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

Diagnosis:  Abnormal outpatient non-invasive evaluation, HTN, CAD
Treatment:  Inpatient admission
The inpatient admission was not medically necessary.

The patient is a female.  At the time of admission to the hospital, she had a past medical history significant for hypertension (HTN), coronary artery disease (CAD), congestive heart failure (CHF), diabetes, and peripheral vascular disease (PVD) with intermittent claudication.  

The patient presented to the hospital for an elective angiogram of the lower extremities, following an abnormal outpatient non-invasive evaluation.  The patient was hemodynamically stable.  She underwent a peripheral angiogram with intervention/atherectomy of the left popliteal artery and tibio-peroneal trunk.  There were no peri-procedural complications reported.  The patient was admitted for observation post procedure with vascular and groin checks.  Complete blood count (CBC) and troponin were also checked.  The patient remained clinically stable and was discharged with a plan for outpatient follow-up.

This patient presented for an elective peripheral angiogram and angioplasty/atherectomy/stent of the left popliteal artery and tibio-peroneal trunk for intermittent claudication.  There were no peri-procedural complications. There was no evidence of infection, bleeding, thrombosis, hematoma, access site complication, vessel perforation, acute vessel closure or any other complication related to the procedure.  There was no fever.  There was no evidence of hemodynamic instability.  There was no report of uncontrollable pain.  Usually, no acute inpatient admission is required, unless there is evidence of a bleeding or thrombotic complication, hemodynamic instability or infection.  None of these complications were documented for this patient, and she was discharged home the next day in stable condition.  Thus the medical record does not support medical necessity for acute inpatient care, and the services provided could have been rendered in an ambulatory setting with post-procedural observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infection (cellulitis)
Treatment: Inpatient admission

The Inpatient admission was not medically necessary.

The patient was a female with generalized anxiety disorder, alcohol abuse, and bipolar disorder who presented to the hospital with bilateral lower extremity edema and erythema.  

The patient's labs were notable for a white blood cell count 7.7, hemoglobin 10.8, creatinine 1.2, glucose 62, and potassium 5.9.  Lower extremity radiographs demonstrated no fracture, and lower extremity Dopplers demonstrated no deep venous thrombosis.  Intravenous fluids and intravenous antibiotics were provided.  The potassium rose during the hospital stay to 6.6; Kayexalate, calcium gluconate, and Lasix were administered.  Nephrology was consulted, and Bactrim and lisinopril were held.  The potassium normalized.  Compression stockings were placed.  Physical therapy was consulted.

The patient was hemodynamically stable and afebrile with a normal white blood cell count.  There was no failure of bacteremia outpatient treatment and no evidence of necrotizing fasciitis or osteomyelitis.  The patient was not immunocompromised.  There was no evidence of acute heart failure or pulmonary edema.  The patient's hyperkalemia was transient and was not associated with electrocardiographic changes, ventricular arrhythmia, or muscle weakness.  The potassium normalized with medical therapy, and dialysis was not required.  There were no decompensated medical comorbidities.  

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

Pregnancy
Inpatient hospital

The patient is a pregnant female at 5 weeks 5 days ( 6 weeks 5 days in other parts of the medical records ) who presented to emergency department (ED) with complaints of vaginal bleeding x 9 days, worsening of bleeding for the past 2 days with lower abdominal cramping. The patient reported that " sac" was seen on ultrasound (US) in the doctor's office.
Her obstetrical history was significant for 2 miscarriages, 1 ectopic pregnancy (initially treated with methotrexate, then ruptured and required left salpingectomy).

The health plan's determination is upheld. The inpatient stay was not medically necessary. Based on provided clinical information, the patient had suspected, stable, unruptured ectopic pregnancy. The patient was hemodynamically stable and had no evidence of acute abdomen.
In this clinical situation, the acute inpatient level of care was not medically necessary. As enhanced surveillance was desired, it could have been safely completed at a lower level of care. the patient had a suspected, stable, unruptured ectopic pregnancy. The patient was hemodynamically stable and had no evidence of acute abdomen. In this clinical situation, the acute inpatient level of care was not medically necessary.
As enhanced surveillance was desired, it could have been safely completed at the lower level of care. Also, the patient did not meet Milliman Care Guidelines (MCG) criteria of medical necessity for an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute appendicitis
 
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial is reversed. 

