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

Chronic Kidney Failure/ESRD
Inpatient Hospital

This is the case of a female with past medical history of coronary artery disease (CAD) status/post (s/p) coronary artery bypass graft (CABG), hypertension (HTN), hyperlipidemia (HLP), diabetes mellitus (DM), chronic kidney disease (CKD) on dialysis, and anemia of chronic kidney disease, who presented to the emergency room (ER) with chief complaint of non-functioning permacath. The patient had notably had a recent admission and discharge after her permacath had become infected and she required removal in the setting of bacteremia. The patient denied fevers, chills, nausea, vomiting, abdominal pain, or other complaints.

On presentation, she was afebrile with systolic blood pressures (SBPs) in the 160s-170s, heart rate (HR) 74, and sating 100% on room air (RA). Exam otherwise noted no abnormalities. Labs noted white blood cell (WBC) count 6.9, hemoglobin (HGB) 9.5, platelets (Plts) 155, and basic metabolic panel (BMP) consistent with dialysis status without hyperkalemia and potassium (K) of 4.3. Chest x-ray (CXR) noted no acute cardiopulmonary process and dialysis catheter in the distal superior vena cava (SVC) region. Computed tomography (CT) head showed no acute abnormality in the setting of the patient initially telling the ED she had gait disturbance but then denying this to the admitting physician. Electrocardiogram (EKG) showed no acute ischemia or arrhythmia. The patient was subsequently brought into the hospital with assessment that she had a malfunctioning permacath and with plans for nephrology consultation.
Nephrology subsequently saw the patient and ordered Cathflo x2 with plans to consult interventional radiology (IR) if Cathflo did not work.
The patient was subsequently able to undergo successful dialysis after Cathflo administration and was able to be discharged.

The health plan's determination is upheld.

This patient presented with a non-functioning permacath in the setting of not being able to receive her usual chronic dialysis at her dialysis center earlier in the day, in addition to hypertension.  Neither condition required inpatient care and resolved quickly. She did not have hyperkalemia, hypoxia, or significant acidosis in the setting of not having been able to complete her dialysis, and she did not have signs of recurrent infection. The catheter was able to function after Cathflo, with her usual dialysis resumed. De-clogging of a dialysis catheter can be managed at a lower level of care status, particularly given this patient did not present with a need for emergent dialysis (she had no hyperkalemia, no fluid overload, no acidosis). Her hypertension on presentation notably resolved quite quickly after her medications were resumed and with dialysis. This patient presented for a procedure appropriate for a lower level of care status without a concomitant process requiring inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Facial Numbness
Treatment:  Inpatient admission

The Inpatient admission was not medically necessary.

The patient presented to the emergency ward with the complaint of left sided headache and facial numbness for 24 hours.  At presentation, she had a normal neurological examination.  CT brain was negative. Subsequent MRI brain was negative. 

The patient's presentation was not consistent with thunderclap headache and was unlikely to be consistent with acute stroke.  According to current standard of care guidelines, the diagnostic studies, monitoring and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Congestive Heart Failure/CHF
Inpatient Hospital

The patient is a man with a history of chronic systolic heart failure (ejection fraction (EF) < 25% by echocardiogram (ECHO) in 2010), mitral regurgitation, hypertension (HTN) and diabetes mellitus (DM) who presented to the emergency room (ER) with complaints of worsening exertional dyspnea over 3-4 months. He had no chest pain, cough, or fever. An ECHO showed an ejection fraction (EF) of 21-25%, with moderate to severe mitral regurgitation. An electrocardiogram (ECG) showed sinus rhythm and left bundle branch block. Troponin was 0.04.

The health plan's determination is upheld. The inpatient admission is not medically necessary. This patient has chronic systolic heart failure and presented with an exacerbation - worsening dyspnea. He had an elevated BNP. However, he was hemodynamically stable, with no evidence for myocardial ischemia, infection, acute renal failure or other condition requiring inpatient treatment. He was treated initially (over the first day) with intravenous diuretics. A lower level of care is appropriate. He underwent cardiac catheterization and biventricular ICD placement during the admission, but these procedures could have been done at the lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypoglycemia

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was reversed.

