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

Diagnosis:  Schizoaffective disorder.
Treatment:  Continued mental health inpatient admission.
The insurer denied continued mental health inpatient admission.  The denial is overturned.

The patient is a woman.  The patient has a history of mental illness and has been diagnosed with schizoaffective disorder.  There is a prior history of psychiatric treatment, psychopharmacology treatment, and psychiatric hospitalizations.  The patient is unemployed, has been sexually abused, and has low educational level.  She had been non-compliant with medications for two days prior to admission. 

The patient represented an elevated risk of dangerous behaviors including aggressive behaviors, self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore, the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained psychotic.  The patient had multiple static risk factors for potentially dangerous behaviors, including history of suicidality, inpatient hospitalizations, trauma, and diagnosis with a severe mental illness.  Therefore, the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained psychotic was acute risk factor for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a female at the time of admission to the hospital, with a past medical history significant for diabetes, HTN (hypertension), thyroid disease and paroxysmal atrial fibrillation. The patient presented to the ER with new onset palpitations and was found to have atrial fibrillation at 154 beats per minute. The blood pressure was stable. The ECG revealed atrial fibrillation with rapid ventricular response. Her initial troponin was 0.03, increased to 0.09, then trended down to 0.07, consistent with increased myocardial demand due to tachycardia. Her heart rate was controlled with IV metoprolol and Cardizem and subsequently switched to oral preparations. She was admitted to telemetry. Echocardiogram was obtained and revealed normal LV function. She spontaneously converted to normal sinus rhythm. A stress test was obtained and revealed no evidence of ischemia. The patient was discharged home with a plan for outpatient follow-up.

The patient presented with atrial fibrillation with rapid ventricular response. Her initial cardiac troponin was normal, but repeat was elevated, consistent with myocardial injury, likely demand ischemia in the setting of tachycardia. The patient required IV metoprolol and Cardizem for rate control. Subsequently, her troponin levels trended down and she spontaneously converted to normal sinus rhythm, but at the time of admission, it was not known that her course would be favorable. Given rapid atrial fibrillation, as well as elevation in cardiac biomarkers/troponin, consistent with myocardial injury, which increases the risk of adverse cardiac events, it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe hyperglycemia

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admission.

The denial is reversed. 

This patient is a male child who presented with polyuria, polydipsia, and a blood sugar greater than 500. The patient's initial blood glucose was 735. The patient's hemoglobin A1c was greater than 16%. The patient's sodium level was depressed at 125, and had a venous blood pH of 7.35. The patient was diagnosed with a new onset of type I diabetes mellitus with dehydration. The patient was started on subcutaneous insulin. The patient and his family received diabetes education.  The patient's glucose levels ranged from 233 to 495, and appropriate adjustment were made to the insulin doses. The patient's family completed the diabetes education.

The majority (75%) of medical centers in the United States that treat new onset type 1 diabetes admit their patients. According to the American Diabetes Association (ADA) statement on treatment of type 1 diabetes, hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education. In type 1 diabetes, the initial hospitalization is to educate the patient and the family in self-injection, drawing up and mixing of insulins, checking blood sugar, recognizing and responding to hyper and hypoglycemia, and evaluating ketosis, as well as nutrition education on carbohydrate counting because there is only one treatment option (insulin). Learning these skills is an overwhelming task for most patients and families and is the reason that this is done with a 2-3 day admission to the hospital. 

In this case, the patient had severe hyperglycemia, dehydration associated with his new onset diabetes. The patient and family required diabetes education as described above. The patient and family received appropriate diabetes education while the insulin doses were adjusted during the hospitalization. The requested hospitalization is consistent with generally accepted standards of medical practice and is therefore considered medically necessary for this patient.

