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

This patient is a young child with no significant past medical history, who presented with seven days of intermittent fever, runny nose, cough, congestion and increased work of breathing. The child's parents report that her symptoms began one week prior with fever to 102 Fahrenheit and a cough. The patient had sick contact with a younger sibling who was in the PICU of another hospital with adenovirus. In the emergency room at the outside facility the patient was evaluated and determined to need admission. The child's examination revealed nasal flaring, tachypnea, respiratory distress. The patient was found to have prolonged expiration and wheezes. She was noted to have oxygen saturations ranging from 90% to 92% on room air. The patient was placed on supplemental oxygen with saturations improving only to 93-95% per the Registered Nurse (RN) documentation at the time of transfer. The patient was given Albuterol/Atrovent nebulizers three times with reported good response. The patient was assessed to have good aeration at 1- 1/2 hours post three treatments. She was on 2 liters (L) of oxygen via nasal cannula.
The patient demonstrated improved work of breathing and tolerating by mouth (PO). The patient's father was made aware that the child needed to be admitted. At issue is the medical necessity of the inpatient admission.The health plan's determination is overturned. The inpatient admission was medically necessary. 

This patient presented with a history of fever, increased work of breathing and URI symptoms. She was noted to be in respiratory distress with hypoxia, nasal flaring, subcostal retractions and wheezing in the ER. Her chest x-ray was positive for hyperinflation, peribronchial cuffing and prominence of bronchovascular markings. Her symptoms were not resolved after ER management. With abnormalities on her CXR she was at increased risk of deterioration of her respiratory status in the face of hypoxia and respiratory distress. She was given steroids and well as beta agonist treatment but persisted with hypoxia. Due to a persistent oxygen requirement and abnormal chest x-ray, clinical progression of her disease process and/or worsening was a concern. Continuous pulse oximetry and frequent respiratory assessment would be needed to monitor her clinical status especially given the fact that she was requiring 2L of O2 to maintain her saturations.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with sickle cell disease.  She  was admitted with the diagnosis of an uncomplicated acute pain crisis after presenting to the emergency room (ER).  She complained of being "light headed" and was transfused 1 unit of packed red blood cells.  Her pain was reported as a 10/10.  She received intramuscular and oral narcotics.  The patient also received IV fluids.  She  was discharged.  At issue is the medical necessity of the 3 day inpatient stay.
The health plan's determination is upheld.  The inpatient hospital stay was not medically necessary.  Although the patient reported 10/10 pain, her pain was controlled with a regimen that could have been administered at a lower level of care.  The packed red cells that were transfused did not require admission.  There is no evidence in the included documentation that the patient could not maintain oral hydration.  The patient did not have an active infection.  She did not require surgery and did not have acute chest syndrome.  She did not require intravenous (IV) narcotics.  She was hemodynamically stable and did not require intensive nursing care.  There were no other issues documented that required inpatient care to address them.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes with neurologic complications, frequent falls
 
Treatment: Personal Assistance Services

The insurer denied coverage for Consumer Directed Personal Assistance Services. The denial was reversed.

The most recent Uniform Assessment System (UAS) includes diagnoses: type 2 diabetes mellitus with diabetic neurologic complication, hypertension, morbid obesity, autoimmune thyroiditis.

The UAS form includes time allocated for aide services Monday through Friday for most IADLs and one ADL. The UAS indicates patient lives with parent. It is noted that mother and sister assist daily/as needed, but no details of the care they provide is documented. 

The patient had 3 falls in 30 days prior to the UAS, and continues to be at risk for falls. For IADLs, the patient needs either extensive or maximal assistance for meal preparation, housework, shopping, transportation, stairs.  For ADLs, the patient needs limited assistance for bathing. 

In the absence of a plan of care that identifies informal caregivers as capable and available to provide all the patient's care needs, it is medically necessary for assistance to be provided through personal care services; in this case, CDPAS.  It is recommended that approval is given for CDPAS 14 hours per week.
Appeal type: Medical necessity
Decision: Upheld

The patient has history of a squamous cell carcinoma of the cheek skin, which was treated with Mohs microsurgery with positive margins.  There was a recurrence at the parotid gland and masseter muscle, and this was resected revealing a 3.2 centimeter (cm) mass.  Radiation therapy is recommended to this area to attempt long term control and proton beam approach is requested.  The health plan's determination is upheld.