This patient is a female child who presented to the Emergency Department with abdominal pain. The patient stated that the pain was sharp and radiating from the left lower quadrant to the right lower quadrant.  The patient had nausea without vomiting.  The physical examination revealed tenderness in the bilateral suprapubic region left greater than right with no palpable hernias.  The diagnoses included rule out appendicitis versus ovarian pathology versus viral syndrome.  The patient's temperature was 98.8.  The patient's blood pressure was 143/64 and her heart rate 78.  The patient underwent a computed tomography (CT) scan which indicated acute appendicitis with reactive lymph nodes.  The patient was then admitted to the surgical team on the pediatric floor with a diagnosis of acute appendicitis. The patient underwent nonoperative treatment including intravenous antibiotics. The patient remained afebrile.  The day following admission, the patient tolerated the diet, voided, and ambulated without difficulty.  The patient was discharged with antibiotics.  

This case was previously denied as the patient was admitted for belly pain.  It was stated the patient could have received care in the Emergency Room or the observation area, instead of being admitted to the hospital.  According to MCG 23rd Edition, Pediatric General Admission Criteria GRG, they include "other severe infectious situation."  Inpatient admission was indicated in this case based on both guidelines and clinical justification since the patient presented to the Emergency Room with radiographically confirmed acute appendicitis that required intravenous antibiotics, serial abdominal exams, and intravenous fluids.  Due to the acuity of presentation and intensive clinical needs, any setting other than inpatient admission would not be prudent in this case. 

The inpatient admission was medically necessary for this patient. The health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  HIV, migraines, seizures
Issue under review:  Consumer directed personal assistant services
Determination:  The Consumer directed personal assistant services are medically necessary.

This is an adult female with a history of asthma, HIV, migraine headaches and seizure disorder.  Due to impairments related to these conditions, she requires assistance with the majority of her activities of daily living (ADLs).  The patient is status post (s/p) recent left flat foot reconstruction, cotton osteotomy and calcaneal osteotomy.  Due to a post-operative fall, she broke her post-operative cast and has been ordered by her Podiatrist Dr. Eisenberger to remain completely non-weight bearing to her left leg while wearing an ankle-foot orthosis (AFO) boot.  She will require follow up x-rays and clinical assessments to determine whether her surgical repair was successful, and she can resume weight bearing as tolerated to the left lower extremity.  For these reasons, the currently approved plan of CDPAS is not sufficient to meet the patient's needs.  Hence, the proposed treatment of an increase in CDPAS for improved assistance with completion of the patient's ADLs is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hypertension and hyperlipidemia. He presented to the emergency department (ED) complaining of seven days of intermittent, sharp, substernal chest pain that occurred both at rest and with exertion but was worse with exertion. He reported having had an abnormal nuclear stress test two weeks prior and indicated that he was told it needed to be repeated. In the ED, his blood pressure was 116/85 millimeters of mercury (mmHg) with a heart rate of 88 beats/minute. His respiratory rate was 20/minute. Room air oxygen saturation was 100%. His cardiac and respiratory exams were unremarkable. His electrocardiogram was normal. His serum troponin level and chest x-ray were normal. He was admitted to the hospital to rule out acute coronary syndrome. A repeat troponin level was normal. He had an episode of chest pain with no associated electrocardiographic changes. He was treated with acetaminophen. An echocardiogram was performed and was unremarkable. Myocardial perfusion imaging was performed and showed no evidence of ischemia. The progress note from this date stated that the patient was medically cleared for discharge. The health plan's detemination is upheld. An inpatient level of care was not medically necessary. This patient, with multiple cardiac risk factors, presented with chest pain that was thought to be suspicious for acute coronary syndrome (ACS). He reported having had an abnormal cardiac stress test. Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and a normal electrocardiogram. He did not require intensive monitoring or infusion of intravenous cardioactive medications. There is no indication in the records provided that other potentially life-threatening diagnoses were thought to be likely. His HEART score was 3, indicating a low risk for major adverse cardiac events. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes. Moreover, based on the records provided, there was no medical indication for continued hospitalization after perfusion imaging showed no evidence of ischemia.
Appeal type: Medical necessity
Decision: Upheld

Cancer
Radiation Therapy

The patient is a male with lymphoma of L (left) parotid gland. He was treated with several chemotherapy followed by adjuvant radiation therapy (RT) using Proton beam therapy. The Proton beam treatment is the subject of review.

