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

Diagnosis: Left hip osteoarthritis  
Treatment: Inpatient hospital stay  

The insurer denied coverage for inpatient hospital stay. The denial is upheld.  

This patient is a female with a history of osteoarthritis, carpal tunnel syndrome, hyperlipidemia, and hypertension. This patient presented to the hospital for a scheduled left hip arthroplasty. The patient reported 8 out of 10 left hip pain and 7 out of 10 right hip pain. The patient underwent an uncomplicated left hip arthroplasty. The patient was admitted to surgery with left hip osteoarthritis. The patient was given intraoperative antibiotics, postoperative antibiotics, and deep vein thrombosis prophylaxis. On post-operative day#1, the patient was mobilized with physical therapy. The patient's hospital course was uncomplicated. Upon discharge, the patient's pain was well controlled with oral medications. The patient was tolerating a regular diet and voiding spontaneously. The patient was allowed to weight bear as tolerated on the left lower extremity. The patient's care plan was implemented and the patient was discharged in hemodynamically stable condition.  

The medical record demonstrated that this patient was treated solely for osteoarthritis to her left hip. The patient did not have associated major co-morbidities. The patient's operative procedure and hospitalization were uncomplicated. The patient had limited blood loss, and did not require intervention. The patient did not require management of other underlying medical problems. The patient's vital signs were stable. There were no problems with her wound. The patient was able to tolerate oral pain medication, and there were no delays in obtaining and completing physical therapy services. The patient's discharge was timely with all post-operative arrangements completed.  

Based on the review of the medical record and clinical guidelines, there were no extenuating circumstances that warranted this patient's inpatient admission. These services could have been completed at a lower level of care. Thus, the inpatient hospital stay was not considered medically necessary for this patient.  

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

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

Diagnosis: Skeletal Class I, Maxillary and Mandibular Crowding, Class II Canines, and Deep Impinging Overbite.

Treatment: D8080 braces

The insurer denied D8080 braces. The denial was upheld.   

This is a male patient who consulted an orthodontist for orthodontic treatment. Diagnostic examinations were performed that included lateral cephalometric radiograph, panoramic radiograph, and montage of extraoral and intraoral clinical imaging. It was determined that he had skeletal Class I, maxillary and mandibular crowding, Class II canines, and deep impinging overbite. A HLD index was completed and braces were recommended.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

It is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, the use of a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

The treating Orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage, and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 16 points (3 points overjet, 6 points overbite, 5 points anterior crowding and 2 points labiolingual spread).

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

Based on the above, the medical necessity for D8080 braces is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fractured nose
Treatment: Septorhinoplasty CPT code 30435: Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)  
The insurer denied coverage for Septorhinoplasty CPT code 30435: Rhinoplasty, secondary; intermediate revision (bony work with osteotomies). 
The denial is upheld. 

This patient is a female with a history of fractured nose. According to the Plastic Surgeon's appeal letter the procedure was performed to treat "intermittent nasal pain on her right dorsum."  Another appeal letter also stated that the patient was unable to wear eyeglasses due to pain.  The patient's plastic surgeon was concerned about extrusion of the bone spicule through the skin. However, the plastic surgeon's preoperative consult note did not mention any complaints of pain, and analgesics were not listed on this patient's medication sheet. In addition, the patient's nasal exam finding was a small dorsal bump with thin skin; imminent skin breakdown was not described. A specific painful spicule was not documented in the exam findings. The submitted photos did not show any evidence of skin redness or irritation consistent with impending skin breakdown. The records did not provide compelling documentation of a medical problem due to this patient's nasal dorsum such that this procedure should be classified as medically necessary.

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

The carrier's denial of coverage for the Septorhinoplasty CPT code 30435: Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) performed is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Persistent asthma.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.  The denial is upheld. 

This patient is a female with persistent asthma who presented to the Emergency Department (ED) with complaints of worsening shortness of breath (SOB) and wheezing along with some productive white cough and chest pain.  The patient had multiple ED visits in the past week and had been discharged from the ED earlier after treatment on Prednisone and inhalers.  The patient did not feel better on medications, so the patient came back to the ED.  At ED presentation, the patient's temperature was 98.2 F, heart rate was 160, respiratory rate was 24, blood pressure was 131/72 mm hg, and oxygen saturations were 100%.  On exam, the patient was noted to be in severe respiratory distress with bilateral wheezing present.  The patient's peak expiratory flow (PEF) was 160.  The patient's baseline PEF was 300.  The patient's lab showed: white blood cell (WBC) count of 9.6 K, hemoglobin of 14.3, and electrolyte within normal limits.  The patient's chest x-ray was unremarkable.  The patient's electrocardiogram (EKG) showed sinus tachycardia at 144.  In the ED, the patient was treated with intravenous (IV) steroids, bronchodilator (BD) and magnesium.  However, with continued wheezing, the patient was admitted to the hospital.  The patient improved with treatment and was discharged on oral medications and bronchodilator.