The health 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 admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: central nervous system /neuromuscular disorder headache 
Treatment: Inpatient hospital  
The insurer denied the inpatient hospital stay
The denial is upheld in whole 

This case involves a patient with history of sickle cell disease, requiring multiple hospitalizations for acute chest syndrome, deep vein thrombosis (DVT) and pulmonary embolism (PE), avascular necrosis of the right hip status post replacement as well as prior history of cerebrovascular accident (CVA) without residual weakness, presented to the hospital with complaints of back pain and blurry vision.
No, the requested health service/treatment of inpatient stay is medically not necessary for this patient. This presentation can be managed under a lower level of care. Based on the documentation provided in this medical record, there are no clear indications for admission of this patient to the inpatient level of care. The patient did not have a stroke or a seizure. There is no evidence of acute chest syndrome. There is no hypoxemia, active wheezing cough, and chest x-ray is clear. There is no evidence of acute renal failure. The patient's hemoglobin is 7.7, which is in the typical range for a patient with such complicated sickle cell disease.
The patient's clinical examination was inconsistent with a TIA, and there is no evidence of active hemolysis in the laboratory evaluations. The patient did not require multiple transfusions. There is no evidence of an infectious process, leading to the patient's symptoms.
As a result, this hospital presentation can be accomplished under a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Digestive System/Gastrointestinal.
Inpatient hospital.
Diagnosis: left sided chest pain, nausea and vomiting.
Treatment: Inpatient stay.
The insurer denied the inpatient stay.
 The health plan's determination is overturned.

The patient is a man who presented to the hospital with a chief complaint of left sided chest pain, nausea and vomiting. He stated that he had been drinking alcohol excessively over the past three days. He reported vomiting multiple times on the day of presentation. Past medical history included alcohol abuse, coronary artery disease (CAD), hyperlipidemia and hypertension. 

The inpatient hospital admission was medically necessary. The patient presented with multi organ dysfunction, demonstrating metabolic acidosis, acute kidney injury, tachycardia, and alcohol withdrawal. He required close monitoring of electrolytes, lactate levels, and symptoms of alcohol withdrawal to guide benzodiazepine treatment. This intensity of care is appropriate for inpatient management given the patient's complexity. He did experience rapid improvement and was discharged after electrolytes normalized but he required inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Kidney Disorder 
Inpatient Hospital 

Diagnosis: Acute Renal Failure 
Treatment: Inpatient stay 

The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a male with no significant history who presented to the emergency department (ED) with complaints of bilateral flank pain, urinary pressure and suprapubic pressure upon urination. 

The inpatient stay was medically necessary. The patient was clearly in acute renal failure with initial creatinine of 2.1 that did not improve initially despite intravenous fluids. The creatinine increased to >=1.5 times the presumed baseline value and was presumed to have occurred within the prior seven days. The creatinine level continued to rise and peaked at 3.2. The patient required intravenous fluids and frequent monitoring of blood levels of BUN and creatinine as well as a renal biopsy. There was adequate clinical need that warranted an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Substance Abuse
Inpatient Hospital

Diagnosis: Substance abuse
Treatment: Inpatient hospital stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is an adult male who presented to the emergency department with request for detoxification treatment and was medically screened and admitted to inpatient level services for detoxification of heroin and alcohol and cocaine use, as well as use of benzodiazepines and cannabis; he had been using up to one bundle of heroin daily with intravenous (IV) administration together with one pint of liquor and an unspecified amount of cocaine, cannabis and benzodiazepine on a daily continuous basis. 

