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

Diagnosis: CHARGE syndrome; pulmonary artery dilation.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This patient was a male child with a history of situs inversus totalis, Goldenhar vs coloboma, heart defects, atresia choanae, growth retardation, genital abnormalities, and ear abnormalities (CHARGE) syndrome, Tetralogy of Fallot (TOF) with repair, and left pulmonary artery (LPA) dilation with stent placement. He presented to the hospital for a diagnostic cardiac catheterization and possible LPA balloon angioplasty. He then undergoes an elective (ambulatory) diagnostic cardiac catheterization and undergoes another balloon angioplasty of the LPA and the Left upper pulmonary branch. There are no complications and he is admitted overnight to an Intensive Care Unit for observation. The insurance company is denying coverage for the full hospital admission which is being appealed by the hospital. 

After review of the medical record the denial should be upheld. The following is the rationale for this decision:

1.	Based on the MCG Health Ambulatory (24th Edition) Guidelines for Cardiac Catheterization and Angiography, Congenital Heart Disease is one of the indications for an ambulatory procedure. Note: in the Criteria section repaired Tetralogy of Fallot is mentioned.
2.	The administration of anesthesia and the balloon dilatations were performed without incident and the Nurses Care Plan Note indicated "alert and oriented, no discomfort. Right groin dressing intact, soft, good pedal pulse. Tolerated fluids. Voided." The note was written 2 hours after procedure and prior to inpatient admission.
3.	Similar observations were noted shortly after inpatient admission.
4.	The child was discharged on the following day Less than 24 hours after the end of the procedure and clearly was ready for discharge sooner.

Therefore a full admission was not medically necessary for this child. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I skeletal relationship, class II canines,
moderate maxillary spacing, moderate mandibular
crowding, missing maxillary right first premolar,
and anterior crossbite with gingival attachment
loss (mandibular left canine)
Treatment: Braces and Monthly Visits, Pre-service
The insurer denied the Braces and Monthly Visits, Pre-service
The denial is upheld. 

The patient is a male.  The request is for orthodontic treatment (Braces), monthly visit, Pre-service.  Per the dental clinical summary-- this patient presents with a class I skeletal relationship, class II canines, moderate maxillary spacing, moderate mandibular crowding, missing maxillary right first premolar, and anterior crossbite with gingival attachment loss (mandibular left canine).

No, the proposed treatment of orthodontic therapy, monthly visits is not medically necessary.

A crossbite is when an upper tooth/teeth are inside/palatal to the corresponding lower tooth/teeth. The presence of a crossbite is not supported by the x-rays or photos submitted.  The photos do not display positioning of the mandibular left canine as noted in the dental clinical summary.

A class II canine is when the distal surface of the mandibular canine is mesial to the mesial of the maxillary canine by at the least the width of a premolar.  This clinical condition is also not evident in the photos.  It is not supported by the documentation.

The clinical claim of anterior crossbite and a class II canine are not evident in the photos submitted.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Capsular contracture with deformity. 
Treatment: 19371-50 - peri-implant capsulectomy breast, complete, including removal of all intracapsular contents; 19342 - insertion or replacement of breast implant on separate day from mastectomy; and Inpatient Hospital Admission, Pre-service. 

The insurer denied the 19371-50 - peri-implant capsulectomy breast, complete, including removal of all intracapsular contents; 19342 - insertion or replacement of breast implant on separate day from mastectomy; and Inpatient Hospital Admission, Pre-service. 

The denial is upheld. 

The patient is a male to female transgender. She has undergone breast implant placement as a treatment for her gender dysphoria. She now has capsular contracture with deformity and pain. Breast implant exchange and capsulectomies are planned. 

No, the proposed treatment is not medically necessary. 