Based on the review of the literature and the medical records provided, this patient did not need acute hospitalization.  The patient could have been placed in Observation status while diagnostic testing and treatment were initiated.  The patient improved overnight after treatment.  The patient was afebrile and hemodynamically (HD) stable.  The patient was tolerating oral intake, and was able to speak in full sentences.  The patient was not hypoxic, and the patient's white blood cell count was normal.  The patient had no pneumonia evident on chest x-ray.  The patient was stable to be discharged after a period of observation on oral steroids and bronchodilator with close follow-up in an outpatient setting.  Thus, inpatient admission was not medically necessary to treat this patient's medical condition.

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

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

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

The Inpatient admission was medically necessary.

The patient has a past medical history significant for HTN (hypertension), COPD (chronic obstructive pulmonary disease), gastritis, paranoid schizophrenia, anxiety, alcohol and tobacco abuse. He presented to the emergency department for evaluation of new onset chest pain, shortness of breath, and abdominal pain. 

The patient was hemodynamically stable. The ECG (electrocardiogram) revealed normal sinus rhythm with multifocal PVCs (premature ventricular contraction), prolonged QT interval, LVH (left ventricular hypertrophy) and non-specific ST-T changes. The chest x-ray revealed cardiomegaly and mild vascular congestion. The cardiac troponin was mildly elevated, suggestive of myocardial injury. 

The patient was admitted to telemetry for management of chest pain, r/o (rule out) ACS (acute coronary syndrome) and CHF (congestive heart failure), COPD (chronic obstructive pulmonary disease) and gastritis. The patient underwent a 2D (two-dimensional) echo, which revealed severely reduced LV (left ventricle) function with EF (ejection fraction) at 15-20%. The patient was started on medical therapy for CHF, CAD (coronary artery disease), suspected NSTEMI (non-ST elevation myocardial infarction) and was referred for cardiac catheterization. The catheterization revealed non-obstructive CAD, and the patient was diagnosed with non-ischemic systolic heart failure. He was managed with medical therapy and discharged home.  

The patient presented with new onset chest pain, suspicious for unstable angina. The patient had multiple risk factors for CAD. His troponin was elevated, consistent with myocardial injury, and in the setting of new onset chest pain, suggestive of NSTEMI/ACS. Furthermore, the patient was diagnosed with new onset systolic heart failure with EF of 15-20% by echo. This decrease in the EF was felt to be secondary to NSTEMI, and the patient was referred for cardiac catheterization.  Given this presentation, suspicion for an acute coronary syndrome, as well as risk factors for CAD and newly diagnosed CHF, it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient admission
The insurer denied the inpatient admission.  The denial is overturned.
The proposed inpatient admission was medically necessary.

The patient is a female with asthma who presented to the emergency room with wheezing and shortness of breath. The patient was found to be in asthma exacerbation. The patient received frequent nebulization treatment as well as intravenous (IV) steroids, IV antibiotics and nebulization treatment without much improvement in her symptoms. The patient was admitted to acute in hospital level of care for frequent nebulizations, IV steroids, IV antibiotics and peak flow monitoring. The patient left against medical advice that day.
The patient was in asthma exacerbation and did not improve with emergency room care. The patient was admitted to the acute in-hospital level of care and was improving with heart rate (HR), respiratory rate (RR) as well as shortness of breath (SOB) and wheezing. The patient had a mild asthma exacerbation but only responded partially to the emergency room care. Since patient had treatment resistant asthma exacerbation with reduction in peak flow from baseline and continued symptoms despite emergency room care, the acute in-hospital level of admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status-post fall
Issue under review: Inpatient admission

Determination:
The health plan denied Inpatient admission. The health plan's denial is upheld.

The patient is an adult female with a history of seizure disorder. She presented to the hospital after a fall down stairs, with a forehead laceration with contusion.  The laceration was closed in the emergency department.  In the emergency department, the patient had vomiting.  

The patient was afebrile with a blood pressure 156/90 and pulse 70.  The examination demonstrated the patient to be alert and oriented at the time of admission.  Computed tomography of the brain, maxillofacial area, chest, and spine demonstrated no acute process.  Laboratory indices were unremarkable.  Serial neurologic examinations were performed.

Although the patient had altered mentation on arrival by medics, by the time of admission she was alert and oriented.  Computed tomography of the spine (cervical, thoracic, and lumbar) and maxillofacial area showed no acute process.  Computed tomography of the brain demonstrated no acute intracranial process.  There was no focal neurologic deficit and the patient remained alert and oriented during the hospital stay.  There was no evidence of seizure activity.  There was no evidence of cardiac arrhythmia, internal injury, acute cerebrovascular accident, or acute coronary syndrome.  There was no evidence of persistent bleeding, hemodynamic instability, or need for a blood transfusion. 

In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post Anterior Cervical Decompression & Fusion
Treatment: Inpatient stay
Decision: Denied

Summary:
The patient is a female. She has history of cervical herniation disc with neck and arm pain. The patient underwent C67 ACDF (Anterior Cervical Decompression & Fusion) without complication. 

