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

Diagnosis: Chest Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient has a history of hypertension, seizure disorder, coronary artery disease (CAD) and substance abuse disorder. The patient noted a history of prior cardiac catheterization with nonobstructive CAD. The patient indicated a history of vasovagal syncope with prior evaluation including tilt table. The patient presented to the hospital complaining of chest pain and syncope following cocaine use. The patient reported chest pain radiating to the left arm that worsened with exertion.  Vital signs were stable (blood pressure 124/73, pulse 61 beats per minute).  The physical examination revealed no significant abnormalities.  The 12 lead electrocardiogram (EKG) revealed normal sinus rhythm with non-specific T wave inversions in precordial leads V1-V3.  Serum blood testing revealed no elevation in troponin level (<0.01). An echocardiogram revealed a reduced left ventricular ejection fraction of 45%.  Plans for stress testing were put in place but the patient signed out against medical advice. 

This patient presented with chest pain related to cocaine usage with nonspecific T changes noted as "mild" with negative troponin levels. Such patients are observed and when troponin levels remain negative can be further evaluated as an outpatient including stress testing. 
 
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a medical history significant for asthma who presented to the emergency department (ED with shortness of breath and a five-day history of an asthma exacerbation.  She reported a dry cough, pleuritic chest pain with cough, and no significant relief from bronchodilators at home.
Examination was significant for a regular heart rate and rhythm, poor air movement, diffuse inspiratory and expiratory wheezing, speaking in full sentences, no retractions or accessory muscle usage. She was treated first with DuoNeb's without significant response, parenteral magnesium and dexamethasone, racemic epinephrine with some improvement, and finally albuterol with improvement in wheezing and tachypnea.  She was admitted for ongoing management. Admission orders included albuterol every two hours. She was able to tolerate weaning to every three hours and then every four hours. Pediatric pulmonology was consulted with recommendations to follow-up as an outpatient. She reported headache and dizziness associated with asthma exacerbations. Pediatric Neurology was consulted with recommendations to follow-up as an outpatient. She was subsequently deemed stable for discharge home to continue albuterol every four hours for 24 hours. At issue is the medical necessity of an inpatient stay.

Inpatient hospital admission was not medically necessary for this patient.
Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. Gas exchange abnormalities are due to ventilation/perfusion mismatch from atelectasis and airway over-distention. There are many possible triggers including exposure to allergens and upper respiratory viral infections. Asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough.
In the ED, primary management strategies include correction of hypoxia, rapid improvement of airflow obstruction, and prevention of progression. This is achieved with supplemental oxygen, bronchodilators, and steroids. Fluid hydration may also be necessary. For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED, admission is necessary.
This female teen with a medical history significant for asthma and headaches presented with signs and symptoms consistent with an acute asthma exacerbation. She was treated aggressively in the ED with some improvement but not sufficient to discharge home. While it was reasonable to monitor her in the hospital pending improvement in symptoms, she was overall hemodynamically stable with no need for supplemental oxygen, no evidence of impending respiratory failure, no severe dehydration. She did not require acute inpatient admission and could have been safely managed at lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: cellulitis
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

This is a case of a male admitted for diagnosis of cellulitis of the left upper extremity. The patient presented with chief complaint of cellulitis that failed outpatient antibiotics. He had worsening left upper extremity cellulitis that started seven days prior to admission. He was started on doxycycline at urgent care and then was treated with clindamycin. Temperature was 97.7F, pulse 74, respiratory rate 20, blood pressure 131/94 and O2 (oxygen) saturation 97%. Physical exam showed no acute distress or altered mental status. The left upper extremity had a 4-centimeter (cm) round area of erythema and central scabbing just distal to the elbow.

The inpatient hospital admission was not medically necessary.
The patient in this case was admitted for cellulitis and a superficial soft tissue abscess but did not have a red flag condition which required hospitalization. He did not have toxic shock syndrome, necrotizing fasciitis, joint involvement, involvement of a vascular graft, pyomyositis, gas gangrene or compartment syndrome. There was no fever or leukocytosis. There was no rapid progression of erythema, immuno- compromising condition or inability to tolerate oral therapy. There was no hemodynamic instability. After drainage, he was given a packing and then able to be discharged home.
Although the patient required services in the hospital setting the monitoring, diagnostics testing, and therapeutic interventions could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient had a history of diverticulitis and presented with abdominal pain and fever. The patient was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. A computed tomography (CT) scan showed acute diverticulitis. There was no perforation or fluid collection. Intravenous (IV) antibiotics were given. The patient was discharged on an oral antibiotic and there was a discussion about a referral for a surgical resection.

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-150 for Acute Diverticulitis. Clinical indications for admission include hemodynamic instability, persistent gross bleeding, peritoneal signs, or a significant abnormality seen on an imaging study. This abnormality can be a fistula, obstruction, or free perforation. The patient did not have these conditions. The patient also did not require a drainage procedure, have bacteremia, severe vomiting, or an inability to maintain oral hydration after observation care.