The proposed proton beam radiation therapy for this patient is not considered a standard treatment option recognized in the oncologic medical community.  There is a lack of any significant data published in peer reviewed medical literature supporting the efficacy and safety of proton beam radiation for head and neck malignancies.  There are multiple studies published that are single institution non-randomized trials stating the need for addition trials to determine the efficacy and safety of proton beam radiation therapy as compared to photon beam radiation intensity modulated radiation therapy (IMRT).  This is also not supported by National Comprehensive Cancer Network (NCCN) Guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
 
Treatment: Inpatient admission, diagnostic testing, monitoring

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

The patient presented to the ER with chest pain, radiating to his left shoulder and arm. He had a past medical history of hypertension, hyperlipidemia, and recent strep throat. EKG showed normal sinus rhythm and ST-segment elevation. He received heparin and underwent coronary angiography which showed no significant coronary artery disease. He had reduced left ventricular systolic function consistent with viral myocarditis. The patient was discharged with plans to obtain a cardiac MRI as an outpatient. 

The inpatient admission was medically necessary for this patient. Though the cardiac biomarkers were unremarkable, the clinical presentation and EKG were suggestive of acute coronary syndrome and acute myocardial infarction. The patient's care could not have safely been provided under observational level of care. Per MCG Guideline Angina RRG: M-40-RRG (ISC), the patient had suspected acute coronary syndrome based on symptoms and/or anginal-equivalent, with additional high-risk findings of ST elevation on EKG.
Appeal type: Medical necessity
Decision: Upheld

The patient has a hx of hypertension (HTN), morbid obesity, obstructive sleep apnea (OSA) non-compliant with continuous positive airway pressure (CPAP) who presented to the emergency department 1/23/19 with 1 month history of R (right) leg swelling, redness and pain as well as worsening dyspnea. The patient was admitted for cellulitis treatment and started on vancomycin and piperacillin/tazobactam. 

The health plan's determination is upheld. The inpatient stay is not medically necessary. The patient presented with LE cellulitis and was admitted for IV antibiotics and concern for untreated OSA versus obesity hypoventilation. The patient had significant comorbidities; however, was afebrile and had not previously tried abx (antibiotics) for edema/cellulitis. The patient did not meet acute inpatient status and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, GERD versus Acute Coronary Syndrome (ACS)
 
Treatment: Inpatient admission

The insurer denied the coverage. The denial was upheld.
 
This is a female patient with a past medical history notable for hypertension, hyperlipidemia, and gastroesophageal reflux disease (GERD).  She presented to the Emergency Room (ER) with complaints of chest pain, which was 9/10 in intensity, and associated with diaphoresis and nausea.  The pain was "burning" and non-radiating.  In the ER, she was given Maalox and famotidine which resolved her chest pain.  EKG was unremarkable and troponin was normal.  She was admitted to the hospital with the diagnosis of chest pain, and GERD versus Acute Coronary Syndrome (ACS).  She ruled out for myocardial infarction with serial negative cardiac biomarkers.  An echocardiogram showed normal left ventricular systolic function, with Left Ventricular Outflow Tract (LVOT) obstruction, with systolic anterior motion of the mitral valve.  Nuclear perfusion stress testing was suggestive of mild ischemia.  She remained clinically and hemodynamically stable throughout her brief hospital stay.  She was discharged home on to follow-up with cardiology as an outpatient.
 
The insurer has denied coverage for the inpatient admission. The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.  The acute inpatient admission was not medically necessary.

 The patient presented with chest pain, however the initial evaluation in the ER was unremarkable, including negative cardiac troponin and a non-diagnostic EKG.  Inpatient admission was not medically necessary for this patient.  In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing.  Further evaluation was warranted, however inpatient admission criteria was not met.  Although the patient had new onset symptoms, medical policy criteria were not met for any other additional extenuating circumstances. There were no other high-risk co-morbidities.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

This patient presented with atypical chest pain and a history of DM and HTN. Her pretest probability of coronary artery disease is low (Reference 1).  Utilizing the HEART (History, EKG, Age, Risk factors, initial Troponin) score, she was considered low risk (2 points) (Reference 2).  Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, she also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). 

