Persius/imr-appeals huggingface dataset:
The patient is a female with metastatic lung cancer who presented to the Emergency Department with a primary complaint of chest pain, with associated cough and vomiting. She is currently receiving chemotherapy and has a history of mycobacterium avium-intracellulare (MAI) infection as well. Workup in the emergency room (ER) showed abnormal chest imaging as well as new electrocardiogram (EKG) changes. Vital signs and physical examination were non-diagnostic. She was admitted for "chest pain likely as a consequence of cough secondary to irritation from lung cancer" with a plan for serial troponin measurement and pain control.
Following admission, her troponins were negative. Oncology and Interventional Radiology were consulted, and she underwent a therapeutic thoracentesis. On the day after admission, she was discharged home with a plan for follow-up with her oncologist.

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

No, the requested health service of inpatient stay was not medically necessary.
This admission does not meet criteria for inpatient acute medical admission based upon the standard Milliman Care Guidelines (MCG) guidelines for chest pain, which was both the chief complaint in the ER and the principal diagnosis by the admitting and discharging doctor. The hospital argued that there was concern the signs and symptoms may develop into a serious medical condition. Unfortunately, that is not backed up in any way by the medical documentation from the doctors involved in her care.
In fact, the actual documented assessment and plan of her condition was lacking and does not demonstrate that concern. In fact, it suggests that his belief was that her lung cancer was the cause of her chest pain (but there was no plan to address that). There was no explanation for the EKG abnormalities or how it potentially could represent something serious like acute coronary syndrome, nor does it have a treatment strategy for a serious condition. There were no high risk features of life-threatening acute disease, such as significantly abnormal vital signs or elevated troponin, and pretest probability for a condition requiring cardiac intervention was low (Penumetsa 2012). Her HEART score was only 2, which suggests a very low risk of major cardiac events (Backus 2013). Without supportive documentation, an inpatient stay was not medically necessary, and could have been managed at a lower level of care status, which is appropriate for most chest pain patients even if there is adequate documentation of concerning features.
This is a patient who presented with a request for detoxification services.  The patient reported that he was using alcohol on a continuous daily basis together with the use of crack cocaine and Xanax.  He has a history of bipolar mood disorder and posttraumatic stress disorder with associated symptoms of anxiety.  He was taking Seroquel and Lexapro to address the mood, trauma and anxiety disorders.  He had received multiple past substance use disorder treatments including three recent detoxification treatment episodes.  He had also received multiple other detoxification treatments in the year prior to his presentation without significant follow up for aftercare or use of medication assisted treatment.
The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol or drug withdrawal symptoms.  He had no acute general medical problems; he had a history of lower back pain and neuropathy.  He was tobacco dependent.
The health plan's determination is upheld.
The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring.  The patient displayed no serious disturbance of mental status, despite having a history of ongoing substance use disorder with alcohol and use of crack cocaine and Xanax.  Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment.  There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment recently.
The patient presented to the emergency department (ED) just before midnight with the complaint of coughing and breathing fast for two days. The patient has a history of asthma and did not improve following albuterol. The patient also also began vomiting. The Vital Signs on ED arrival were a temperature of 99.0F, heart rate (HR) 142, respiratory rate (RR) 48, blood pressure (BP) 114/76, and pulse oximetry 90%. The patient was started on supplemental oxygen and given nebulizer treatments and oral steroid
Patient was admitted with a diagnosis of status asthmaticus. After admission placed on albuterol every 2 hours, oxygen, and continued on PO steroid. Patient was also suspected to have a left lower lobe pneumonia and was started on intravenous (IV) ampicillin for this. Patient had initially a poor clinical response to treatment and was then given IV magnesium sulfate x1. The health plan determination is overturned in whole. The inpatient stay was medically necessary. This patient had respiratory distress as indicted by tachypnea and significant retractions and decreased oxygen saturations. Patient had vomiting secondary to increased work of breathing. The severity of his symptoms and poor response to initial treatment warranted inpatient medical care.
Diagnosis: Ascending lymphangitis
 
Treatment: Inpatient admission

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

This patient is a female child with a history of intermittent asthma and allergy to peanut butter who presented to the Emergency Department (ED) with the chief complaint of left arm redness and pruritus. The parent clearly gave the history of this beginning as a small white dot on the dorsum of her finger (2nd metacarpophalangeal joint), which she thought was a bug bite, and reported that by the next morning she woke up with erythema and local itchiness. There was no pain or fever by history.