This patient had a recurrence of diverticulitis but without an abscess or perforation. This could have been treated with a course of oral antibiotics as an outpatient.  The patient did not meet MCG criteria for admission for Acute Diverticulitis. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.

Treatment: Full braces.

The insurer denied coverage for full braces.

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, the montage of extraoral and intraoral clinical images, dental treatment notes as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, ectopic eruption, and anterior crowding among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 26 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index by internal reviewers. The patient's mother is appealing the decision on behalf of the patient.

Upon review of the submitted documentation (study models were not provided for review), 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, New York State requires, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labio-Lingual Deviation Index. 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. 

In this case, the treating orthodontist completes the second portion of the index arriving at 26 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which meets and attains the threshold of 26 points to support orthodontic care. 

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

Reverse denial as the clinical circumstance as presented does meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for full braces is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fall
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a previously healthy male patient who presented to the emergency department (ED) following a 10-foot fall from a ladder. The ED and trauma history and physicals (H&Ps) indicate that he initially was ambulatory with stable vital signs at the time of presentation. There was no reported loss of consciousness.  At the time of surgical assessment, the Glasgow coma score was 15/15. His evaluation with physical exam and imaging identified a lumbar (L) 1 vertebral body fracture and an L1 and L2 transverse process fracture.
He was admitted to the hospital per the trauma service. He was neurologically intact. He was treated with multimodal pain medication and incentive spirometry. A neurosurgical consultation yielded the recommendation for a thoracic lumbar sacral orthosis (TLSO) brace. He was cleared to ambulate. His diet was advanced. He was evaluated by the physical therapy service. He was discharged from the hospital. At issue is the medical necessity of an inpatient stay.

Inpatient hospital admission was not medically necessary in this case. The care provided could have been rendered with a lower level of care. This lower level of care would have provided for emergency department (ED) assessment, trauma and neurosurgery consultations, imaging as prescribed, monitoring, physical/occupational therapy and provision of pain medications during this period of time.
This patient presented to the ED following a 10-foot fall. He was clinically stable at the time of presentation. He was able to ambulate and was able to tolerate a diet. He was provided pain medications and physical therapy was requested. He remained clinically stable throughout the period of monitoring. He was found to have an L1 vertebral body fracture and an L1 and L2 transverse process fracture. These injuries did not require operative treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease (COPD).
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient with a history of chronic obstructive pulmonary disease (COPD) on home oxygen. Her presenting complaints were dyspnea and anxiety.  The physical exam was notable for respiratory distress on arrival, followed by subsequent examination with inspiratory and expiratory wheezing with a prolonged expiratory phase. Lab results were notable for leukocytosis. Radiology was notable for an unremarkable chest x-ray. The patient was initially treated with bi-level positive airway pressure (BiPAP) in the emergency department and admitted to an inpatient level of care for an acute exacerbation of COPD. At issue is the medical necessity of an inpatient stay.

The inpatient level of care is medically necessary.
The patient presented with a severe COPD exacerbation evidenced by hypoxia beyond her baseline and respiratory distress requiring non-invasive positive pressure ventilation on arrival. This presentation is a high risk, and her chances of further decompensation which could have included death or morbidity were elevated. An inpatient level of care was necessary to provide the patient with close, attentive monitoring of her condition's trajectory and response to therapies in addition to rapid diagnostic and therapeutic reassessment. A lower level of care would not have been appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Edentulous.

Treatment: D6751 white glass with metal cap for bridge, tooth 9, D6241, false tooth for bridge, tooth 10, and D6751 white glass with metal cap for bridge, tooth 11.

The insurer denied coverage for D6751 white glass with metal cap for bridge, tooth 9, D6241, false tooth for bridge, tooth 10, and D6751 white glass with metal cap for bridge, tooth 11.

The denial is overturned.

 
Upon review of the submitted documentation which includes copies of undated panoramic radiographs and periapical radiographs, multiple periapical radiographs, intraoral undated clinical photographic images, progress/treatment notes, narrative letter, and insurer correspondence, it appears that this patient presented for dental care with a failing preexisting fixed bridge in the anterior maxilla that had been present for many years. The recommended treatment was to replace the failing pre-existing bridge with a new one spanning teeth # (number) 9-11. The insurer denied this service, stating that medical necessity criteria were unmet. 

Upon review of the documentation, in particular the clinical photographs and radiographs it is evident that the preexisting bridge was failing. In this case, since the patient has a pre-existing fixed bridge, replacement with a fixed prosthesis spanning the # (number) 9-11 site as recommended is the standard of care dental treatment in general dental practice to restore function to the anterior maxillary dentition. As the dentition is already restored with a fixed bridge prosthesis the only treatment that would be considered appropriate for replacement of the current fixed bridge is another. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the patient's best interest. The medical necessity for D6751 white glass with metal cap for bridge, tooth 9, D6241, false tooth for bridge, tooth 10, and D6751 white glass with metal cap for bridge, tooth 11 services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anorexia Nervosa, weight loss. 
Treatment: Full hospital admission. 
The insurer denied the full hospital admission. 
The determination is overturned. 

