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

Diagnosis: Transient Ischemic Attack

Treatment: Inpatient Admission 

The insurer denied the Inpatient Admission. The denial was upheld. 

This is a male patient who presented to the Emergency Department with complaints of left-sided facial numbness, left arm numbness, and slurred speech that resolved by the time EMS had arrived. The patient reported he had sobered up from drinking hours before the event. He had a past medical history of cerebral palsy, immunodeficiency, and multiple surgeries. In the emergency department a comprehensive physical examination was performed which revealed the patient was alert and oriented x3, his gross motor and sensory examination were within normal limits. His cranial nerves II through XII were intact. A Neurology consult was performed and recommendations for an MRI of the brain, chest x-ray, computed tomography angiography of the head and neck, thoracic echocardiogram, Holter monitor, ultrasound of the carotids, blood work-up for Raynaud's phenomenon, fasting lipids, hemoglobin A1c, urethral site sedimentation rate (ESR), C-reactive protein (CRP) and toxicology screen were order and performed. The patient remained clinically stable and was discharged home.  

The Milliman Care Guidelines note an admission is appropriate for a patient with a transient ischemic attack when the patient has focal neurological signs or symptoms that persists or recurs or a cardiac arrhythmia of immediate concern or hemodynamic instability. At the time of admission, the patient did not have focal neurological signs or symptoms that persisted or recurred, cardiac arrhythmia of immediate concern or hemodynamic instability.  The documentation indicated that all signs and symptoms had resolved by the time the patient was brought to the hospital.  There were no exceptional factors to support the necessity for an inpatient admission.  The patient could have undergone all of the requested testing as an outpatient.  

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: Overturned in Part

This is a patient with past medical history significant for coronary artery disease (CAD) with stenting, Atrial fibrillation not on anticoagulation, epilepsy and non-compliance with Keppra, ethanol (EtOH) abuse, and prior subarachnoid hemorrhage, who presented to the emergency department (ED) after the patient had had a seizure at home.  The patient also reported dark stools for the previous three days.  The patient denied nausea, vomiting, abdominal pain, chest pain, fevers, or chills.
The health plan's determination is overturned in part.  The inpatient hospital admission was medically necessary for the part.  The inpatient hospital admission was medically necessary for the first days in question and was not medically necessary for the last day of the admission.  This patient presented with a 5-point drop in his HGB from 12.6 to 7.6 on admission with associated hemodynamic instability with tachycardia, in addition to positive orthostasis on presentation.  Though his vital signs improved after 1U of PRBCs as did his hemoglobin, EGD showed an actively oozing AVM in the duodenal bulb, which is a lesion at high risk for re-bleeding.  He was maintained on Protonix with close monitoring for re-bleeding.  Inpatient admission for this patient with tachycardia, orthostasis, and a 5-point drop in his hemoglobin from baseline with an actively bleeding duodenal AVM was medically necessary.
The inpatient stay was medically necessary for this patient until the last day in question, at which point the patient could have been discharged.  This patient, as noted above, presented with a 5-point drop in hemoglobin from baseline, orthostasis with the heart rate increasing to 140 withstanding, and a duodenal AVM that was high risk for re-bleeding.  Admission, treatment with Protonix drip (gtt), esophagogastroduodenoscopy (EGD) with intervention, and post-procedure monitoring to ensure the patient was not re-bleeding was medically necessary.  Once it was noted the patient's hemoglobin was stable post-procedure, and the patient was taking a regular diet, the patient likely could have been treated at a lower level of care.  Admission at the inpatient care was medically necessary in-part.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Orange Urine and Itching
Treatment:  Inpatient admission

The Inpatient admission for the management of this patient was not appropriate and medically necessary. 

The patient was transferred from the psych unit to the medical unit for the management of abnormal liver function tests.  The abnormal liver function tests were evaluated with ultrasound of the abdomen to r/o (rule out) the possibility of cholecystitis and/or cholelithiasis, and biliary obstruction, and it was essentially unremarkable with no evidence of cholecystitis, cholelithiasis, or biliary obstruction.  The hepatitis serology and autoimmune markers were negative.  The GI was consulted, and the abnormal liver function tests were attributed to secondary to drug-induced liver injury (DILI).  The patient was symptomatically managed with cholestyramine for pruritus, Zofran for nausea, and IV Dilaudid for abdominal pain.  He was started on regular diet, which he tolerated very well.  His KUB (kidney, ureter, bladder) was done to evaluate abdominal pain, and it did not reveal any bowel obstruction.  He was transferred to the tertiary care center for further management of DILI.  During his hospital stay, he had no evidence of infection, GI (gastrointestinal) bleeding, altered mental status or confusion due to hepatic encephalopathy to warrant any intervention.  Therefore, based on this clinical scenario, the acute level care was not appropriate and medically necessary.  The patient could have been safely and appropriately managed at the lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis
 