In the ED she had no fever and her vital signs were stable. On examination there was a tiny scab on the dorsal aspect of the left hand with surrounding erythema, and erythema and swelling tracking up the left forearm, but this was not tender to palpation. There were additional areas of redness and warmth on ventral aspect of the wrist with streaking up the forearm and another area of warmth and redness proximal to the elbow on the upper arm. There was no sign of fluctuance, abscess or drainage. This was a classic presentation of ascending lymphangitis. There was no lymphadenopathy.
The documentation shows that it was unlikely that the cause was infectious, that she had no signs of sepsis, and that she had normal laboratory values. She was admitted for IV antibiotics and observation, but the rationale for that is not documented. Although these areas of redness representing lymphangitis were extensive, the largest being 16.5 cm measured longitudinally, there was no evidence of deeper soft tissue involvement, (no evidence of tenosynovitis, joint involvement, muscle involvement, fasciitis, or compartment syndrome). The patient had no complaints of pain; she had itching and discomfort. Given her age, after receiving 1 dose of IV Clindamycin, the patient could safely have been treated and observed as an outpatient on oral antibiotics to cover both group A Strep and Staphylococcus aureus infection as possible bacterial causes of her cellulitis with lymphangitis secondary to the dorsum of hand lesion as the portal of entry.

Based on the above, the medical necessity for the inpatient admission for acute level of care is not substantiated. The insurer's denial is upheld.
Diagnosis: Testicular cancer
Issue under review: PET/CT

Determination:
The PET/CT is not medically necessary.

For a residual mass under 3cm for pure seminoma with normal tumor markers, the NCCN does not recognize the role of PET/CT for disease management.  Per the NCCN, a patient such as this should be placed on surveillance, and there would be no role for PET/CT, as the patient's lymph node disease is all under 3cm.  

The AP's note that, "... given the substantial size of the lymph nodes, a PET scan is warranted to check fluorodeoxyglucose (FDG) activity," is not correct. Per the NCCN, PET/CT should only be performed if a residual mass is over 3cm. Per the NCCN, following completion of chemotherapy CT scans should be performed, and then, if a mass is over 3cm, then PET/CT can be performed. The NCCN does not base the use of PET/CT on the size of the original masses. This patient's residual LN was less than 3cm, and therefore would not support a PET/CT. Therefore, the 78815 - PET CT is not medically necessary.
Diagnosis: Right upper quadrant pain, hepatocellular carcinoma
Treatment: Inpatient admission 

Summary:
In the hospital, the patient's pain was controlled with IV morphine. He tolerated the diet well and did not have any episode of vomiting. He also remained hemodynamic stable, and did not have episode of hemodynamic instability, no evidence of any infection. He was also seen by General Surgery and as per their opinion, the patient did not have any evidence of cholecystitis and did not require any surgical intervention. Given this clinical scenario, the patient could have been appropriately managed at the lower level of care, and acute level care was not appropriate and medically necessary.
Diagnosis: Right-sided flank pain and groin pain
 
Treatment: Inpatient hospital services

The insurer denied the Inpatient hospital services. The denial was reversed.

This patient is a female who presented to the emergency department complaining of right-sided flank pain as well as groin pain.  The patient does have a history of prior kidney stones as well has anemia, depression, bipolar disorder, asthma, chronic obstructive pulmonary disease.  The documentation indicated the patient resides in a shelter.  She complained of ongoing pain that was worsening. She also complained of a cough feeling like something was stuck in her throat.  The documentation detailed the patient's prior records did show an 8.5 mm stone on the right ureter.  

The plan was to admit the patient and treat her with intravenous (IV) fluids as well as Toradol and have her undergo additional laboratory and diagnostic studies.  The patient's urinalysis did reveal large blood.  It was recommended that the patient begin Rocephin and undergo surgical intervention to place a stent in the next 24 to 48 hours.  The documentation indicated after admission that the patient was placed on NPO (nothing by mouth) status.  The patient was given morphine for pain control.  The patient did appear to be in mild distress secondary to pain and she continued treatment.  The documentation also detailed that she underwent a gynecology consultation due to decreasing hemoglobin.  She did have 2 fibroids that were discovered on ultrasound and it was recommended the patient continue with Provera and have her undergo a transfusion if needed. The patient underwent ureteroscopy with lithotripsy and stent placement under general anesthesia. Subsequently patient was deemed stable and she was discharged.