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of hypertension, diabetes and cocaine use. The patient presented to the emergency department complaining of chest pain that became worse after using cocaine. The patient was admitted to the hospital to rule out acute coronary syndrome. Repeat troponin levels were normal. The serum potassium level remained normal. The patient left the hospital against medical advice. The health plan's determination is upheld.

This patient, with known coronary artery disease, presented with chest pain that was thought to be suspicious for acute coronary syndrome (ACS). Accordingly, monitoring until ACS could be ruled out was a reasonable approach. However, the patient was hemodynamically stable, with normal cardiac biomarkers, and no acute electrocardiographic changes. While the initial serum potassium level was markedly elevated, this was likely a laboratory error due to hemolysis as there were no other findings suggestive of hyperkalemia. The electrocardiogram, renal function and blood pH were all normal and subsequent potassium levels remained normal after a single dose of "hyperkalemia cocktail." The patient did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be safe and is in accordance with the 2010 American Heart Association recommendations on the management of patients who present to the emergency department with acute chest pain and who, like this patient, are at low risk for acute coronary syndrome.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain 
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain. The diagnosis of an acute myocardial infarct (MI) was ruled out by cardiac enzymes, which were negative. There was no evidence of acute myocardial infarction, ACS, decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. No inpatient ischemic evaluation was planned and the patient was discharged home the next day with a plan for outpatient follow-up.  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

This is a patient with hypertension, previous tobacco use and gastroesophageal reflux disease who presented to the hospital  with complaints of chest pain/pressure, 7/10 severity, which began the evening prior to admission. The pain began while at rest, was localized to the left chest and radiated to the left (L) neck. Blood pressure (BP) was 154/86 millimeters of mercury (mm Hg) and pulse 65 beats per minute (bpm). The health plan's determination is upheld. The patient was hemodynamically stable, with negative cardiac biomarkers, no respiratory distress, and no objective evidence for another critical cardiac or pulmonary diagnosis. The patient's HEART score was 2, indicating low probability of adverse cardiac events. Full inpatient admission is not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Paroxysmal positional vertigo 

Treatment: Inpatient admission diagnostic evaluation, and medication management.

The insurer denied inpatient admission. That denial was upheld

The patient has no significant past medical history.  He presented to the Emergency Room (ER) with vertigo and dizziness.  He did not lose consciousness. His pulse on arrival was 40 beats per minute.  EKG showed sinus bradycardia.  He was admitted and seen by cardiology.  Stress testing was normal.  Echocardiogram was unremarkable.  

Additionally, history included that "the patient stated every time he lays flat, leans over or turns his head he begin to feel dizzy with a room spinning sensation and he feels like he will fall over.  The symptoms lasted 3-5 seconds each time.  The patient admitted to similar symptoms about 1 year ago for 2-3 days but it resolved on its own."  He denied syncope.  It was noted in the ED History of Present Illness that the patient had days of vertiginous symptoms.  He was administered a liter of fluids and meclizine. He was orthostatic and a vagal response was entertained as an additional diagnosis. A diagnosis of benign paroxysmal positional vertigo was made and the treatment plan was to administer meclizine.

The acute inpatient admission was not medically necessary.  The patient had initial symptoms which were evaluated in the ER, and they resolved.  There were no signs or symptoms of ischemia, heart failure, need for pacemaker (permanent or temporary), toxicity, renal or liver failure, or focal neurological abnormalities seen on imaging suggesting a stroke. As such, the patient's care could have been provided under observational level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sepsis 

Treatment: Inpatient Admission

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

The patient is a male with past medical history significant for recently diagnosed metastatic esophageal cancer, hypertension, diabetes mellitus, and liver cirrhosis, who presented to the Emergency Department with complaints of fever, hiccups, and weakness.  Vitals on presentation included:  Temperature 100.8 F, Blood Pressure-136/73, Pulse-103, Respiratory Rate-20, Oxygen (O2) saturation-98% on Room Air.  Laboratory results included the following; White blood cell (WBC) count-13.5, hemoglobin (HGB)-7.3, hematocrit (HCT)-23.2, creatinine-1.2, glucose-174.

