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

Diagnosis: Hip Pain
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is overturned.

The patient underwent an elective left total hip arthroplasty via posterior approach. The patient's comorbidities include hypertension, obstructive sleep apnea, and obesity (body mass index (BMI) 37.1). The operative report states that the procedure went well without complications. The patient was transferred to the recovery room in stable condition. There is a daily note stating that the patient's pain was rated 6/10. The provider states that the inpatient level of care is necessary for this patient due to the comorbidities. At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary. In this case, the patient underwent a right total hip arthroplasty. The patient has significant comorbidities that include hypertension, obstructive sleep apnea, and obesity. The Milliman Care Guidelines (MCG) criteria for hip arthroplasty recommend inpatient status for patients with comorbidities that require more prolonged postoperative treatment or monitoring. Given the significant comorbidities, inpatient surgery is consistent with standard of care. Additionally, the MCG criteria for hip arthroplasty recommend ambulatory surgery patients receive appropriate perioperative clinical care and support with use of specific clinical care pathways. There is no indication that the patient had appropriate perioperative clinical care and supports with the use of specific clinical care pathways to support ambulatory surgery. Therefore, the inpatient stay was medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Uterine Fibroids
Treatment: Surgery (ablation with imaging guidance (0404T)
The insurer denied the Surgery (ablation with imaging guidance (0404T).
The denial is upheld.

The patient is a female with uterine myomas. She has been recommended to undergo imaging guided radio frequency ablation of the myomas.

No, the health plan should not cover the requested health service.

There are no data from large, long-term, prospective studies to show that the use of image-guided radio frequency ablation of myomas is better or safer the other treatment options. It is not standard of care and not supported preferentially over other options by professional organizations.

There are no data from large and prospective studies with long-term follow up to show that the use of image guided radio frequency ablation of fibroids is better or safer than other options, including myomectomy or hysterectomy.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Uterine Fibroids
Treatment: Surgery (ablation with imaging guidance (0404T)
The insurer denied the Surgery (ablation with imaging guidance (0404T).
The denial is overturned. 

The patient is a G4P2022 (4 pregnancies, 2 term births, 0 preterm births, 2 abortions, 2 living children) female.  She was seen for a long history of menorrhagia and pelvic discomfort.  She is currently premenopausal and does not desire hysterectomy and has declined at least one form of medical therapy for her condition.  Workup revealed ultrasound measuring 10.5 x 9 x 9.45 cm (centimeters) with three myomas approximately 4 x 4, 4 x 3, and < (less than) 1 cm (centimeters).

The patient's practitioner requests authorization to perform transcervical radiofrequency ablation therapy of the myomas.  The health plan contends that the treatment is not medically appropriate because insufficient evidence exists for improvement of health outcomes and cites its medical policy on Uterine Fibroid Ablation Surgery 00077.  The practitioner contends that the procedure is effective and submitted several articles and cites MCG (Milliman Care Guidelines) 25th edition criteria that support the use of the procedure if the patient is premenopausal, symptomatic, desires uterine conservation, and has demonstration of the myomas on imaging.

Yes, the health plan should cover the requested health service.

In addition to the large list of articles provided by the applicant demonstrating efficacy of the procedure, and the MCG criteria, there is other support for the utilization of this procedure in this patient.  The American College of Obstetricians and Gynecologists has published a practice bulletin addressing methods for treatment of symptomatic uterine leiomyomata in which it presents evidence that transcervical radiofrequency ablation is effective and can be used for treatment of this condition and that there are no good comparative studies regarding different modalities for treatment, so that shared decision making between patient and practitioner should govern the choice of treatment.

Additionally, based on the ultrasound documentation in the medical records, uterine preservation is desired; the patient's fibroids are less than 10 cm (centimeters) in any diameter; and the patient's uterine size is less than 15 weeks.

Therefore, given the above, the treatment should be covered, as it is medically appropriate.

Yes, because the treatment requested is considered standard treatment for the condition.

The consensus in the ACOG (American College of Obstetricians and Gynecologists) practice bulletin is that there are no good comparative studies between different modalities of treatment, so shared decision making between patient and practitioner should govern the choice of treatment. However, the proposed treatment is considered standard treatment for the condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure. 
Treatment: Inpatient admission. 