According to referenced literature, an inpatient admission may be needed for a patient when there is evidence of kidney stones as well as severe pain, urinary tract infection, the need for IV hydration, and a stone removal procedure is needed.  Within the documentation it was noted this patient did present complaining of worsening flank pain.  The documentation did detail she had recently been seen and diagnosed with a kidney stone.  She was recommended to have a stent placed however did not do so.  Therefore, the inpatient admission was needed as she did have prior care with ongoing worsening symptoms.  The documentation did detail she required morphine for pain control and had evidence of large blood in her urine.  The patient needed IV hydration as well and a stone removal procedure.  The patient underwent surgical intervention and continued to have rose-colored blood drain into her Foley.  She also complained of nausea and vomiting postoperatively.  Therefore, the continued inpatient services were the most appropriate level of care that could have been provided to this patient.  The health care plan did not act reasonably, with sound medical judgment and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated.  The insurer's denial is reversed.
This case involves a female who underwent a biopsy of the left calf.  The pathology report detailed the patient had a malignant melanoma with a maximum tumor thickness of 0.4 mm.  There was no ulceration and the pathologic stage was pT1a.  The patient did undergo the requested DecisionDX testing revealing the patient was a class I, which is associated with the lowest risk of recurrence.  

The DecisionDx-Melanoma, a 31-gene panel assay, is stated to determine the risk of recurrence and metastases of the melanoma.  However, the test is not the standard of care.  The DecisionDx-Melanoma test is not recommended by the panel of expert authors of UpToDate. The following are the guidelines for diagnosis and prognosis of cutaneous melanoma offered by the expert authors in UpToDate: "SUMMARY - A simple, accurate staging and prognostic system provides important insight into the prognosis of patients with cutaneous melanoma, thus facilitating appropriate treatment.  Staging and prognosis are based upon the tumor (T) node (N) metastasis (M) system, which incorporates information about the primary tumor, regional lymphatics, and potential distant metastatic sites."

The patient would not be considered a good candidate for the requested testing and it was not the best available treatment for the patient at the time of testing.  As such, the requested service is not likely to be more beneficial than any other standard treatment or procedure.  

The carrier's denial of coverage for DecisionDX-Melanoma testing should be upheld.
Diagnosis: Hematemesis

Treatment: Inpatient Hospitalization

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

This is an elderly male patient who presented to the emergency department (ED) with complaint of two episodes of hematemesis (bright red blood) with small clots occurring in one day. The patient exhibited normal bowel sounds, abdominal distention, and ascites noted. He has a history of diabetes mellitus, essential hypertension, pleural effusion, gastroesophageal reflux disease (GERD), portal vein thrombosis, shortness of breath, cryptogenic cirrhosis complicated by refractory ascites, requiring Denver hunt status post revision in late 2018, esophageal varices (recent bleeding, repeat hematemesis and esophagogastroduodenoscopy),end stage renal disease (ESRD) on hemodialysis (Monday-Wednesday-Friday), and liver disease.  The patient was admitted overnight and discharged home with plan to follow up with his gastroenterologist.

Per MCG, clinical indications for admission for Liver Disease Complications (M-570) include hepatic encephalopathy that is moderate to severe and unresponsive to observation treatment, infected ascites, severe hepatitis, severe vomiting, and acute hepatic decompensation. The patient did not have these conditions. Gastrointestinal (GI) bleeding is an indication for admission. However, in this case, there was no evidence of active GI bleeding either by history or based on the endoscopic findings. The patient did not have any high risk endoscopic features and was hemodynamically stable. The patient only reported a minimal amount of blood after he vomited. This patient had cirrhosis. There was no indication of an active GI bleed. 

Based on the above, the medical necessity for the inpatient hospitalization is not substantiated.  The insurer's denial is upheld.
Diagnosis:  Deep Vein Thrombosis

Treatment:  Inpatient Admission

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

This is an elderly male patient, who presented to the emergency department with a one-week history of right leg swelling, pain, and tenderness to palpation.  He stated he could not walk on his right leg due to pain.  He had a medical history of hypertension.  It was recommended the patient undergo laboratory studies and an ultrasound.  The patient's laboratory studies revealed an elevated D-dimer of 8.55.  The ultrasound revealed an occlusive deep venous thrombus of the sapheno-femoral junction, proximal, mid, and distal superficial femoral veins and popliteal vein likely sub-acute status.  His chest x-ray was negative for acute pulmonary process.  It was recommended the patient be admitted for further care.  The patient was treated with Lovenox, Amlodipine, and Eliquis.  It was reported that the patient was alert, oriented, and was able to ambulate.  The patient experienced no significant adverse events during his hospital admission.  He was discharged when deemed medically stable with recommendations for follow up. 

