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

Diagnosis: Hip Pain
Treatment: Hip arthroplasty
The insurer denied the Hip arthroplasty.
The determination is overturned.

This is a female patient with a complaint of bilateral hip pain. The patient underwent a successful left total hip arthroplasty and began experiencing similar arthritic pain in the contralateral right hip. Plain radiographs revealed moderate right hip osteoarthritis. The patient did attempt activity modifications and a home exercise program. An intra-articular hip injection did provide some temporary relief of her right hip pain. The patient had updated plain radiographs which revealed osteoarthritis of the right hip on the femoral and acetabular side with osteophytes present. The patient's orthopedic provider recommended right total hip replacement for the patient based on her failed conservative treatment and persistent function limiting right hip pain. The patient's health plan denied the surgery as not medically necessary. At issue in this case is the medical necessity of the proposed right total hip replacement surgery.

The requested health treatment of hip arthroplasty is medically necessary for this patient based upon the documentation in the provided medical records and the recommendations of the peer-reviewed literature. The records document that this patient had successful left total hip replacement surgery. She had persistent weight bearing pain in the contralateral right hip and plain radiographs confirmed osteoarthritis in the right hip as well. The patient initiated a conservative treatment program which involved activity modifications and a home exercise program. She was not able to take oral nonsteroidal anti-inflammatory drug (NSAID) medication due to prior gastric bypass surgery. In addition, an intra-articular cortisone injection for the right hip provided temporary pain relief in the involved right hip. The orthopedic provider recommended waiting 6 months after the injection to re-assess her hip pain and to avoid surgery and its inherent risk of infection after the injection. Plain radiographs revealed moderate right hip osteoarthritis. The provider planned for right total hip replacement surgery based on her failed conservative treatment and persistent pain with functional limitation. The proposed right total hip replacement is indicated and medically necessary based on the provided documentation and the peer-reviewed literature, including the American Academy of Orthopedic Surgeons (AAOS) Clinical Practice Guideline: Management of Osteoarthritis of the Hip published in 2020.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncopal Episodes
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female for which an inpatient hospitalization is under review. There was history of hypertension, hyperlipidemia, and cerebral vascular accident (CVA). The patient was walking and had a syncopal episode. She had urinated and defecated. She had neck, chest, shoulder, and upper arm pain after the fall. Vital signs and the oxygen saturation were normal. The patient had a negative evaluation for structural injury. The creatinine and electrolytes were normal. Troponins were negative. The patient remained stable. She then requested to leave against medical advice.

The proposed treatment was not medically necessary.

This patient presented with syncope, chest pain, and remained stable. There was no recurrent syncope, imminently dangerous cause (i.e., pulmonary embolism [PE]), respiratory distress, myocardial infarct (MI) / acute coronary syndrome, hemodynamic instability, cardiac disorder such as aortic stenosis / idiopathic hypertrophic subaortic stenosis (IHSS), unstable arrhythmia, syncope related serious injury, severe electrolyte abnormalities, need for prolonged intravenous medications, introduction of high-risk medications requiring in-hospital monitoring, dehydration, need for a temporary pacemaker, need for invasive monitoring, need for emergent cardioversion, or an unstable neurologic syndrome (i.e., cerebral vascular accident). In this setting, an acute inpatient level hospitalization, compared to for example observation, has not been established as standard of care towards improved cardiac outcomes. Therefore, it is considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right Hip Pain
Treatment: MRI of pelvis
The insurer denied the MRI of pelvis.
The determination is overturned.

The patient has a history of ankylosing spondylitis and degenerative joint disease (DJD). The patient is on Cosentyx 150 milligrams (mg) for management of ankylosing spondylitis (AS). The patient is having right (R) hip pain. X-rays showed mild DJD, R greater than (>) left (L), and no inflammatory arthropathy. An x-ray of the lumbar spine  showed mild to moderate DJD. Magnetic resonance imaging (MRI) of the pelvis was denied by the health plan, as the patient does have a history of sacroiliitis or a disease-causing arthritis of the spine, the patient is not on a biologic and the patient has not had x-rays done. At issue is the medical necessity of the MRI of the pelvis.

