, hyperlipidemia and alcohol abuse. He lost consciousness while driving. Paramedics arrived and his initial rhythm was sustained ventricular tachycardia requiring electrical cardioversion. He was transported to the emergency department where he had multiple episodes of sustained and non-sustained torsades de pointes.
Coverage for the LifeVest is at issue.

Based on the medical records provided, the LifeVest wearable cardioverter defibrillator was not medically necessary. The LifeVest wearable cardioverter defibrillator (WCD) is an external device often used as a bridge to implantable cardioverter defibrillator (ICD) implantation in patients with contraindications to immediate implantation (such as infection) or those with recent myocardial infarction or newly diagnosed nonischemic cardiomyopathy and left ventricular ejection fractions of 35% less. It is not intended as a replacement for the ICD for use in secondary prevention of sudden cardiac death. Unlike the ICD, one of the largest barriers to the overall effectiveness of the WCD, is lack of compliance. Even compliant patients cannot wear the device 100% of the time as it must be removed for bathing. Unlike with the ICD, there are no data, that long-term use of the WCD improves cardiovascular outcomes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Lower extremity pain and tremor. 
Treatment:  Inpatient stay.
The health plan denied the inpatient stay.  The denial was upheld.

The patient is a male with a history of heart failure, cerebrovascular accident, atrial fibrillation on anticoagulation, chronic lower extremity edema, and obesity.  He presented to the hospital with left lower extremity pain and tremor.  Labs demonstrated a creatinine 1.5, sodium 129, potassium 2.6, international normalized ratio 3.0, troponin 0.077, and white blood cell count 20,500.  The electrocardiogram showed sinus rhythm with no acute ischemic changes.  Lower extremity Dopplers demonstrated superficial vein thrombosis of the greater saphenous vein and branches.  Intravenous antibiotics were provided for site colitis.  Potassium supplementation was administered intravenously and orally.

The patient did not fail outpatient antibiotic treatment and did not have bacteremia, altered mentation, necrotizing fasciitis, need for surgical intervention, or osteomyelitis.  The patient's hypokalemia is not accompanied by evidence of muscle weakness, arrhythmia, or electrocardiographic changes.  There was no evidence of seizure activity.  The patient was known to have chronic lower extremity edema.  The patient was hemodynamically stable and afebrile.  The patient had only superficial venous thrombosis and no evidence of deep venous thrombosis.  The patient had only a mild degree of acute kidney injury and did not have uremia, hyperkalemia, or volume overload.  Dialysis was not required.  In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive System/Gastrointestinal
Treatment: Inpatient Stay
The insurer denied: Inpatient Stay
The denial is: Upheld in whole.

The patient is a male with a history of diabetes, hypertension, and alcohol abuse. He presented to the emergency room with tremors, nausea, and vomiting after drinking heavily for the past several days but stopping the previous night. He was afebrile, but his vital signs were notable for a blood pressure of 188/102. He was well appearing, in no acute distress, and oriented x 3. The physical exam was otherwise unremarkable; no tremor was noted, and his mental status was normal. Labs were notable for a glucose of 238, and a hemoglobin 12.5 grams per deciliter (g/dl). The ethanol level was less than 10 milligrams per deciliter (mg/dl). The chest x-ray and electrocardiogram (EKG) were non-contributory. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with vitamins, insulin, and hydralazine. He was observed using the Clinical Institute Withdrawal Assessment (CIWA) protocol. The following day, he had no complaints and was discharged to home. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole. 

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints. The services provided during the acute care stay could have been safely and efficiently provided at a lesser level. Therefore, based on the standard of care and peer reviewed literature, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Episodic cluster headaches.
Treatment:  Emgality (300MG Dose) 1000MG/ML SC SOSY.

The insurer denied the Emgality (300MG Dose) 1000MG/ML SC SOSY.  The denial is upheld. 

The patient is a male with cluster headache disorder.  He has tried and failed topiramate, verapamil 240 mg daily and metoprolol for preventive therapy.  

No, the requested Emgality is not medically necessary. 