According to the surgeon's office note, the patient has Baker I/II capsular contracture. She has breast ptosis. Her implants are high.  Although the patient appeal letter describes pain, the provider's office notes do not document any complaints of pain. Generally, grade I/II capsular contractures are not painful. The proposed procedure will primarily improve appearance, because the provider's note does not provide documentation of a functional issue caused by the implants. 
Mastopexy is a cosmetic procedure. According to an article by Di Summa et al: "Mastopexy is one of the most performed cosmetic surgery procedures in the U.S."  A study by Watfa et al also states: "Mastopexy is one of the most performed cosmetic surgery procedures in the United States." Mastopexy is a cosmetic procedure for all indications and is cosmetic for this indication.  According to Chapter 58, Grabb and Smiths Plastic Surgery, "Mastopexy is a procedure designed to elevate breast tissue and the nipple areola complex to correct breast ptosis. Mastopexy procedures are derived from breast-reduction procedures except that only skin is removed with little or no parenchymal resection. Breast reduction surgery is often performed to relieve neck, back, shoulder, and arm pain. The patient receives significant medical and quality-of-life benefits. Although the appearance of the breast is a factor, the medical benefits are often the primary concern of the patient. Mastopexy is almost always a cosmetic procedure. Consequently, the trade-offs (i.e., scars) are less well tolerated by the mastopexy patient than by the breast-reduction patient." 

Mastopexy will not improve health outcomes and is not clinically appropriate from a functional or medically necessary standpoint. It is being performed for appearance and patient convenience. Therefore, it is not medically necessary. 

This procedure is planned primarily to improve appearance of the breasts, based on the information documented in the provider's note.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: biliary colic and cholelithiasis.

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld. 

This female patient has a history of hypertension. She presented to the Emergency Room (ER) with complaints of abdominal pain and nausea. Computed tomography (CT) scan and ultrasound of the abdomen revealed findings that were consistent with acute cholecystitis. Intravenous (IV) fluids were started and the patient was kept on a clear liquid diet. She was admitted for further care. General surgery consulted over the case. The patient was on 4 milligrams (mg) of IV Zofran every 8 hours (Q8H) as needed (PRN), 40 mg of IV Pantoprazole Q12H PRN, and morphine PRN for pain. They noted that there was currently no indication for surgery and recommended awaiting Gastroenterology recommendations. They recommended avoiding non-steroidal anti-inflammatory agents (NSAID), discontinuing herbal preparations, and potentially having an endoscopy. The patient was initially on a clear liquid diet and was later able to tolerate a pureed diet. She had a laparoscopic cholecystectomy. There were no complications and the patient was monitored after surgery. She remained hemodynamically stable and was discharged.

According to the guidelines of  MCG Health Inpatient and Surgical care- 25th edition Gall bladder or bile duct inflammation or stone ORG: M-555 (ISC) the goal length of stay is ambulatory or 2 days and assumes optimal recovery, decision making, and care. Patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs.  In addition, MCG Inpatient and Surgical Care 25th Edition cholecystectomy by laparoscopy notes that the operative status criteria is ambulatory. This patient did not require inpatient hospital care for 6 days for this procedure. The patient did not have acute cholecystitis, had no indication for a prolonged hospitalization, and a 4 day delay prior to having an uneventful laparoscopic cholecystectomy. She also did not need to be kept in the hospital 2 more days following the surgery as she could have been discharged within a 23 hour observation period. Based upon these findings the health care plan did act reasonably and with sound medical judgment.

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

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

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

The patient is a male with a past medical history significant for dyslipidemia, who presented to the emergency room (ER) with a complaint of syncope. The patient reports he had a sudden onset of pressure-like left-sided chest pain, associated with diaphoresis, followed by a syncope with loss of consciousness and fall. 

The patient was hemodynamically stable on admission with negative orthostatic changes. Electrocardiogram (ECG) revealed normal sinus rhythm with sinus arrhythmia. The cardiac enzymes were negative. The patient was evaluated by cardiology and a possible ischemic event with resulting ventricular arrhythmia was suspected. He was admitted to telemetry for monitoring and an echocardiogram and a cardiac catheterization were performed for further work-up. His coronary angiogram revealed no obstructive coronary disease and he was discharged home with a plan for outpatient follow-up.