According to current literature a patient may be admitted to inpatient care when there is evidence the patient is considered a high risk for acute complication, such as documentation of a recent surgery, recent Gastrointestinal (GI) bleed, and history of intracranial bleeding, history of active bleeding with anti-coagulation or there is evidence of active substance abuse.  Additionally, if there is a limb threatening infection, then a patient may be admitted.  The submitted documentation did not indicate any of the above conditions.  There is no personal allergic reaction in response to anticoagulation requiring monitoring beyond observation care that would warrant the requested inpatient stay.  There is a lack of submitted documentation detailing why this patient could not have continued care in an observation level.  The patient could have been observed and treated with anticoagulation therapy.  Therefore, the inpatient admission was not medically necessary, and the prior denial remains upheld.  The health plan acted reasonably and with sound medical judgment, in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
The patient is a male with a Class I occlusion with minimal overbite and overjet. The orthodontist states he has anterior crossbites on teeth 7 and 10. He has a convex profile. He is treatment planned for 24 months of orthodontics with extraction of 5, 12, 21 and 28 to correct his malocclusion. This was denied by the health plan based on lack of medical necessity. The subject under review is the medical necessity for the requested orthodontic treatment.

The health plan's determination is upheld. 

The requested treatment is not medically necessary for this patient.
The patient has an excellent occlusion and appropriate overbite and overjet. There is some minor spacing, but this alone does not rise to the threshold of medically necessary. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. Although the patient has some minor spacing, his teeth are in a solid Class I occlusal relationship. He has minimal overbite and overjet on 7 and 10, but the photographs do not indicate any incisors in a traumatic relationship. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.1 This patient presents with none of those conditions.
Diagnosis: Pain due to Sickle Cell
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The patient is a teenage male with medical history significant for sickle cell SS disease on a monthly transfusion program, with multiple PICU admissions, including admissions for pain crises and acute chest syndrome. He was referred to the ED for evaluation of abdominal pain. The pain initially started in his knee and shoulder the day prior. It migrated to his abdomen, was periumbilical in location, rate 6/10, and described as stabbing. It was unrelieved by Percocet and ibuprofen. He had no other symptoms, no fevers, anorexia, vomiting. He did report onset of a nonproductive cough. 

The patient's vital signs included temperature 37.2, heart rate 90, respiratory rate 20 with 97% saturation in room air. Examination was significant for no acute distress, clear lungs, and diffuse abdominal tenderness, worst in the periumbilical area. His port was inaccessible, so an IV was started and he was treated with Dilaudid. Laboratory evaluation revealed hemoglobin 9.8 with 2+ sickle like cells, 5.4% reticulocytes, total bilirubin 4.6, AST (aspartate aminotransferase) 63, and WBC (white blood cells) 14.2K with 52% neutrophils and 7% bands. 

The patient was diagnosed with sickle cell crisis with vasoocclusive abdominal pain, and admitted for further pain management. Admit orders included round-the-clock Toradol, maintenance IV fluids, Tylenol as needed for moderate pain, Dilaudid as needed for severe pain, ranitidine for GI (gastrointestinal) protection, folic acid, albuterol for his dry cough, and Hematology consultation. 

The patient's pain was severe overnight, requiring Dilaudid in the morning. He was transfused as per his transfusion program. By the day of discharge, his pain had improved, and he had no tenderness on exam. He was deemed stable for discharge home, to follow-up with Hematology in one to two weeks and pediatrician in one to two days.

This male teen presented with abdominal pain characteristic of previous vasoocclusive crises, preceded by extremity pain, rated 6/10. He had failed outpatient treatment with Percocet, and required Dilaudid in the ED with marginal improvement. He had a cough but was otherwise stable with no fevers. He was due for his routine transfusion. Based on his presentation and the standard of care at the time, acute inpatient admission for parenteral pain management was medically necessary and appropriate. This intensity of care could not have been safely provided at a lower level.