The health plan's determination is upheld. The Proton Beam Radiotherapy: Radiation Therapy Consultation, Special Radiation Treatment Procedure, Guidance for Localization of Target Delivery of Radiation Treatment Delivery/Proton Treatment Delivery, Simple is not medically necessary for this patient. Medically necessary treatment is defined as those which are In accordance with generally accepted standards of medical practice in the United States. In this case, the generally accepted standard of medical practice in the United States is intensity modulated radiation therapy (IMRT). Thus, Proton beam therapy is not indicated for this patient's condition. The prescribed dose as consolidation radiation therapy (RT) in early stage lymphoma is moderate and can be delivered using photon beam with 3D CRT (conformal radiotherapy) or IMRT technique maintaining dose constraints of organs at risk (OAR).
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System/Neuromuscular Disorder
Genetic testing

The patient is a male with history of severe headaches related to cerebrospinal fluid (CSF) leak at T3-T5. The patient presented to his primary care physician (or provider) with complaints of right testicular pain. Office notes indicate the patient's son was being evaluated for possible hemochromatosis. The patient had a testicular ultrasound ordered and was sent for a genetic lab test for hemochromatosis. The health plan denied coverage for CPT 81256, genetic testing for hemochromatosis. The patient's PCP wrote a letter stating the patient had genetic testing for hemochromatosis in evaluation for headache of uncertain etiology, syncope and diplopia.

The health plan's determination is upheld. CPT 81256: genetic testing, is not medically necessary for this patient. The office notes indicate the patient's son had "possible hemochromatosis". The patient had complaints of right testicular pain at this office visit. The office notes indicated the patient had severe headache related to CSF leak at T3-T5. There are other laboratory tests that would be done first to assess possibility of hemochromatosis. Typically, liver function tests are abnormal with hereditary hemochromatosis. In addition, serum iron, TIBC (Total iron binding capacity), transferring saturation and ferritin laboratory tests are typically ordered in evaluation of iron overload/hereditary hemochromatosis. Certainly, if there is documented history of a first degree relative with hereditary hemochromatosis then a genetic test would be medically necessary. There was no documentation of a first degree relative with hereditary hemochromatosis in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth pain and swelling
 
Treatment: Nerve Treatment on tooth #20

The insurer denied coverage for Nerve Treatment on tooth #20.  The denial is upheld. 

This patient is a female who was denied a root canal on tooth #20.  The denial states that the patient has pain and swelling.  It was denied as the patient has eight or more posterior teeth in contact.  There are no clinical notes.  The clinical documentation consists of one periapical radiograph that is not clear.
According to the American Association of Endodontists (2020), "Patients typically need a root canal when there is inflammation or infection in the roots of a tooth.  During root canal treatment, an endodontist who specializes in such treatment carefully removes the pulp inside the tooth, cleans, disinfects and shapes the root canals, and places a filling to seal the space".  Brazier, Y. (2017) states, "If the pulp becomes injured or diseased, it cannot repair itself, and the tissue dies.  If there is a deep cavity, a cracked tooth, or a loose filling, bacteria can enter the pulp.  The bacteria will eventually destroy the pulp.  If the bacteria penetrates through the root openings, it can cause an infection in the bone.  An infection will weaken the bone and break it down.  The ligaments around the tooth will swell, and the tooth will become loose.  A pulp injury will make the tooth sensitive to high and low temperatures.  There may be pain when chewing, and some people have a continuous, throbbing pain".
 
The health care plan acted according to the guidelines of the plan language.  The standard of care does not rule out endodontic treatment if the patient has eight or more teeth in contact.      

To perform successful endodontic treatment, it is first necessary to correctly diagnose the affected tooth or teeth.  A series of tests should be performed.  These include: Palpation, mobility, percussion, bite test, sensitivity to cold and heat, pulp vitality tests, transillumination and periodontal probing.  Compilation of the information obtained from the results of all tests enables accurate endodontic diagnosis and formulation of a treatment plan.  As a result of this comprehensive testing, the offending tooth should have been identified and a pulpal diagnosis made.  There is no chief complaint, history, or diagnostic tests to support the need for endodontic therapy for tooth #20.  There are also no large carious lesions or obvious periapical pathology.  There is a periapical radiolucency but this appears to be from the mental foramen.  Therefore, the Nerve Treatment on tooth # 20 is not medically necessary.

Based on the above, the medical necessity for Nerve Treatment on tooth # 20 is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

The patient was evaluated in the emergency room (ER) with stabbing chest pain and dyspnea, which started 1 1/2 hours prior to presentation. The pain was 7/10 in severity, worse with movement and resolved spontaneously. The patient's blood pressure was 102/68 millimeters of mercury (mmHg), with a pulse of 52 beats per minute (bpm) and a respiratory rate of 17/minute. The patient was afebrile and had an oxygen saturation of 100% on room air. An electrocardiogram (EKG) showed sinus bradycardia at 48 bpm, normal axis and intervals, and no ST elevation or depression. Troponin was negative.
The patient was admitted and was seen in cardiology consultation.The patient was noted to have bigeminy. Troponins x2 were negative. An echocardiogram (ECHO) showed normal left ventricular (LV) size and function. The ejection fraction (EF) was 59%. Potassium and magnesium levels were supplemented. Initiation of a beta blocker was to be considered if the premature ventricular contraction (PVC) burden was over 10,000 on Holter monitoring. The patient was felt not to require further inpatient evaluation. The patient was discharged to follow up with cardiology for Holter results.