Treatment: Inpatient admission, surgical intervention, medication, monitoring

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

This case involves a female with a past history of a cesarean section 5 months ago, and recent treatment for H. pylori gastritis. She presented with subjective complaints of abdominal pain 15 hours in duration.  The patient's pain was localized in the right upper quadrant, and was associated with nausea/vomiting x4 episodes.  The pain was non-radiating. The patient stated she had an ultrasound in the past demonstrating cholelithiasis.  The emergency department ultrasound demonstrated a 1.5 cm x 1.5 cm gallstone in the cystic duct with thickened wall and a positive Murphy's sign.  The patient was admitted to general surgery for further evaluation.  She underwent an uncomplicated laparoscopic cholecystectomy.  The patient was stabilized and discharged.  The patient was given antibiotics and she had a Jackson-Pratt drain in place.

MCG indicate that a cholecystectomy is generally performed on an ambulatory basis.  An inpatient stay may be appropriate for patients who have failure to achieve discharge status criteria or those who have active co-morbidities. The guidelines also indicate that an exception for ambulatory surgery would include patients in need of an emergent procedure. The patient had an uncomplicated past medical history and was otherwise healthy, with the exception of recent H. pylori gastritis.  The patient had known cholelithiasis. She had no active co-morbidities. The patient was not documented as having complications from the surgical procedure.  The records failed to support the patient could not have been cared for at an observation level of care. 

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

Diagnosis: Abdominal pain, vomiting, duodenitis
 
Treatment: Inpatient admission, medication, monitoring

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

The patient had a history of alcohol and marijuana abuse and presented with abdominal pain and vomiting. There was no abdominal rebound or guarding. There was leukocytosis at 15.8 K. A Computer Axial Tomogram (CAT) scan was negative for acute disease. An endoscopy revealed duodenitis. The symptoms resolved with Proton Pump Inhibitors (PPI) therapy.

Clinical Indications for admission for vomiting (M-370) include; gastrointestinal obstruction, hemodynamic instability, severe electrolyte abnormalities, severe pain, bacteremia, high fevers and acute renal failure. The patient did not have these conditions. 

Clinical indications for admission for duodenitis (M-560) include intestinal obstructions, perforation, peritoneal signs, ongoing bleeding, severe anemia, and severe dehydration. The patient did not have these conditions. 

The patient had marijuana induced vomiting. The patient required intravenous hydration, Metoclopramide and Protonix. This treatment could have been given with observation status. The patient was stable to have had an outpatient endoscopy. The patient did not meet MCG criteria for admission for either symptom: vomiting or duodenitis. The patient could have been managed at the Observation level of care. An inpatient admission was not medically necessary. 

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

Diagnosis: Right hip and leg pain

Treatment: In admission

The insurer has denied coverage for. The denial was upheld.

This is a male child with right hip and leg pain.  He had minor trauma and was limping.  Early imaging of x-rays revealed no abnormality.  He developed temperature to 103 F and worsening limp.  Additional imaging reported cystic lesion in the right iliac wing with mass effect. A diagnosis of Langerhans cell histiocytosis was made.  The patient underwent surgical intervention of incision to bone, curettage of the benign bone lesion.  Hematology and physical therapy consultations were completed.  He was placed on non-weight bearing status.  The patient was cleared for discharge with follow-up by Orthopedics and Pediatrics.

 Review of the record indicates biopsy was delayed until hospital day three and surgical intervention was delayed until hospital day nine, without apparent clinical rationale.  Clinical documentation supports the member was stable for surgical intervention sooner. In this patient's case, the parents knowingly remained at an out-of-network facility, despite being aware of the lack of coverage for out-of-network care (outside of Emergency Services). The medical record indicates the young child had hip pain and a fever.  His vital signs showed fever and tachycardia.  He underwent diagnostic work-up which established the presence of a hip mass.  His condition stabilized. No emergent diagnostic studies or biopsies were scheduled.  He was provided with oral pain medications.  

 The Plan asserts that the care the member received could have been provided at an observation level care and the procedure(s) were appropriate to be managed on an ambulatory basis.  The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.  The inpatient hospital services were not considered medically necessary for this patient. These findings do not substantiate the medical necessity of ongoing care at the out-of-network facility.  There were no emergent conditions to warrant ongoing hospitalization.  The child did not require treatment for other associated conditions.