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

This male patient with multiple medical conditions including alcohol abuse, diabetes, hypertension, and seizures presented after a witnessed seizure.  He is reported to have had three seizures this month.  It is unclear if the patient is compliant with seizure medications. 

The patient's vital signs (VS) were as follows: temperature 98.8, pulse 133, respiratory rate 19, blood pressure 111/70, and oxygen saturation 96%.  Exam was remarkable for postictal.  Labs revealed the following: sodium (Na) 237, potassium (K) 3.0, blood urea nitrogen (BUN)/creatinine (Cr) less than (<) 4/0.9, white blood cell (WBC) 8.72, hemoglobin/hematocrit (H/H) 11.8/353, and alanine aminotransferase (Alt) 77. His chest x-ray showed no acute disease (NAD).  His electrocardiogram (EKG) showed sinus tachycardia, no acute changes.  The patient's head computed tomography (CT) revealed no acute disease (NAD).  Keppra was loaded in the emergency room (ER).  The patient was admitted.  His plan of care include intravenous fluids and Keppra. 

On day two, the patient's vital signs were stable (VSS).  The patient admitted to noncompliance with Keppra.  Neurology was consult on day three and recommended magnetic resonance image (MRI) of brain to better define linear intensity, electroencephalography (EEG), and home dose of Keppra.  On day four, the patient's vital signs were stable.  He was cleared by Neurology for discharge.  On day five, the patient was discharged. 

No, the proposed Inpatient Hospital Admission was not medically necessary. 

This patient was admitted after a witnessed seizure due to medication noncompliance.  The patient was hemodynamically stable.  There were no focal neurological findings on exam.  Imaging did not show acute pathology.  He did not have signs of acute alcohol withdrawal.  He did not have recurrent seizures while in the emergency department (ED).  He had not failed a lesser level of care and there was no indication for an inpatient level of care to resume anti-epileptic medication.  An electroencephalography (EEG) was not performed during the hospital stay.  The patient was clinically stable and remained stable during his hospital stay.  He did not receive intervention that required an acute inpatient level of care.  The proposed treatment is not medically necessary. 

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted tooth covered by bone, Tooth 16

Treatment: D7240 extraction of impacted tooth covered by bone, Tooth 1 and D7240 extraction of impacted tooth covered by bone, Tooth 16

The insurer denied coverage for D7240 extraction of impacted tooth covered by bone, Tooth 1 and D7240 extraction of impacted tooth covered by bone, Tooth 16.

The denial is overturned.

According to the documentation submitted, this is the case of a patient with dental concerns.  Oral and Maxillofacial Surgery Specialist requested authorization for D7240 extraction of impacted tooth covered by bone, Tooth 1 and D7240 extraction of impacted tooth covered by bone, Tooth 16. 

The plan acted on their guidelines for removal of teeth. The guidelines are not the standard of care.

The American Association of Oral and Maxillofacial Surgeons (AAOMS) advocates practicing evidence-based medicine and dentistry. The data published and becoming available support what many of us practice on a day-to-day basis. This paper provides support that "asymptomatic" does not indicate "disease free" when referring to third molars. Third molars should be carefully assessed clinically for evidence of pathology even in the absence of symptoms. The AAOMS Parameters of Care states that an impacted third molar that is so positioned that it will probably not erupt by the middle of the third decade constitutes pathology with dental and medical consequences. To limit known risks and complications associated with surgery, it is medically appropriate and surgically prudent to remove impacted third molars before the middle of the third decade and prior to complete root development.

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

The insurer's denial of coverage for D7240 extraction of impacted tooth covered by bone, Tooth 1 and D7240 extraction of impacted tooth covered by bone, Tooth 16 is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Discogenic low back pain

Treatment: Lumbar fusion/arthrodesis

The insurer is denied coverage for lumbar fusion/arthrodesis.

The denial is overturned. 

This male patient has a history of severe lower back pain radiating to the lower left extremity.

The patient has exhausted extended conservative treatment to include physical therapy with continuous daily prescribed exercises, weight loss management, activity modifications, work modifications, epidural steroid injections and medications with worsening of pain and decreased tolerance of his activities of daily living. His symptoms of severe low back pain with translation, bending and lifting are consistent with his lumbar MRI [magnetic resonance imaging] that shows significant degenerative disc disease at L5-S1 with Modic changes. He has no other findings on MRI that would cause his severe back pain and discogram is not needed. He does not have any diagnoses of mental illness, drug abuse or smoking that would preclude him from surgery. He has no leg pain and has no neurological deficits. The requested surgery meets InterQual guidelines as well as generally accepted standards of care and the CPT [current procedural terminology] codes are medically necessary.