This patient is a female who presented to the emergency room (ER) with altered level of consciousness (LOC). The patient has a long standing history of diabetes and heroin use. Upon emergency medical services arrival the patient had a blood sugar of 26mg/dL. The patient stated that she did take her insulin and oral anti-hyperglycemic medication the night before but did not eat. In the emergency department (ED), the patient received intravenous (IV) dextrose. The patient was transferred from the ED to an inpatient unit with a chief complaint of hypoglycemia. The patient left against medical advice.

The patient presented to the emergency room (ER) with altered level of consciousness (LOC). The patient has a long standing history of diabetes and heroin use. Upon emergency medical services arrival the patient had a blood sugar of 26 mg/dL. The patient stated that she did take her insulin and oral anti-hyperglycemic medication the night before but did not eat. In the emergency department (ED), the patient received intravenous (IV) dextrose. The patient was transferred from the ED to an inpatient unit with a chief complaint of hypoglycemia. The patient needed inpatient monitoring for hypoglycemia and uncontrolled diabetes. In addition, the patient needed further education regarding the care of her diabetes. Therefore, the inpatient hospital admission is considered medically necessary for this patient.

Per Yu O. et al. (2018), "The study cohort consisted of 14,012 initiators of sulfonylureas matched to 14,012 initiators of metformin. The mean treated follow-up time was 1.41 (standard deviation, 1.84) years. Use of sulfonylurea was associated with an elevated incidence of severe hypoglycemia compared with metformin as the initiating monotherapy for type 2 diabetes (incidence rate, 2.4/1000 person-years; 95% CI, 1.90-2.90; HR, 4.53; 95% CI, 2.76-7.45). Sulfonylureas, when prescribed as the initiating monotherapy for the treatment of type 2 diabetes, is associated with a 4.5-fold increase in the risk of severe hypoglycemia."

The inpatient hospital admission is medically necessary. The patient needed inpatient monitoring for hypoglycemia. In addition, the patient needed further education regarding the care of her diabetes.

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

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Withdrawal symptoms; Hyperglycemia

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was reversed.

This patient is a male who was admitted to this hospital after an unresponsive episode in which he was not responsive to verbal cues and his speech reportedly was incomprehensible, and he was binge drinking and had hyperglycemia. He had blood glucose of 467 and was non-compliant with medications. He was drinking beers from morning until night for 3-4 days in a binge. He reportedly had past episodes. He also had hypertension including a blood pressure of 162/83 and had other reported withdrawal symptoms including sweats, tremors, and he was given Librium intravenously (IV) in addition to IV Hydralazine and IV hydration. He was discharged. The insurer denied coverage for inpatient hospital treatment.

This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment. The chart notes provided enough specific evidence to support that he was in need of hospital treatment .The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also indicates that patients using large amounts of alcohol or benzodiazepines are at a higher risk of having delirium tremens 3-4 days after cessation of use. It also states that patients with comorbid medical conditions complicating that management of withdrawal are candidates for inpatient hospital treatment.

According to the LOCADTR, he did require 24 hour treatment; as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use large amounts of alcohol in binge drinking despite serious medical issues and he needed detoxification medication to modify withdrawal symptoms and to prevent more serious withdrawal and had comorbid medical conditions complicating the management of withdrawal. It was not likely that he could safely be managed in an outpatient setting. He needed 24 hour treatment as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting, including severe and life threatening withdrawal symptoms.

Inpatient hospital treatment was medically necessary. It did not appear that the health care plan acted reasonably or in the best interests of the patient.  

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned in Part

Cardiac/Heart Problem
Inpatient Hospital

The patient is a man with nonischemic cardiomyopathy, chronic systolic heart failure, with ejection fraction (EF) 30%, s/p implantable cardioverter defibrillator (ICD) placement, chronic kidney disease (stage 3), morbid obesity (body mass index (BMI) > 40), sleep apnea, not compliant with continuous positive airway pressure (CPAP), hypertension and asthma.
He presented with dyspnea and a cough productive of yellow/white sputum. He had recently been hospitalized with a congestive heart failure (CHF) exacerbation and was discharged the day prior to this admission. He was admitted for further evaluation and treatment. He was felt to have been prematurely discharged, and required additional diuresis. It was also noted that he needed help at home.