Although the patient has been treated with the preferred agent, the dose was not in the therapeutic range for cluster headache prevention.  In both randomized controlled clinical trials demonstrating the efficacy of verapamil for cluster headache prevention, 360 mg/day was used.  Moreover, open-label studies have demonstrated that the efficacy of verapamil to prevent cluster headache is a dose-dependent effect.  There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Emgality relative to verapamil 360 mg per day.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Vertigo
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

This patient with a past medical history (PMH) of asthma, coronary artery disease (CAD), diabetes mellitus type 2 (DM2), hypertension (HTN), coronary artery disease (CAD) status/post (s/p) stent placement, rheumatoid arthritis (RA) and syncope was admitted with complaints of (c/o) a four to five day history of vertigo associated with standing. Vital signs were unremarkable. The physical exam notable for no apparent distress (NAD), no focal neurologic deficits. Lab work was remarkable for negative cardiac enzymes. A chest x-ray (CXR) showed no acute pathology, a computed tomography (CT) scan of the head showed no acute intracranial abnormality. An electrocardiogram (EKG) showed sinus tachycardia. The patient was diagnosed with vertigo and treated with IV fluids, meclizine, benzodiazepines (BZDs) and anti-emetics. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with a several-day history of dizziness and vertigo associated with nausea and vomiting. The patient did not have any acute hearing loss, double vision, fixed neurologic deficits, severe headache, associated head trauma, fever, high clinical suspicion for central vertigo or cerebrovascular accident (CVA), cerebellar infarct or hemorrhage, vertebrobasilar insufficiency, acute suppurative labyrinthitis, intractable nausea/vomiting or inability to ambulate. The patient was treated with IV fluids and responded well, with symptomatic improvement, to meclizine and anti-emetics, while receiving a thorough imaging and biochemical work-up. Given the patient's clinical stability and provided interventions and clinical monitoring, these could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient hospital

Diagnosis: GI Bleed
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male with a medical history of obesity, diabetes mellitus type 2, hypertension, hyperlipidemia, obstructive sleep apnea, and gastritis. He presented to the emergency department with diarrhea for five days and new onset of bright red hematochezia. He was noted to be on aspirin daily and 3-4 tablets of Advil per week. Vital signs were unremarkable. Physical examination was notable for soft abdomen, and rectal exam showed no mass or hemorrhoids. Labs showed low hemoglobin of 11.5 g/dL and hematocrit of 36.7%. He was treated with intravenous famotidine and continued on oral pantoprazole. Gastroenterology consultation concluded that there was diverticular bleeding, outlet bleeding, ischemic colitis, or infectious colitis; the recommendation was clear liquid diet, bowel preparation, nil per os (NPO) after midnight, and colonoscopy bowel preparation.

The inpatient hospital admission was not medically necessary. In this case, the patient presented with hematochezia, consistent with lower gastrointestinal bleeding. However, there was no sustained tachycardia or hypotension, and no significant visible ongoing gastrointestinal bleeding; the hemoglobin remained stable. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset. Gastroenterology performed a colonoscopy, which was appropriate but did not show any ongoing bleeding. Although a colitis was found, there was no evidence of toxic megacolon, perforation, or other complications which would warrant the inpatient level of care. The standard of care for lower gastrointestinal bleeding and colitis was performed, and all of the measures that were undertaken, including monitoring, Gastroenterology consultation, and colonoscopy, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This patient with a past medical history of asthma who presented to the emergency room (ER) with shortness of breath, a cough, and wheezing. She had associated left sided chest pain/spasms. Her peak flow prior to treatment was 150. She was noted to have wheezing on exam. She had some accessory muscle use and a prolonged expiratory phase. She had been hospitalized once before for asthma, but never been intubated. She had no fever.
The patient was admitted for an asthma exacerbation. She was given nebulizer treatments, intravenous (IV) magnesium, and IV SoluMedrol. She improved and was discharged on oral steroids along with nebulizer treatments.
The patient's initial vital signs were: temperature 97.5 degrees Fahrenheit, heart rate (HR) 110, respiratory rate (RR) 18, blood pressure (BP) 104/65, and oxygen saturation 96% on room air. Her lab results and chest x-ray were normal. A ventilation-perfusion (V/Q) scan showed no pulmonary embolism (PE).
At issue is the medical necessity of at an inpatient stay.
This patient's hospitalization was medically necessary at an inpatient level of care. The patient presented with an acute asthma exacerbation, with diffuse wheezing and accessory muscle use on exam. Normal peak flow for a female of age 53 and 69 inches tall is approximately 430. The patient's pre-treatment peak flow in the ER was 150. This can be classified as a severe asthma exacerbation. According to an American Family Physician (AFP) article on the management of acute asthma exacerbations, patient's who have severe asthma exacerbation "Usually requires emergency department visit and likely hospitalization".
Per the Milliman Care Guidelines, 23rd edition, for Asthma, the patient did meet inpatient criteria. She had a respiratory findings (dyspnea, accessory muscle use) that persisted despite emergency room treatment. Furthermore, her peak expiratory flow rate was only 35% of predicted pre-treatment. Per the guidelines, less than 25% pre-treatment, or less than 40% post-treatment, are indications for hospitalization. A post-treatment peak flow was not recorded.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecomastia
Diagnosis: Mastectomy
The health plan has denied Mastectomy