This is a female teen with a medical history significant for panic disorder and obsessive-compulsive disorder (OCD) with restricted eating and a 50-pound (lb) weight loss over two years. She had an electrocardiogram and labs in anticipation of starting an eating disorder program, was noted to have heart rate less than 40, and was referred to an outside emergency department (ED). She was seen in the outside ED with labs and a repeat electrocardiogram, again with heart rate in the 40s, so was referred to a children's hospital for admission. 
The therapist reported that her primary care practitioner would not clear her medically because of the bradycardia and positive orthostatics. In the ED, she was not orthostatic, had no suicidal ideation, and labs from the previous day were within normal limits. After much going back and forth about admission and suitability for the eating disorder outpatient program, adolescent medicine accepted her for admission. 
Admission orders included cardiorespiratory monitoring, labs to evaluate for refeeding syndrome, regular diet with calorie count, consideration for psychiatric consultation due to history of anxiety, daily weights, daily orthostatics. Additional orders included nutritional rehabilitation program (NRP) hydroxyzine prior to meals to help with anxiety, nutrition consultation, possible anxiolytic, strict bed rest, vitamin and mineral supplementation, follow-up celiac panel and other specialty labs. 
She was stabilized and transferred from general pediatrics to adolescent medicine for further nutritional rehabilitation. On the new unit, her NRP started at 1600 kcal/d (kilocalories per day) with the same plan for advancement. 
At issue is the medical necessity of an inpatient stay. 
The inpatient stay was medically necessary. 
Anorexia nervosa is a medical condition with both physiologic and psychological components affecting people of all ages from all walks of life. Factors that would support need for medical stabilization include the following: heart rate less than 50 beats per minute (bpm), orthostatic changes in heart rate (sustained increase of more than 40 bpm), blood pressure less than 90/45, orthostatic blood pressure changes more than 20 mmHg (millimeters of mercury) drop in systolic blood pressure (SBP), glucose less than 60, hypokalemia, hyponatremia, hypophosphatemia, hypomagnesemia, hypothermia less than 36 degrees Celsius (C), and/or body mass index (BMI) less than 75% of median BMI for sex and age.
The adolescent in this case met many of these factors and did so until the date of discharge. Specifically, she did not reach 75% (percent) of median BMI even by the day of discharge, but was at 74% deemed adequate. She was no longer orthostatic by heart rate or blood pressure, and she was tolerating the provided 4200kcal/day.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Head Injury
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult male who presented to the emergency ward under the aegis of emergency medical services (EMS) after being found confused. At presentation, the patient had elevated serum ethanol levels. A computed tomography (CT) of the head showed a left parietal hyper-density suspicious for possible acute hemorrhage.

The requested health service was medically necessary.

The computed tomography of the brain at presentation was consistent with possible acute intracranial hemorrhage. This condition requires acute hospitalization, frequent neuro-checks, neurosurgical assessment, and repeated serial imaging (1, 2). This could not have been provided at a lower level of care. Therefore, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld. 

This is a female patient who presented to the emergency department (ED) with generalized lower abdominal pain. Her vital signs were unremarkable. Lab results were unremarkable. The white blood cell count (WBC) was 8.72. A computed tomography (CT) scan of the abdomen/pelvis demonstrated appendicitis. The patient was started on Zosyn. The patient was taken to the operating room and underwent a laparoscopic appendectomy with extensive lysis of adhesions without complications. The diet was advanced. The patient was again monitored overnight. She was discharged home. At issue is the medical necessity of an inpatient stay.

Inpatient stay was not medically necessary for this patient. The patient had acute appendicitis, but did not have evidence of other complications. The patient did well after surgery and was able to be discharged home early the next morning. The patient achieved discharge criteria in a reasonable amount of time. She did not have any evidence of complicated appendicitis. The patient did not have any evidence of active comorbidities requiring inpatient management. There were no complications such as wound infection, wound dehiscence, enterocutaneous fistula or continued ileus. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Class I occlusion.
Treatment: braces/monthly visits.
The insurer denied braces/monthly visits.
The health plan's determination is upheld. 

The patient in question is a female with a Class I occlusion with 4 millimeters (mm) overjet and 3 mm overbite. She has moderate maxillary and mandibular crowding. 

Braces and Monthly Visits are not medically necessary for this patient.
There is no medical reason to correct her malocclusion with braces. While the patient has crowded teeth, there is no posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. The patient's overjet is slightly more than ideal but her overjet would not affect oral health-related quality of life unless it was greater than 6 mm. If her teeth were aligned it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons, braces are not medically necessary.