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

Diagnosis:  Staged PCI
Treatment:  Inpatient admission
The inpatient admission was not medically necessary.  Inpatient level of care was neither indicated nor provided.

This was an elective, uncomplicated catheterization and PCI that was scheduled after a recent intervention for an MI.  The patient was always hemodynamically stable with normal vital signs.  EKG (electrocardiogram) was without acute
changes, and no malignant ectopy.  The only care that was given after the uncomplicated radial catheterization was monitoring, IVF, and routine medications.  This meets definition of outpatient care without any indication for a higher level.  Many institutions protocols include a same day discharge.

CMS (Centers for Medicare and Medicaid Services), RAC (recovery audit contractor) surveys, the proposed two midnight rule, and all guidelines specify this as an outpatient procedure for an uncomplicated PCI.

Radial catheterization was developed with one of its advantages being the safety in early ambulation and discharge.  The overnight stay for observation and telemetry does not change that determination.  While possible, bleeding post radial artery intervention is rarely seen, nor does it require extended monitoring.

The letter of appeal was carefully considered, but it offered no evidence to support a higher level of care.  The only care provided was telemetry, which is frequently performed in observation and outpatient status.  The patient was admitted for monitoring and routine post-Cath care; neither required an inpatient level of care.  There was no "complex" care that required in this patient's care post-catheterization.  While there was always a potential for an adverse event, one did not happen, and no actual treatment was needed.

It is unclear in the appeal, why this patient represented a high risk patient, as he had been discharged home after his last intervention and remained stable.  Milliman criteria requirements for ACS (acute coronary syndrome) do not apply, as the patient does not meet criteria to support that diagnosis.  It is incorrect to label the presentation of this case as unstable angina, as the patient was pain-free.  EKG showed no acute changes.  All testing and therapy would have been appropriate, safe and guidelines consistent in an outpatient setting.  Thus, inpatient level of care was not medically necessary.

The denial was consistent with guidelines and usual community care.  Post cardiac care as described is routinely performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Right upper quadrant pain
Treatment:  Inpatient admission
The proposed treatment was not medically necessary. 

The patient presented with typical signs and symptoms of acute cholecystitis without any evidence of sepsis.  The patient was afebrile, hemodynamically stable with normal vital signs, and no evidence of any systemic infection. 

There was no indication that this patient needed inpatient admission, and she could have been managed at a lower level of care.  After an uncomplicated elective laparoscopic cholecystectomy, patients can drink clear liquids once awake from anesthesia, and their diet can be advanced as tolerated.  Most otherwise healthy, reliable patients with good home support can leave the hospital within six hours after surgery.  Cochrane reviews have found no significant differences for important clinical outcomes for patients discharged the same day versus admitted overnight following laparoscopic cholecystectomy.  A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, which included 15,248 patients older than 65 years of age who underwent elective laparoscopic cholecystectomy, identified congestive heart failure, American Society of Anesthesiologists class IV, bleeding disorder, and renal failure requiring dialysis as significant independent predictors of inpatient admission and mortality.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain, Palpitations, Fatigue, Dizziness and Giddiness
 
Treatment: Outpatient Positron Emission Tomography (PET) Scan

The insurer denied the Outpatient Positron Emission Tomography (PET) Scan. 
The denial was reversed.  

This case involves a middle aged female who presented for an initial cardiology evaluation in early 2019.  The patient had anemia and reported non-radiating, midsternal chest pain, pressure-like in nature, lasting approximately one hour and relieved by rest, with dizziness and palpitations. The patient stated that she could not walk up a hill as she was limited by chest pain. The patient was not currently on medications. The echocardiogram in early 2019 revealed decreased left ventricular (LV) function and diastolic compliance.  The left ventricular ejection fraction was 79%.  There was mild cuspid regurgitation (CR). The ECG at that time revealed normal sinus rhythm. No carotid bruits noted and there were strong carotid pulses bilaterally. She had no jugular vein distention (JVD) and had a regular rate and rhythm without S3 and S4.  There were no murmurs or rubs appreciated. The patient's laboratory studies revealed total cholesterol of 169, triglycerides of 48, a high density lipoprotein (HDL) of 45 and a low-density lipoprotein (LDL) of 114. The diagnoses included chest pain, palpitations, fatigue, dizziness and giddiness. The patient was to undergo a myocardial perfusion imaging test to rule out coronary artery disease. 