Determination:
The health plan's denial is upheld.

The patient is an adult male. He has large breasts following weight loss. His large breasts make him uncomfortable. Mastectomies for gynecomastia are planned. Photos show a male with Grade III gynecomastia.

The mastectomies are cosmetic. The patient has gynecomastia, but the records do not document any health or functional problems caused by the enlarged breasts. There is no documentation of an endocrine evaluation and exclusion of an endocrine cause. There is no documentation of a concern for a breast malignancy, and there are no diagnostic studies provided. Gynecomastia is a benign condition that does not cause health or functional problems.  

According to a 2009 review article from the Mayo Clinic, "Overall, gynecomastia is a benign condition and is usually self-limited. Over time, fibrotic tissue replaces symptomatic proliferation of glandular tissue and tenderness resolves. If the appropriate work-up does not reveal considerable underlying pathology, reassurance and periodic follow-up are recommended...Patients with gynecomastia have a favorable prognosis. These patients present with 2 main concerns: ruling out breast cancer and cosmetic correction. The first concern is adequately addressed by following the appropriate diagnostic evaluation. Breast cancer is rare in males, representing less than 1% of all cases of breast cancer; only 1% of mammograms in men reveal breast cancer.  Therefore, the decision to treat and the choice of treatment should be based on the degree to which this condition has affected the quality of life and mental health of patients and on their desire for cosmetic correction."  

The records do not provide any evidence of a concern regarding breast cancer. The procedure will primarily improve appearance and self-esteem and therefore is cosmetic and not medically necessary. Observation, reassurance and use of analgesics as needed are reasonable management approaches for this condition. The patient is likely to derive emotional benefit from the surgery, but his physiologic health will not be improved.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The Inpatient admission was not medically necessary.

The patient is a male. He was admitted with a febrile urinary tract infection/prostatitis. 

The patient's vitals were 102-127-16-112/70.  The WBC (white blood cell) count was 13,980.  The urinalysis had nitrites and leukocyte esterase.  CT imaging was consistent with cystitis/prostatitis.  IVF (IV fluids) and IV antibiotics were started.

On the day after admission (day #1), the patient's Tmax (maximum temperature) was 101.1.  IVF and IV antibiotics were administered.

On Day #2, the patient had headaches.  IVF and IV antibiotics were administered.  Cultures were negative.

On Day #3, the patient was seen by infectious disease.  Pyelonephritis was suspected and a renal ultrasound ordered.  Antibiotic therapy was changed to oral levofloxacin.  The Tmax was 100.9. The WBC count was 6190.

On Day #4, oral levofloxacin was continued.
  
On Day #5, the patient was discharged home.

Treatment of uncomplicated pyelonephritis/prostatitis with IV antibiotics did not require an acute inpatient level of care.   He did not have complicating features such as obstruction, abscess or immunosuppressed status.  IV antibiotics can be administered at an observation level of care in hemodynamically stable patient with an appropriate response to antimicrobial therapy.  There were no compelling reasons to support an acute inpatient level of care, as he was medically stable throughout the hospital stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headaches
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The Inpatient admission was medically necessary.