The inpatient detoxification treatment and withdrawal management could have been safely and effectively provided with lower level services after evaluation and treatment in the emergency department. The patient in this case was using heroin, alcohol, cocaine and other substances of abuse on a continuous daily basis. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have warranted admission for inpatient level services. Moreover, the withdrawal symptoms were not reported to be severe and the patient had received detoxification treatment 9 days prior to his presentation accounting for minimal or light withdrawal symptoms; and, the patient's clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment or monitoring. There were no safety concerns in this case and no history of recent complicated withdrawal from drugs or alcohol. The patient was considered to be motivated for detoxification treatment, and had access to substance use disorder services in the community. Thus, medical necessity is not met in this case for the requested benefit of an admission and continued inpatient detoxification and other medical services in keeping with prevailing standards of professional practice, and consistent with the American Society of Addiction Medicine (ASAM) Criteria and scientific literature. The application of NY State OASAS LOCADTR 3.0 Guidelines also indicated that inpatient level substance use disorder treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebrovascular Accident.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with a medical history of cerebrovascular accident without residual deficits and diabetes mellitus.  The patient was brought to the Emergency Room (ER) by the ambulance with complaints of bilateral foot weakness and a cough. Her presenting vital signs were: blood pressure was 156/93, heart rate was 71 bpm, temperature was 98.6 F, and respirations were 16.  The patient was alert, awake, and responding to voice.  The patient reported that the weakness began a couple of days prior to presentation. The patient was able to stand with an unsteady gait; she was dragging her left foot.    The patient noted that the last time she had similar symptoms she had a stroke, which had resolved. The patient's physical examination revealed cranial nerves II through XII were grossly intact with no focal neurologic deficits. A computed tomography (CT) scan of the head was performed with negative results. A lumbar puncture was performed that revealed normal results. The patient was admitted to the hospital to rule out a cerebrovascular accident. It was reported in the patient's history and physical note that the problem was Guillain-Barre syndrome (GBS) based on recent upper respiratory infection in 2 days of progressive bilateral lower extremity weakness, and hyporeflexia. A magnetic resonance imaging (MRI) of the brain was performed that revealed no acute infarction. The patient was discharge to a rehabilitation facility for reconditioning. 

Based on the review of the medical record, the patient presented to the Emergency Department (ED) with lower extremity weakness with a prior history of upper respiratory infection (URI), raising the suspicion for Guillain-Barre Syndrome (GBS).  The patient's lumbar puncture was negative from the standpoint of GBS. The patient's magnetic resonance imaging (MRI) of the brain and computed tomography (CT) of the head CT were both negative from the standpoint of acute stroke. The patient's diagnostic tests, such as the lumbar puncture, CT imaging study of the brain, MRI of the brain, and neurology consultation all could have been performed in the ED setting or at an observation basis. Clinical guidelines do not support inpatient admission for this patient. Thus, inpatient admission was not medically necessary. 

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

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

Cardiac/Circulatory Problems
Inpatient Hospital

Diagnosis: Chest Pain
Treatment: Inpatient hospital stay. The insurer denied the inpatient hospital stay. The health plan's determination is upheld.

The patient is female. She has a history of hypertension, hyperlipidemia, coronary artery disease (CAD) with prior stenting with the last catheterization and chronic HFrEF (Reduced ejection fraction) who presented to the hospital with chest pain for two weeks. She was sent to the emergency room (ER) after seeing her cardiologist in the office with complaints of exertional chest pain relieved with rest and associated with nausea and shortness of breath.

The Inpatient Hospital Admission is not medically necessary for this patient. Due to the stability of the patient and with the lack of elevated enzymes and no evidence of other high-risk presentation findings such as heart failure, high-risk findings on ECG, elevated troponin, evidence of shock or an abnormal rhythm such as ventricular arrhythmias, a lower level of care was appropriate. This is supported by the 2014 Guidelines on the management of NSTEMI.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea
Treatment: Inpatient Stay
Decision: Denied

Summary:
The patient is a female who was admitted through ER. Her presentation included dyspnea, cough and minor symptoms for six weeks, and body aches for days. She had recent nuclear stress test that was "concerning," and then sent to ED for possible cardiac catheterization. 

This was an elective, uncomplicated catheterization that was scheduled after a "concerning" nuclear test, which was result of a patient with low probability of significant CAD (coronary artery disease). She was always hemodynamically stable with normal vital signs, normal EKG, normal LV (left ventricle) function, and no ectopy. The only care given after the uncomplicated radial catheterization was monitoring, IVF, and routine medications. This meets definition of outpatient care without any indication for a higher level. Many institutions protocols include a same day discharge. 
 