The MRI pelvis is medically necessary for this patient. The patient is having ongoing right hip pain and her provider is requesting an MRI of the pelvis to further evaluate. The patient does meet the plan's criteria for the study for the following reasons: she has a diagnosis of ankylosing spondylitis, she is on Cosentyx and she had x-rays done of the hips and lumbar spine that do not reveal the cause of ongoing R hip pain. The standard of care is to get an MRI if a patient has ongoing pain and the x-ray does not reveal the source, especially if she has a history of ankylosing spondylitis. The patient may have erosive disease causing chronic pain but there is no way to know without an MRI. Given the history of AS, she is more prone to osteoporosis and fracture, which may have been missed on an x-ray, further justifying an MRI.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: palpitations, lightheadedness, and syncope

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is an adult presented to the hospital complaining of palpitations, lightheadedness, and syncope.  She was transported to the hospital via ambulance. Paramedics noted narrow complex tachycardia at a rate of 170 beats per minute.  She was treated with adenosine and tachycardia resolved. Past medical history was significant for hypertension and gastroesophageal reflux disease.  Upon arrival to the emergency department (ED) vital signs were stable:  pulse 101 beats per minute and Blood Pressure 117/78 mmHg.  Physical examination revealed no abnormality.  Electrocardiogram (ECG) on emergency medical service (EMS) arrival revealed narrow complex tachycardia with a short RP interval. Electrocardiogram (ECG) in the emergency department revealed sinus rhythm without ST or T wave abnormalities.  Serum blood testing revealed an elevated troponin level (0.18 ng/ml). The patient was admitted for observation and treatment. Echocardiogram revealed a left ventricle ejection fraction (LVEF) of 55% without significant valvular abnormalities.  She was treated with metoprolol and discharged home with cardiology follow up.

This patient presented with narrow complex tachycardia at a rate of 170 beats per minute.  She reported an episode of syncope and several episodes of lightheadedness and near syncope. Such patients require careful evaluation with telemetry monitoring. (Reference 1) The patient also had an elevated troponin level, a known predictor for hospital admission. (Reference 2) Given symptomatic tachyarrhythmia and syncope, inpatient hospital admission was medically necessary. This patient could not have been managed at a lower level of care.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal/Other/Acute right elbow pain
Pharmacy/Prescription Drug/Pain Injection (tendon injection)

Diagnosis: Orthopedic/Musculoskeletal/Other/Acute right elbow pain
Treatment: Pharmacy/Prescription Drug/Pain Injection (tendon injection)
Summary: The health plan denied the requested Pain Injection (tendon injection) as not medically necessary. The health plan's determination is upheld.

The patient is a male who presented for an office visit with right lateral elbow pain. The patient had a prior extensor tendon sheath injection with complete resolve of the symptomatology. Physical exam of the right elbow showed no erythema, no swelling, and nontender over the medial epicondyle. The diagnoses includes a resolved right lateral epicondylitis.
At issue is the medical necessity for the requested health service/treatment of Pain Injection (tendon injection).

I uphold, in whole, the health plan's determination of medical necessity.

The health plan acted reasonably as documentation did not indicate 50% improvement in pain for at least 6 weeks from the prior similar injection. The request is not medically necessary. Documentation does not substantiate at least 6 weeks of 50% improvement from a prior similar injection.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female with a medical history of Ulcerative Colitis, sigmoid colon perforation, anemia, Clostridioides difficile, endometriosis, ovarian cyst, and myomectomy. She presented to the emergency department with abdominal pain, fever, watery bowel movements, nausea, and vomiting. She had been on cefdinir for conjunctivitis and had just initiated prednisone. Vital signs were notable for tachycardia with heart rate of 119/minute. Physical examination was notable for soft, non-distended, diffusely tender abdomen. Labs showed elevated platelet count of 416, low sodium of 133, elevated lipase of 67, elevated C-reactive protein of 98, and elevated erythrocyte sedimentation rate of 34; testing for Clostridioides difficile was negative. A Computed tomography scan of the abdomen and pelvis showed pancolitis with acute on chronic inflammatory changes compatible with Ulcerative Colitis flare.