The health plan's determination of medical necessity is upheld in whole.

No, the inpatient admission was not medically necessary. The patient presented with chest pain, but was hemodynamically stable, with normal vital signs, and no ischemic EKG changes. Initial cardiac biomarkers were negative. The patient's chest pain resolved spontaneously in the ER, and there was no objective evidence for an acute coronary syndrome or other critical cardiac or pulmonary diagnosis. A lower level of care would have been appropriate
Per Milliman Care Guidelines for patients admitted with chest pain, inpatient admission is indicated for "hemodynamic instability, respiratory distress, chest pain indicative of serious diagnosis other than coronary artery disease (e.g., aortic dissection) severe pain requiring acute inpatient management, angina or myocardial infarction." None of these conditions apply in this case. A lower level of care, not full inpatient hospitalization, would have been appropriate in order to rule out a myocardial infarction.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, diaphoresis
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a male with a past medical history significant for hypertension, dyslipidemia, diabetes mellitus, spinal cord injury, and polysubstance abuse. He presented to the ER for evaluation of sub-sternal chest pain, non-exertional, associated with dyspnea and diaphoresis. 

The patient was hemodynamically stable. He reported recent cocaine abuse. His cardiac enzymes were negative. ECG (electrocardiogram) revealed normal sinus rhythm with LVH (left ventricular hypertrophy), no acute ischemic changes. The patient was admitted to telemetry to rule out ACS (acute coronary syndrome). He was seen in consultation by cardiology service and a nuclear stress test was ordered, which revealed no evidence of ischemia. The patient was subsequently discharged to detoxification unit with plans for outpatient follow-up.

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative, and the patient was referred for a nuclear stress test. Ischemia was ruled out by stress testing. There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elbow Pain
 
Treatment: Magnetic Resonance Imaging MRI of the arm without dye

The insurer denied the Magnetic Resonance Imaging MRI of the arm without dye. The denial was upheld.   

This is a female patient with a history of major depression disorder. She was evaluated by an orthopedist for complaints of right elbow pain. A magnetic resonance imaging (MRI) of the right elbow was performed that revealed common extensor tendinitis and no full thickness tears. There was slight enlargement of the ulna nerve at the level of the tunnel. 

MRI is of benefit if additional information assists in establishing a diagnosis. The scientific literature describes MRI should be recommended if conservative treatment has not been beneficial. The diagnosis can alter the decision, prognosis and plan of care. The necessity for more invasive procedures (surgical treatment) can be assessed. The performance of the MRI should have an impact on a patient's treatment regimen. If diagnostic tests are not clinically useful, they are not medically necessary.

The medical record demonstrates the patient had right elbow pain. There was no description of history present illness. There were no positive findings on physical examination. i.e. decreased motion and tenderness. There were no radiographs completed. There was no differential diagnosis. There was no treatment provided. 

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

Based on the above, the medical necessity for the magnetic resonance imaging of the arm without dye (pre-service) is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left arm numbness and lower extremity numbness 
Treatment: Inpatient admission 

The inpatient admission was not medically necessary. 

The patient is a male with history of recent AVR (aortic valve replacement) and MVR (Mitral Valve Replacement). He was seen in the ED for left arm numbness and lower extremity numbness. 

The patient's clinical exam revealed normal vital signs and no neurologic findings. CT and MRI of the brain did not reveal any evidence of acute hemorrhage or ischemic event. The patient was admitted to the hospital for anticoagulation with IV heparin and oral Coumadin. 

The patient had no clinical signs of a stroke or serious acute neurologic event. The CT and MRI did not reveal any findings consistent with an acute stroke or hemorrhage. The patient had stable vital signs. He was ambulatory. His pain was controlled. He was, tolerating a diet. There is no documentation of a medically necessary reason for acute inpatient admission. 

Anticoagulation with Lovenox as an outpatient has been shown to be effective for bridging to adequate INR (international normalized ratio) levels in patients with mechanical cardiac prostheses. There is no documentation as to why this was not considered in this patient and not offered. 

Therefore, inpatient admission for IV heparin cannot be considered medically necessary in this case.