The health plan's determination is overturned in part. A 2 day inpatient stay was medically necessary. The patient was felt to have decompensated heart failure - he was dyspneic, tachypneic, and with signs of acute CHF - including pulmonary rales and moderate leg edema. These symptoms and signs did not resolve in the emergency room. Per Milliman Guidelines, inpatient admission is indicated for patients with heart failure who have tachypnea and dyspnea over baseline which persist despite emergency room treatment. He also had a cough, productive of yellow sputum, and this comorbid condition, along with heart failure, is another reason for admission. Per Milliman guidelines, the usual length of stay is 2 days. Hospitalization beyond this time frame is not supported by the medical records provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient hospital admission

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

This patient is a female with a past medical history notable for hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, anemia, and chronic kidney disease. She underwent a nuclear stress test on the day of presentation and had 10/10 chest pain. The EKG was unremarkable. The vital signs were notable for blood pressure 194/70, which improved to 150/70. She had normal troponin and B-type natriuretic peptide (BNP) level. The chest radiography was normal. Because she had ongoing chest pain, she was referred for urgent coronary angiography, which revealed non-obstructive coronary artery disease. There were no complications. She was observed overnight and then discharged home.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 
 
Although, the patient presented with chest pain following a stress test, the initial evaluation in the ER was unremarkable, including a non-diagnostic EKG. The inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional cardiac testing and control of the blood pressure. 
Further evaluation was warranted, however inpatient admission criteria was not met. There was no evidence of other medical conditions warranting inpatient level of admission.

Based on the above, the medical necessity for the inpatient hospital admission from is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: OCD
Issue under review: Transcranial magnetic stimulation

Determination:
The Transcranial magnetic stimulation is not medically necessary.

The patient is an adult male. He was treated with multiple sessions of Transcranial Magnetic Stimulation (TMS) for OCD (obsessive compulsive disorder). 

The provider's assertion that there is a wealth of evidence of supporting OCD as an indication for dTMS (Deep Transcranial Magnetic Stimulation), and his referring to it as the "gold standard" are not accurate. Studies to date are suggestive, but at times contradictory and inconclusive, regarding the efficacy of dTMS in the treatment of OCD. 

Also, the provider's citing approval by the FDA is misleading, as the FDA approval of dTMS for OCD is specifically as a Humanitarian Use Device (HUD), which clearly means the FDA considers there to be inadequate evidence of efficacy at this time. The FDA HUD approval was based on a single study involving 99 patients. Other published studies implying FDA approval are reprints by the manufacturer of the device and fail to note the HUD status.

While the patient's YBOCS (Yale Brown Obsessive Compulsive Scale) score has improved, there is insufficient evidence to attribute this to the specific treatment as opposed to other factors, such as patient expectations, placebo, observer bias, unknown changes in the patient's life, etc. 

Therefore, given the above, the TMS is not medically necessary for the patient at this time.
Appeal type: Medical necessity
Decision: Upheld

Substance Abuse/Addiction
Mental Health: Outpatient

The patient is a young adult male who presented for partial hospital program (PHP) treatment to address substance use disorder with alcohol, cannabis, anxiolytic class substances of abuse. The patient has a history of using Xanax with up to five bars daily as well as up to two grams of cannabis and intermittent use of alcohol with binge drinking. He has a history of poly-substance use with the anxiolytic as his drug of choice with use since age 16 years. Thus, his substance abuse had started at an early age. He had no history of delirium tremens or withdrawal seizures, but did report frequent blackouts. His referral for PHP level care occurred after being "kicked out" of a sober living house in the context of attempting to sell a stolen bike. The patient has a history of psychiatric disorders best characterized as unspecified anxiety disorder and major depressive disorder at the time of presentation, as well as, a history of attention deficit hyperactivity disorder (ADHD) and a remote history of bipolar disorder by the patient's report. There is also a history of self-harming behavior and trauma history related to his sister's suicide attempt and the death of a friend.

The health plan's determination is upheld. The PHP services in question were not medically necessary. The structure and intensity of services necessary for a successful rehabilitation/substance use disorder treatment can be/could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports. There is no evidence that PHP level structure or services is medically necessary for a successful outcome in this case. And, there were no biomedical, psychiatric or general medical issues that warranted the PHP level of care.On the dates in question, the patient was generally motivated and capable of effectively engaging and continuing his substance use disorder treatment in a less restrictive treatment setting with sober supports and/or housing.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pelvic pain
Treatment: Inpatient admission
The Inpatient hospital admission was medically necessary

The patient is a female. She was G0 when she presented to the emergency room with complaints of pelvic pain. An ultrasound revealed a 15x10x7 cm left ovarian cyst. She was admitted to the inpatient service. 