Yes, the proposed inpatient admission was medically necessary.

The patient presented with a syncope episode. Although a majority of patients with syncope as their main presentation can be managed in the observational or emergency department setting, an inpatient admission is usually necessary for patient with suspected acute cardiac pathology, ischemic, unstable angina, arrhythmia, or neurological event. The patient in this case had symptoms consistent with an ischemic event, as well as possible ventricular arrhythmia and was evaluated for this suspected diagnosis, including a cardiac catheterization.  Given the presentation, as well as clinical suspicion for an acute coronary syndrome/unstable angina and ventricular arrhythmia, he would not be an appropriate candidate for an emergency department chest pain observation unit, and 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: Upheld

Diagnosis: Dehydration
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female teen with unremarkable medical history. She presented to the ED (emergency department) with two-day history of sore throat and inability to eat or drink due to pain. Treatment with Nyquil and Excedrin were ineffective.

The patient's vital signs included temperature 37.2, heart rate 138, respiratory rate 20, and pain ten out of ten (10/10). Physical examination was significant for no acute distress, inflamed erythematous tonsils with no peritonsillar swelling or exudate, uvula midline, dry mucous membranes, cervical adenopathy, tachycardia, benign abdomen, and non-focal neurologic exam. Laboratory evaluation revealed negative rapid Strep and Covid testing, negative influenza screen, thyroid screen within normal limit, unremarkable complete blood count, and unremarkable metabolic panel.

The patient was treated with IV (intravenous) fluids for dehydration, parenteral dexamethasone and Toradol for pain, acetaminophen, and Unasyn. She was admitted for management of dehydration with ongoing tachycardia and pain, with admitting diagnosis of tonsillitis likely of viral origin. Admission orders included continuous cardiopulmonary monitoring, soft diet, maintenance IV (intravenous) fluids, and parenteral Toradol as needed for pain.

The patient did well overnight, feeling better on hospital day two, with minimal throat pain while swallowing and improved appetite. She was deemed stable for discharge with recommendations to use acetaminophen and Magic Mouth Wash as needed.

No, the Inpatient admission was not medically necessary.

Pharyngitis, or sore throat, is a relatively common presenting symptom to the ED (emergency department). It may be a benign isolated process or it may be associated with life-threatening airway compromise. Other conditions such as thyroid disease and cardiac disease may masquerade as pharyngitis. Complete history and physical examination are essential to narrow the very broad differential diagnosis and guide evaluation and treatment.

This female teen presented with such severe sore throat, rating her pain ten out of ten (10/10). She was unable to eat or drink, resulting in clinical dehydration. She was treated in the ED (emergency department) with IV (intravenous) fluids and parenteral non-steroidal pain medication as well as a dose of Unasyn for possible bacterial etiology. Following admission, she continued on IV (intravenous) fluids, with significant improvement in her pain and ability to eat and drink. Testing was unremarkable leading to a diagnosis of tonsillitis likely of viral origin. While it was reasonable and medically necessary to monitor her in the hospital for adequacy of oral intake and pain management, she was overall hemodynamically stable with no airway compromise. She did not require acute inpatient admission. She could have been safely managed at a lower level of care, such as observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders/Cellulitis
Treatment: Inpatient Hospital
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a man with a history of coronary artery disease (CAD), diabetes, hypertension, alcohol abuse, cerebrovascular accident (CVA), paranoid schizophrenia and chronic lower extremity edema/cellulitis who was admitted to the hospital. He presented from a shelter with left lower extremity pain and chest pain. He had multiple emergency department visits with similar complaints and often reported not being able to obtain his medications. He had reportedly been receiving Aspirin and Brilinta for CAD. Vital signs showed a blood pressure of 152/83 millimeters of mercury (mmHg), a temperature of 98.4 Fahrenheit, a heart rate of 82/minute and a respiratory rate of 18/minute. On physical exam, his heart was regular, breath sounds were normal, the lower extremities had chronic stasis changes and there was a left lower extremity large clean based ulcer and right lower extremity bullae. Labs showed a D dimer of 276, a white blood cell count (WBC) of 3.8, a hemoglobin of 10.9, a glucose of 336, and troponin was negative. An electrocardiogram (EKG) showed normal sinus rhythm and a right bundle branch block with no evidence of ischemia. A chest x-ray was stable with no evidence of acute pneumonia. The patient was admitted for chest pain and suspected acute coronary syndrome (ACS). The plan of care included monitor mental status, monitor for alcohol withdrawal, start Bactrim for cellulitis, physical therapy, social work consult, and monitor for worsening cellulitis/sepsis. He also underwent a left lower extremity ultrasound which was negative for deep vein thrombosis (DVT). He stated that his chest pain resolved and his EKG remained stable. The wound care service was also consulted to assist with his lower extremity vesicles and wounds. Social work reconnected the patient with a safety net clinic although he reportedly had been previously connected and refused to present for appointments. The plan for follow up was finalized and he was discharged on oral antibiotics.
At issue is the medical necessity of the inpatient stay.