He was empirically started on intravenous antibiotics (vancomycin, cefepime, and Flagyl) for possible infection.  The patient received a blood transfusion and Venofer for symptomatic anemia.  His chest x-ray was negative for infiltrate.  Blood and urine cultures remained negative.  Infectious Diseases consulted for possible aspiration pneumonia.  He improved clinically and was discharged to continue outpatient management including initiation of chemotherapy.  According to the documentation, the patient presented with fever, tachycardia, leukocytosis, and symptomatic anemia.  The source of infection was unclear; the patient was subsequently covered with triple intravenous antibiotics.  The patient also required blood transfusions for symptomatic anemia.  Based on these multiple abnormalities in a high-risk patient with metastatic cancer, hospital admission was medically necessary for intravenous antibiotics and additional diagnostic evaluation.

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

Diagnosis: Chest pain
Treatment: Inpatient admission
Inpatient level of care was not medically necessary.

This is a patient with known CAD and renal failure who was admitted for atypical chest pain and mild hyperkalemia. Treatment was limited to IVF and ASA. No evidence of ischemia was found and no intervention was indicated.

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome (ACS). Blood pressure (BP) was normal. Exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia.  EKG showed non-ischemic changes. Chest x-ray (CXR) was normal. The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for ACS such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG).   The patient left against medical advice.

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry and IVF, frequently performed in a lower level of care. The patient was admitted for monitoring, and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of active CAD. All tests showed absence of ischemia.  While there is always a potential for an adverse event, one did not happen and no actual treatment was added.

Milliman criteria requirements were not fulfilled as there was never any evidence of ACS present. This episode could not be described as active or unstable angina as no findings corroborating that diagnosis were found. It is not the TIMI risk score that determines level of care, but the need of inpatient level of care actually performed.  All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

This denial explanation is consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impaction of teeth

Treatment: IV sedation each 15 minutes x 2

The insurer has denied coverage for IV sedation each 15 minutes x 2. The denial was reversed.

This patient is a female under the care of both an Oral Maxillofacial Surgeon (OMS) and Orthodontist.  The orthodontist removed the maxillary appliances, but left the lower appliances in place due to the impaction of teeth 18 and 31. The patient has impacted wisdom teeth, the lower two preventing the second molars from properly erupting.  The orthodontist recommended removal of the third molars and luxation of the second molars into a more favorable position for eruption.

In the review of the records provided, it appears that the recommended treatment plan is both medically necessary and follows the standard of care.  The teeth need to be removed to allow for eruption of the second molars.  The second molars are now positioned mesially due to the lack of arch length and position of the wisdom teeth.  To treat this patient will require removal of the wisdom teeth and luxation of the second molars into a more favorable position.  

Anesthesia is medically necessary for the patient who is undergoing the above stated surgery. Due to the degree of difficulty, invasiveness of the surgery, need for the patient to be still, proximity to vital structures i.e. inferior alveolar nerve, and pain control, this request is both appropriate and medically necessary. "Several sedation options are used to minimize pain, anxiety, and discomfort during oral surgery procedures.  Minimizing or eliminating pain and anxiety for dental care is the primary goal for conscious sedation.  Intravenous conscious sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands.  No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate as well as cardiovascular function.  Patients must retain their protective airway reflexes, and respond to and understand verbal communication.  The drugs and techniques used must therefore carry a broad margin of safety." (Southerland, J. H., Brown, L. R., 2016).

"The use of sedation and general anesthesia in dentistry is safe and effective when properly administered by trained individuals.  The American Dental Association strongly supports the right of appropriately trained dentists to use these modalities in the treatment of dental patients and is committed to their safe and effective use." (American Dental Association).


The carrier's denial of coverage for IV sedation each 15 minutes x 2 is reversed.  The medical necessity is substantiated.