The patient is a female with history of headaches and grade III papilledema. She underwent angiogram with venous sinus stenosis.

Yes, the use of venous sinus stenting (VSS) has been shown in several studies to be an appropriate treatment option for patients such as this one who have idiopathic intracranial hypertension (IIH)... Inpatient stay after Venous sinus standing is appropriate and medically necessary. There is approximately 5-10% risk of postoperative complication, such as hemorrhage or stroke, and this requires close observation in acute inpatient level of care. This cannot be done in lower level of care, and therefore, the admission was medically necessary.

The literature supports this. "Stenting of VSS is safe and results in reduction of intracranial pressure in patients with IIH. This is associated with improvement in papilledema, RNFL thickness, VF parameters, and symptoms associated with intracranial hypertension" (2).  "VSS for patients with IIH with venous sinus stenosis is now an established and effective treatment option" (1).

The procedure and associated admission have become an established care pathway, and it should be approved. The procedure has been shown to be safe and effective. Therefore, the Inpatient admission should be covered by the health plan, per above.
Appeal type: Medical necessity
Decision: Upheld

Obesity
Surgical Services  (All)

This patient is a female who weighs 200 pounds giving a body mass index of 39.1 kg/m2. Weight related co-morbid conditions include: gastroesophageal reflux disease (GERD) and pre-diabetes. Psychological clearance was obtained. Medical clearance was obtained. Dietary clearance was obtained. The patient completed several months of supervised weight loss efforts. A Laparoscopic Sleeve Gastrectomy is being requested and is under review.

The health plan's determination is upheld. The Laparoscopic Sleeve Gastrectomy is not medically necessary for this patient. This patient has a body mass index (BMI) (ranging from 39.1 to 38.5 kg/m2) which is less than 40 kg/m2 and greater than 35 kg/m2 but is without any serious obesity related co-morbid conditions. This patient does not have documentation of diabetes, hypertension or sleep apnea. Bariatric surgery is indicated for primary treatment of morbid or clinically severe obesity which is not documented for this patient at this time. Therefore, the requested procedure is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Teeth Spacing Problem
Dental/Orthodontic Procedure

The patient in question is a female with a bilateral posterior crossbite. She has moderate crowding in the lower and severe crowding in the maxilla. Teeth number (#) 7 and 10 are in anterior crossbite. She is treatment planned for orthodontics to correct her crossbite. This is under review.

The health plan's determination is overturned. Braces are medically necessary for this patient.

This patient presents with a posterior crossbite, crowding, and constricted arches. She would be an excellent candidate for orthopedic rapid maxillary expansion to assist with orthodontic correction. Such a procedure can only be performed before the patient reaches skeletal maturity, otherwise the ability to achieve orthopedic expansion is greatly reduced. Given that the patient is a young teenager, and skeletal maturity in females usually occurs around 15-16 years old, she is nearing the end of the time that orthodontics alone can correct her crossbite. Therefore, the braces are medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Inflammatory bowel disease
Issue under review:  PCR testing for GI pathogen

Determination:
The PCR testing for GI pathogen was not medically necessary.

The patient is an adult male with a history of IBD (inflammatory bowel disease). He presented with bloody diarrhea.  His MD ordered stool gastrointestinal pathogen panel via nucleic acid.

The patient had bloody diarrhea, and his treating provider was concerned about an infectious etiology.  The standard of care is to check stool for infectious etiologies via cultures.  The requested gastrointestinal pathogen panel by nucleic acid has not been shown in the medical literature to be more effective than conventional stool studies in the evaluation of bloody diarrhea.

The PCR testing for gastrointestinal pathogen is not of proven benefit.  It is not generally recognized by the medical community as effective and appropriate for the diagnosis or treatment of the patient's particular condition, bloody diarrhea. 

As further studies are needed to determine if gastrointestinal pathogen panel by nucleic acid is effective for the diagnosis of bloody diarrhea, it is unproven and not medically necessary for this patient, and the plan appropriately denied it.