Per the medical literature, cardiac PET scans are indicated for the evaluation in a patient with suspected or known coronary artery disease when a patient meets criteria for nuclear cardiac imaging/myocardial perfusion study and is likely to experience attenuation artifact with single photon emission computed tomography (SPECT) imaging due to factors such as morbid obesity, large breasts, breast implants, previous mastectomy, chest wall deformity, pleural/pericardial effusion, or the patient had a previous inadequate SPECT/ myocardial perfusion imaging (MPI) due to inadequate findings, technical difficulties with interpretation, or discordant results with previous clinical data.  Myocardial perfusion imaging is appropriate for patients who have a body mass index of greater than 40 kg/m2. The provider indicated that there was suspected coronary artery disease.  The testing was being ordered to rule out coronary artery disease.  Therefore, the suspicion of disease existed. The patient met the criteria for myocardial perfusion imaging due to her body mass index of greater than 40 kg/m2.  

Based on the above, the medical necessity for an outpatient positron emission tomography (PET) scan is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld. 

This is a middle aged male patient who presented to the emergency room (ER) in mid-2019 with diarrhea and dizziness. He was admitted with dizziness, bradycardia, and hypotension due to hypovolemia. Initially he had a heart rate of 63 beats per minute, a respiratory rate of 16 breaths per minute, a temperature of 36.4 C, an oxygen saturation level of 98% on room air, and a blood pressure of 96/60. The patient's symptoms improved after receiving two intravenous (IV) normal saline boluses.  Labs were obtained and the patient was hydrated and evaluated. Orthostatics blood pressures were negative but the patient was unable to stand. The patient's condition improved after treatment and he was then discharged. 
 
Per MCG, clinical indications for admission for (M-170) include having a suspected severe infection, severe abdominal tenderness, severe vomiting, or severe dehydration. Severe dehydration is manifested by persistent tachycardia or systolic blood pressure under 90 that does not respond to treatment. This patient had hypotension from dehydration. However, he responded to treatment. After intravenous hydration was given in the Emergency Room, his symptoms resolved. He did not meet MCG criteria for admission for gastroenteritis.

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Osteoporosis

Treatment: Prolia 

The insurer denied Prolia.  The denial was upheld. 

This is a female patient who presented for her annual gynecological exam in mid-2019.  At that time of the exam, a bone mineral density scan was performed.  The test revealed osteoporosis of the spine and hips.  The patient had a past medical history of Graves' disease and nephrolithiasis and had recently been diagnosed diabetes.  She was a candidate for treatment of osteoporosis.
The standard of care indicates that the first line of therapy for osteoporosis is oral bisphosphonates.  Intravenous bisphosphonates is an acceptable alternative.  This patient's medical provider opted to prescribe denosumab, which is an acceptable alternative treatment.  The justification for avoiding bisphosphonate use is stated as "severe GERD."  However, there is no indication in the medical record that the patient has gastroesophageal reflux disease (GERD).  The gastrointestinal review of systems states that she has no heartburn.  No medications for treatment of GERD are listed, and GERD is not mentioned as a diagnosis.  There is no indication that she cannot tolerate oral medications.  Moreover, regarding intravenous bisphosphonates, GERD is not listed as occurring in more than 1% of patients who take zoledronic acid in the section of adverse events in its package insert.   Without further documentation to support use of denosumab, it is considered appropriate to prescribe a trial of bisphosphonate treatment- the consensus preferred initial therapy for postmenopausal osteoporosis.

The carrier's denial of coverage for Prolia (denosumab) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Reversible inferolateral ischemia
 
Treatment: Cardiac PET perfusion imaging scan

The insurer denied the Cardiac PET perfusion imaging scan. The denial was reversed.

The patient is a woman with a history of obesity, hyperlipidemia, hypertension, and chest pain.  She was referred for a Persantine Cardiolite nuclear perfusion stress test.  This test revealed severely limited technical quality findings, severe attenuation artifact including breast attenuation, and extracardiac activity.  It was equivocal for partially reversible inferolateral ischemia.  On this basis, she was referred for PET perfusion stress testing. 

The use of PET perfusion stress testing is medically necessary.  The patient underwent conventional, and more widely available, SPECT perfusion imaging, however, given her obesity and breast attenuation, the test was suboptimal.  Reversible myocardial ischemia could not be ruled out.  Given that PET perfusion imaging has improved spatial resolution compared with SPECT imaging for the detection of ischemic myocardium, the use of PET perfusion imaging is an appropriate and rational next test of choice.  Cardiac catheterization, which was an alternative diagnostic strategy, is more invasive, and carries more potential unnecessary risks to the patient. 

The carrier's denial of coverage for Cardiac Positive Emission Tomography (PET) Scan is reversed.  The medical necessity is substantiated.