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

The carrier's denial of coverage for lumbar fusion/arthrodesis is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pediatric drug ingestion/overdose

Treatment: inpatient level of care

The insurer is denied coverage for inpatient level of care

The denial is upheld. 

This male patient has no significant medical history. 

Based on the clinical information provided for review and MCG policy P-150 Drug Ingestion or Overdose, Pediatric, coverage criteria are not met.  The patient presented s/p [status post] ingestion of unknown quantity of metoprolol, atorvastatin, and aspirin.   The patient was noted to have emesis x 1 and tachycardia.  He was admitted to telemetry for close monitoring of potential cardiovascular compromise from metoprolol.  However, the patient was monitored without significant complication and documentation did not show presence of hemodynamic instability, dangerous arrhythmia, respiratory abnormalities, concern for prolonged toxicity due to substance ingested, need for psychiatric evaluation to clear for discharge, inability to maintain oral hydration despite observation care, toxic drug level that persists despite observation care or necessitates ongoing treatment beyond the observation care time frame; or need for treatment (eg, lipid emulsion therapy, prolonged infusion of antidote, sodium bicarbonate) necessitating inpatient care.  Therefore, the care needs could have been safely met at a lesser level of care such as observation and this admission was not medically necessary.

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

The carrier's denial of coverage for inpatient level of care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Canine malocclusion.
Treatment:  D8080 Braces and D8670 Monthly Visits, Pre-service.

The insurer denied the  D8080 Braces and D8670 Monthly Visits, Pre-service.  The denial is upheld.

The patient is a female with Class II skeletal and canine malocclusion. She has a deep bite and buccal crossbite on the upper left posterior of tooth #13. 

The reason for denial was that the patient did not a have high enough score on the Handicapping Index.  The appeal is because the crossbite is being called a "handicapping malocclusion".

No, the proposed braces and monthly visits are not medically necessary.

The patient does not have a "handicapping malocclusion" in that it does not cause speaking or eating problems. The patient also did not reach a score of 26 on the index scale.  This is the standard score needed to indicate necessity.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, Knee.

Treatment outpatient procedure code 27447 x (times)1, knee replacement surgery.

The insurer denied coverage for outpatient procedure code 27447 x1, knee replacement surgery.

The denial is upheld.

This is a patient with a history of morbid obesity, osteoarthritis, diabetes, hyperlipidemia, hypertension, and sleep apnea. She presented to the Orthopedic Surgeon's office for a preoperative visit for a right total knee arthroplasty (TKA). The patient reported 10 out of 10 right knee pain. She has tried and failed oral (PO) And injectable medications. She also tried and failed physical therapy (PT). The patient was offered preoperative nutrition counseling. The physician recommended a right TKA arthroplasty to treat severe osteoarthritis. 

The scientific literature has reported an increased rate of complications in people who undergo surgery and are morbidly obese. There are problems with exposure, increased risk of infection and necessity to treat underlying comorbidities. Current recommendations are focused on weight reduction prior to elective surgery. There should be documentation of nutritional counseling, specific weight loss goals and possible bariatric surgery. 

The facts were the patient was evaluated on one occasion with a BMI  (body mass index) of 47.55. She returned at a later date to schedule surgery with no change. There was a report of discussion for weight loss, but none documented. 

There would be no extenuating circumstances to proceed with elective surgery without a documented treatment plan and defined weight loss. 

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

Outpatient procedure code 27447 x1, knee replacement surgery is not considered medically necessary for this patient.