The inpatient hospital stay was not medically necessary. The patient presented with abdominal pain fever, and diarrhea, and with imaging suggestive of Ulcerative Colitis disease flare. However, there was no complication such as intra-abdominal abscess, bowel perforation, toxic megacolon, peritonitis, severe bleeding, or sepsis, which would require the inpatient level of care. She was treated appropriately with corticosteroids, and a colonoscopy was not deemed necessary. Although her pancreatic duct appeared abnormal, there was no acute pancreatitis, biliary obstruction, or other cause for the inpatient level of care, and outpatient imaging was recommended for follow-up. The interventions performed, including labs, monitoring, imaging, Gastroenterology consultation, and corticosteroid therapy, could have been performed at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: right frontal arteriovenous malformations (AVM)
Treatment:  implantation of Vivistim paired vagus nerve neurostimulator 
The health plan denied the implantation of Vivistim paired vagus nerve neurostimulator.
The health plan's determination is overturned.

The patient is a female with right frontal arteriovenous malformations (AVM) status/post (s/p) multiple embolizations and gamma knife radiation, found to have persistent nidus s/p embolization who subsequently underwent cerebral angio embolization followed by craniectomy with resection.
She was taken back to the operating room (OR) for clot evacuation, right hemicraniectomy and left sided Intracranial pressure monitoring (ICP) bolt placement. She developed left hemiparesis and dysphagia. Cranioplasty was performed and the patient was discharged to rehabilitation.

The proposed treatment, implantation of the Vivistim Paired Vagus Nerve Stimulation System, is likely to be more beneficial than any standard treatment for the insured's disabling condition. The patient has upper extremity monoplegia due to ischemia. The patient will benefit from the treatment. Since then, the patient has completed standard of care outpatient upper extremity rehabilitation, advanced technology upper extremity rehabilitation, non-invasive brain stimulation with transcranial magnetic stimulation (TMS) with some improvement. The patient was evaluated via a telehealth visit. The magnetic resonance imaging (MRI) of the brain showed evidence of ischemia. The patient was diagnosed with monoplegia of the left upper extremity due to ischemia. There was a recommendation for implantation of the Vivistim Paired Vagus Nerve Stimulation System to treat her severe upper limb deficit.

The health plan's determination regarding the proposed treatment is overturned in whole.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: right frontal arteriovenous malformations (AVM)
Treatment:  implantation of Vivistim paired vagus nerve neurostimulator 
The health plan denied the implantation of Vivistim paired vagus nerve neurostimulator.
The health plan's determination is upheld.

The patient is a female with a history of an intracranial arteriovenous malformations (AVM) that has been treated with embolizations, radiation and surgery. She has a left arm monoplegia as a result of an embolization. The neurologic examination shows plegia in the left arm. The provider has recommended a vagus nerve stimulator (VNS).

The VNS procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. While this is a promising technology, further studies with larger groups and longer follow up is cited in the literature. Dawson et al. cite, "Long-term loss of arm function after ischaemic stroke is common and might be improved by vagus nerve stimulation paired with rehabilitation. Vagus nerve stimulation paired with rehabilitation is a novel potential treatment option for people with long-term moderate-to-severe arm impairment after ischaemic stroke".
Liu et al. cite, "The study suggested that VNS combined with rehabilitation therapies offers improving benefits, tolerance and prospect for upper extremity (UE) recovery after stroke. Transcutaneous Auricular Vagus Nerve Stimulation (Ta-VNS) technology can reduce the stroke symptoms, providing an alternative technology for patients with stable stroke who are reluctant to opt for other invasive treatments. However, better-designed randomized controlled trials (RCT's), large samples, follow-up and various measures to reflect the restoration of function are needed to confirm our findings in future studies". Zhao et al. cite, "This study revealed that VNS paired with rehabilitation can facilitate the recovery of upper limb function in patients with stroke on the basis of Fugl-Meyer Assessment of Upper Extremity (FMA-UE) scores, but the long-term effects remain to be demonstrated".
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