A laparotomy and left ovarian cystectomy was performed. The patient recovered uneventfully and was discharged.

The proposed treatment is medically necessary. The medical records and medical literature were thoroughly reviewed. The patient underwent an exploratory laparotomy. Exploratory laparotomy is not an ambulatory procedure. The postoperative care of patients who have undergone laparotomy includes inpatient observation for postoperative complications, including intra-abdominal hemorrhage, postoperative pelvic infection and progression to normal bowel function. Adequate analgesia can require IV pain medication that also requires a more acute level of care, as in this case. The patient required IV pain medication through postoperative day 1. Normal return of bowel function after a laparotomy typically presents with bowel sounds occurring first, followed flatus and then by bowel movements. 

The physician documentation in the medical records indicates that the patient was tolerating only clear liquids and had not returned to normal bowel function on postoperative day 1. She had normal gastrointestinal function on postoperative day 2 including normal bowel sounds. She was not tolerating a normal diet or requiring oral pain medication until postoperative day 2. The patient did not have normal urinary function on postoperative day 1, having had the Foley catheter removed on that day. Therefore, she did not exhibit normal urinary function immediately, and required observation for this condition. 

It is the standard of care for the post-laparotomy patient to demonstrate adequate return of bowel function with normal bowel sounds and flatus and not require IV pain medication, as well as observation for major postoperative complications, prior to discharge. Premature discharge of the patient, or placing the patient in an intermediate care unit would not have met the standard of care and could have adversely affected the patient's care. Therefore the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Periapical lesions
Issue under review: Cyst removal, IV sedation

Determination:
The Cyst removal, IV sedation are not medically necessary.

The clinical documentation consists of a periapical radiograph of tooth #14 that shows periapical lesions at the apex of all 3 roots of tooth #14.

Based on the provided documentation, the appropriateness of the apicoectomy cannot be established. According to the American Association of Oral and Maxillofacial Surgeons, in order to bill for cyst removal, there must be documentation of additional work associated with the cyst removal when these codes are submitted in conjunction with extraction codes. This would also apply to apicoectomies. There is no biopsy report or operative report showing that a cyst was removed. Therefore, the cyst removal was not necessary, based on the available information. The decision to use sedation/general anesthesia for a particular dental procedure should only be determined by considering the needs of the patient, the requirements of the operating dentist and the effect on the quality of the dental treatment. The provider has determined that it is needed in this particular case. However, the sedation would not be needed without the cyst removal. 

There is no documentation that an apicoectomy was the treatment of choice. Dental surgical interventions on the periapical area or apicoectomies are indicated when the lesions of the periapical area cannot be treated by endodontic treatment or when the endodontic treatment cannot be conducted. There is no clinical information that documents when the root canal was performed, if the lesions are existing or new and no documentation that the root canal was adequate and a retreatment could not be performed. There is also lack of documentation as to why a lesion on the palatal root appears to have been left alone.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell disease 

Treatment: inpatient admission 

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

This patient is a female with sickle cell disease who presented to emergency department (ED) with pain in her arm. She had hemoglobin (Hb) of 7.6, a reticulocyte count that was more than 9, and the pain had been ongoing for 2 weeks. The computed tomography (CT) scan showed atypical pneumonia and avascular necrosis of the humeral head. She was admitted with acute sickle cell crisis due to dehydration. Per the ED documentation the patient had malaise. Laboratory results in the ED revealed hemoglobin 7.6 grams/deciliter and hematocrit 21.3%. Initially recorded vital signs were: blood pressure 116/79, respiration 17, oxygen saturation by pulse oximetry 95, and temperature 99. Per the history and physical the patient also complained of severe shoulder and leg pain.  In addition, she reported an inability to sleep for 2 days because of pain; pain level 8/10. Per the discharge summary the patient had abdominal distention due to hepatomegaly and was asymptomatic during the stay.  She was discharged home with an appointment with gastroenterology.

The insurer has denied coverage for the inpatient admission as not medically necessary.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The patient's hemoglobin was 7.6; there was no pneumonia, no infection, no evidence of acute chest syndrome. The patient was managed with only pain medications and IVF. There is no evidence for the need of blood transfusion or intravenous antibiotics therapy. The patient could have been managed in observation and given intravenous fluids (IVF).