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

The insurer's denial of coverage for outpatient procedure code 27447 x1, knee replacement surgery is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac Ischemia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient is a gentleman that presented to the hospital complaining of palpitations and shortness of breath for a four-day period. The past medical history was significant for hypertension, diabetes and systolic congestive heart failure, with a left ventricular ejection fraction (LVEF) of 20-25% (percent). Upon arrival, the patient was hypotensive at 84/41 millimeters of mercury (mmHg) and his heart rate was 120 beats per minute (bpm) and irregularly irregular. On physical exam, the patient was dyspneic and diaphoretic. A 12-lead electrocardiogram (ECG) revealed atrial flutter with rapid ventricular rate and a prolonged QTc (interval on ECG) interval of 536 milliseconds (msec). Serum blood testing revealed an elevated troponin of 0.17 nanograms/milliliter (ng/ml), a brain natriuretic peptide (BNP) of 3500 and an elevated creatinine level. The patient was admitted to the hospital for treatment. Telemetry revealed atrial flutter with periods of 1:1 atrioventricular (AV) conduction. Ultimately, the patient required transfer to another institution for additional care.

Patients presenting with atrial arrhythmia and ventricular rates up to 130 require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days (1). This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. The current standard of care is consistent with hospital admission when patients present with symptomatic, rapidly-conducted atrial fibrillation.

This patient presented with shortness of breath, atrial flutter with rapid ventricular rates and hypotension with a systolic BP (blood pressure) of 84 mmHg. ECG and troponin levels were consistent with a diagnosis of non-ST (interval on ECG) elevated myocardial infarction (NSTEMI). He appropriately underwent cardiac catheterization prior to discharge (2). In addition, the patient had a prolonged QT (interval on ECG) was treated with sotalol. The American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for the management of atrial fibrillation recommend careful telemetry monitoring for patients treated with class III antiarrhythmic agents as QT prolongation can lead to ventricular arrhythmia and even sudden cardiac death (3).

Based on the above, acute inpatient admission was medically necessary to treat this patient and ensure that he was on appropriate medical therapy for cardiac ischemia, atrial fibrillation, hypotension and QT prolongation on ECG.

The health plan did not act reasonably, with sound medical judgement or in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This patient presented to the hospital following a syncopal episode. She noted confusion and lip twitching upon arrival. Past medical history was significant for diabetes mellitus, hypertension and cerebral vascular accident (CVA) without residual deficit.  Of note, the patient reported an unexpected death in the family early that day, just preceding the onset of syncope. In the emergency department (ED), vital signs were stable, blood pressure 145/84 with a pulse of 83. Physical examination was within normal limits and no deficits were noted on neurological examination. The patient was not orthostatic.  12 lead electrocardiogram revealed normal sinus rhythm without abnormality. Serum blood testing and computed tomography (CT) head were also within normal limits. Echocardiogram demonstrated a preserved left ventricular ejection fraction without valvular abnormalities. The patient was ultimately discharged with a diagnosis of neural reflex syncope.

The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with syncope that occurred after hearing about the death of a family member.  She presented to the hospital for evaluation and treatment. Upon arrival to the hospital, vital signs, physical examination and electrocardiogram were all normal.  CT head revealed no evidence of intracranial pathology.  Echocardiographic study revealed a structurally normal heart.  Serum blood testing revealed no abnormalities.  The patient was discharged the following day. This patient presented with neural reflex syncope, a benign process.  

According to the European Society of Cardiology, this patient was a low risk patient for future morbidity and mortality. (Reference 1) In a study of individuals presenting to the emergency room, patients that were low risk or intermediate risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing. (Reference 2).  In this case, the patient  falls into a low risk category and could be managed at a lower level of care.

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

Diagnosis: Abdominal pain

Treatment: Inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission.

The denial is upheld. 

This female patient has a history of hypertension, fibroids, depression, post-traumatic stress disorder, morbid obesity, gestational diabetes, preeclampsia, 7 weeks post cesarian section (c-section).

This patient presented with abdominal pain and stable vital signs. Her evaluation was normal except for a fibroid uterus. She was admitted for pain management.
Pain management does not require hospital admission. There was nothing in this patient's presentation that warranted admission. Her abdominal examination was benign. Her laboratory evaluation was normal.  Note that the provider decided to discharge the patient from the emergency department but admitted her because "she was previously admitted for pain management for fibroids."

Except for pain management and topical nystatin for a fungal infection, nothing was done in the hospital.  Once an acute medical condition was ruled out in the emergency room, the patient could have been sent home with a prescription for nystatin and an analgesic to be followed as an outpatient by gynecology.

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

The carrier's denial of coverage for inpatient hospital admission is upheld.  The medical necessity is not substantiated.