Per clinical documentation, this patient presented to the emergency department with right upper quadrant abdominal pain. Vital signs in the emergency department (ED) were within normal limits. The patient was afebrile. Abdominal ultrasound demonstrated findings most consistent with chronic cholecystitis. White blood cell count was elevated to 13.0. The patient underwent a laparoscopic cholecystectomy. There were no reported complications. There is no further clinical documentation of a need for inpatient admission. Per Milliman Care Guidelines (MCG) criteria, admission is indicated when common bile duct obstruction is indicated via imaging and there are signs of systemic inflammation [7]. Peer-reviewed literature and MCG criteria indicate that inpatient admission is not necessary in this circumstance. Per provided clinical documentation, inpatient admission was not medically necessary. Observation status would be more appropriate. 

Acute cholecystitis and biliary complaints are common inpatient diagnoses. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions [1]. Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay [2, 4, 5]. Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting [3]. In patients without abnormalities of the bile duct or abnormal liver function tests (elevated alkaline phosphatase (ALP) and total bilirubin), ambulatory laparoscopic cholecystectomy is safe and feasible [5, 8]. A 50% increase in the liver function tests can be labelled as mild elevation and is considered negligible by many. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld


 
Diagnosis: Abdominal Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The insurer has denied coverage for an inpatient. In their Final Adverse Determination letter, they write that the patient had belly pain, nausea, and vomiting. They were not unstable. There is no report of any serious or severe findings. The insurer denied this service based on MCG (Milliman Care Guidelines) 26th Edition, Abdominal Pain, Undiagnosed.

In an appeal letter, the hospital writes that the patient was admitted for further evaluation and management for abdominal pain and that a 2.3-centimeter hypo enhancing lesion in the left kidney was concerning for neoplasm. The patient received the antibiotic ciprofloxacin. A repeat CT (computed tomography) scan of the abdomen and pelvis was performed after the infection resolved and the patient was discharged.

The patient presented with abdominal pain and vomiting. At the time of admission the patient was afebrile, and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. The liver enzymes were elevated. An abdominal ultrasound showed hepatic steatosis. Proton Pump Inhibitor (PPI) therapy was given, and hepatitis serology was ordered. A computed tomography (CT) scan showed a kidney density. The urologist advised that no acute interventions were needed but that antibiotics should be given. A follow up CT scan was advised after the treatment with antibiotics. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-05 for Undiagnosed Abdominal Pain. Clinical indications for admission include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, and bacteremia. The patient did not have these conditions. 

This patient had abdominal pain and was diagnosed with an infection in their urinary tract. This could have been treated with a course of oral antibiotics as an outpatient. No acute interventions were needed. The abdominal scans could have been obtained with observation status. The patient was not in acute liver failure and the liver enzymes could have been monitored as an outpatient. The patient did not meet MCG criteria for admission for Undiagnosed Abdominal Pain. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. The denial is upheld.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Penile swelling and bloody discharge
Treatment: Inpatient admission
The health plan denied inpatient admission. The denial is upheld.

The patient is an adult male. He presented to ER (emergency room) with penile swelling.

The patient was afebrile and hemodynamically stable. Ultrasound showed fracture. He underwent a repair. He was admitted overnight after surgery. There were no postoperative medication. He was discharged home the next day.

The majority of patients who present with pile fracture can be discharged within 24 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. The procedure performed is considered a minimally invasive outpatient procedure and as such in the absence of a "high risk surgical patient" does not warrant acute inpatient care. The information provided and the patient's perioperative clinical status does not suggest the need for acute inpatient care. A lower level of care status for this patient's clinical presentation and post-operative course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.