The letter of appeal was carefully considered, but it offered no evidence to support a higher level of care. The only care provided was telemetry and routine diagnostic Cath, both frequently performed in observation and outpatient status. The patient was admitted for monitoring and routine post Cath care; neither required an inpatient level of care. There was no "complex" care that was required in this patient's care post catheterization. While there was always a potential for an adverse event, one did not happen, and no actual treatment was needed. In the appeal letter, it referenced that this care could not be managed in an outpatient setting. That opinion is inconsistent with actual care given, community practice and guidelines. All of the testing and therapy that were provided would have been appropriate, safe and guidelines consistent to be in an outpatient setting. Thus, inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite.
Treatment: Braces.
The insurer denied the braces.
The denial is overturned.

Yes, the Braces are medically necessary.

The patient is a female. The request is for orthodontic benefits.

The patient has a deep, impinging overbite with soft tissue damage to her palate. This is an automatic qualifying condition according to the handicapping index scale. Orthodontic treatment is needed to correct this problem.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite.
Treatment: Braces.
The insurer denied the braces.
The denial is overturned.

Yes, the proposed braces are medically necessary. 

The patient is a female.  The request is for orthodontic benefits.

The patient has a crossbite between teeth #7 and #27. This anterior tooth crossbite with gingival attachment loss is an automatic qualifying condition according to the handicapping index scale. Orthodontic treatment is medically necessary to correct this problem.
Appeal type: Medical necessity
Decision: Upheld

Cardiac Inpatient Hospital.
Diagnosis: Chest pain.
Treatment: Inpatient Stay.
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a man with a history of persistent atrial fibrillation, hypertension, hyperlipidemia and obstructive sleep apnea. He presented to the emergency department complaining of three days of intermittent chest pain and dyspnea. His blood pressure was 147/87 mmHg with a heart rate of 80 beats/minute. His respiratory rate was 18/minute with a room air oxygen saturation of 98%. An electrocardiogram showed atrial fibrillation with a ventricular rate of 90 beats/minute. There were no ischemic changes. 

The inpatient stay is not medically necessary. This man, with known cardiac risk factors, presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. On the other hand, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He 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 at a lower level of care. This approach has been shown to be both safe and effective and is in accordance with the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With NonST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a male. The patient fell of a dirt-bike two days prior and scrapped his right lower extremity (RLE). There was no fever or chills. There was RLE swelling, pain, and redness. X-ray of the right tibia/fibula and right foot revealed no fracture. 
The patient was thought to have cellulitis with possible septic arthritis. He was started on intravenous (IV) vancomycin and ceftriaxone and was admitted. He had an allergic reaction to ceftriaxone so this was discontinued. He left the hospital against medical advice (AMA) before the evaluation of right ankle was complete.

The patient meets the initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (IDSA) (1), as he had systemic signs of infection (elevated WBC), and deeper infection suspected (septic arthritis). Thus, this admission was warranted, supported by IDSA guidelines. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth pain 

Treatment: D2751- white glass with metal crown on Tooth #30

The insurer denied coverage for D2751- white glass with metal crown on Tooth #30.

The denial is upheld. 

The patient is a male. Upon review of the documentation provided which includes periapical radiographs, panoramic radiograph, narrative letter from patient and insurer correspondence, it appears that this patient presented for evaluation of pain #30.  He recommended a full coverage crown.  

The objective documentation provided for review is periapical and panoramic radiographs.  It appears that there is no evidence of fracture or other pathology specifically affecting #30.  There does not appear to be any radiographic evidence of caries.  There is no periapical pathology.  If there is a fracture of the restoration, there is ample coronal structure to support a direct placement restoration obviating the need for a full coverage restoration.  The radiographs do not substantiate the requested dental services as enumerated above and therefore the crown is deemed not medically necessary.

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

The carrier's denial of coverage for D2751- white glass with metal crown on Tooth #30 should be upheld.  The medical necessity is not substantiated.