The records do not indicate that the patient received any treatment during the hospitalization that would require acute inpatient level of care. Generally, patients who require significant IV pain medications, who experience a complication, have vital sign instability or other critical care issue or who have neurological issues after surgery are appropriate for acute inpatient level of care. In this patient, there was no issue that would warrant the patient to be admitted to the hospital for acute inpatient level of care for one night. For this reason, the acute inpatient level of care is deemed not medically necessary. The patient's hospitalization could have been at a lower level of care, such as observation or outpatient level of care. If the patient had a complication or other issue that required acute inpatient level of care, this could have been adjusted at a later time.
Appeal type: Medical necessity
Decision: Overturned

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

The Inpatient admission was medically necessary.

The patient is a male infant with maternal history significant for GBS (Group B streptococcus) positive and chronic hepatitis B status post immunoglobulin and vaccine. He presented to the ED because of clear drainage from his right ear. He had no fevers and was otherwise well. He had not yet received his two month vaccines. 

The patient's vital signs included temperature 99.6, heart rate 146, respiratory rate 35, with 100% saturation in room air. Examination was significant for well appearance, no distress, clear discharge from the left ear, perforated left tympanic membrane with thick white discharge and clear liquid discharge, bulging right tympanic membrane with no perforation or discharge, no nasal discharge, moist mucous membranes, clear lungs, regular heart rate and rhythm, benign abdomen, and non-focal neurologic exam. He was diagnosed with bilateral suppurative acute otitis media with left perforation, with concerns for bacteremia/meningitis due to age and unvaccinated status. Full sepsis work-up was performed including lumbar puncture. Laboratory evaluation was significant for negative urinalysis, thrombocytosis (platelets 587K), hyperkalemia with no visible hemolysis (potassium 6.2), metabolic acidosis (CO2 [carbon dioxide] 18), and elevated lactate 4.6 on venous blood gas. Cerebrospinal fluid gram stain revealed 3+ white blood cells with no organisms. Cultures of urine, blood, cerebrospinal fluid, and ear drainage were all obtained and were pending. Chest x-ray was unremarkable. 

The patient was given a dose of ceftriaxone prior to admission to the pediatric floor. Admission orders included continuation of ceftriaxone pending culture results. ENT (otolaryngology) was consulted, performing a deep swab that was positive for Strep pyogenes. Urine, blood, and spinal fluid cultures all remained negative. By hospital day three, the ear drainage had improved sufficiently, that in conjunction with negative cultures, he was deemed stable for discharge, to follow-up with ENT and to complete a course of antibiotics with amoxicillin and ofloxacin drops.

This infant did not present with fever, rather with unilateral ear drainage. On exam, he was found to have bilateral suppurative otitis media with unilateral perforation. Because of the risk of serious bacterial infection due to hematogenous spread in such a young infant with suppurative acute otitis media, full septic work-up was warranted with management based on guidelines for acute febrile illness as above. Treatment with parenteral antibiotics pending culture results was medically necessary, consistent with current recommendations. Lower level of care would not have been safe or appropriate in this case. The full duration of his hospital stay was medically necessary at an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

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

The Inpatient admission was medically necessary.

The patient is a male with a past medical history significant for HTN (hypertension), dyslipidemia, aortic stenosis, and coronary artery disease (CAD). He was status post recent open heart surgery with bioprosthetic aortic valve replacement and coronary artery bypass surgery with two arterial grafts placement (less than a month prior to the admission). 

The patient presented to the ER with palpitations and was found to be in atrial flutter with rapid ventricular rate. His pulse was elevated at 146/minute, and he had tachypnea. Initially, the patient was treated with IV (intravenous) Diltiazem and started on a drip, which failed to control the rate. The patient was then treated with IV Amiodarone and started on oral load, however his arrhythmia persisted. 

The patient was admitted to ICU, and cardiology consultation was obtained. His arrhythmia continued despite medical therapy. He was started on Heparin drip and TEE (transesophageal echocardiogram)-guided electrical cardioversion was performed the day after admission with conversion to normal sinus rhythm. Echocardiogram revealed a moderate size pericardial effusion, and he was started on steroid therapy for suspected Dressler's syndrome. The patient was discharged home the day after admission with a plan for outpatient follow-up with cardiology and CT surgery.

The patient presented with new onset atrial arrhythmia, uncontrolled heart rate, despite treatment with two intravenous antiarrhythmic agents in the ER. In addition, the patient has increased risk of complications due to his co-morbidities and recent open-heart surgery. There was increased risk of bleeding with the use of anticoagulation, due to his recent surgery, and the newly diagnosed pericardial effusion. He eventually required TEE-guided cardioversion, as he failed medical therapy with antiarrhythmics. Given this presentation, acute uncontrolled atrial arrhythmia, as well as multiple risk factors, co-morbid conditions and known CAD, s/p (status post) recent open-heart surgery, it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.