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

No. The patient primarily received an outpatient evaluation for chest pain and outpatient therapy for cellulitis. Although he has risk factors for cardiac ischemia and a history of CAD, his chest pain resolved shortly after admission and he had no EKG changes or significant elevation of cardiac enzymes. He was hemodynamically stable and primarily received antibiotics for cellulitis and wound care along with coordination of care with social work. He did not receive acute interventions during the hospital stay for suspected cardiac ischemia. The patient needed further management, but this could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left upper lobe mass
Treatment: Surgery (bronchoscopy with bronchial alveolar lavage) in an Outpatient Hospital
The insurer denied the Surgery (bronchoscopy with bronchial alveolar lavage) in an Outpatient Hospital.
The denial is overturned.

The patient is a male with a left upper lobe mass and lymphadenopathy who underwent endobronchial ultrasound for diagnosis as an outpatient.

This patient had a left upper lobe mass and lymphadenopathy.  The size of the mass was five centimeters; the positron emission tomography (PET) activity in the mediastinal lymph nodes would make performing endobronchial ultrasound (EBUS) standard.  It would be standard to perform endobronchial ultrasound to stage and diagnose this patient's lung cancer and to accomplish this as a same day procedure. In this case, the patient had the procedure in a hospital and was discharged the same day which would be standard. The procedure is usually performed in the operating room (OR) or in a bronchoscopy suite which was the case for this patient.

The procedure was performed in the appropriate setting and as a same day procedure which is standard and therefore should be covered. Denying coverage as the procedure occurred in a hospital rather than at another location is not reasonable, based on sound medical judgement or in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's Disease Flare

Treatment: Inpatient Services

The insurer denied coverage for inpatient services

The denial is upheld

The patient has Crohn's disease and presented with abdominal pain. He was afebrile and the vital signs were stable. There were no peritoneal signs. A computerized axial tomography scan was read as thickening of loops of the small intestine with distention that was compatible with a Crohn's disease flare. Intravenous antibiotics were given. He was treated with oral prednisone. He improved and was able to tolerate a diet.

Clinical indications for admission for Inflammatory Bowel Disease include hemodynamic instability, abdominal abscess, fertilizing Crohn's disease, toxic megacolon, perforation intestinal obstruction, severe vomiting, severe dehydration, severe anemia, and the need for urgent inpatient surgery. The patient did not have these conditions. He had areas of intestinal narrowing due to the Crohn's disease but did not have internal obstruction. There was a concern that he could develop an obstruction, but at this time the oral contrast passed throughout the small bowel.

This patient had Crohn's disease and was treated with intravenous hydration, antibiotics, and oral steroid. This treatment could have been given observation status. He did not meet Milliman Care Guidelines (MCG) criteria for admission for Inflammatory Bowel Disease. 

The healthcare plan acted reasonably and with sound medical judgement. An inpatient admission was not medically necessary. 

The insurer's denial of coverage for the inpatient is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Concern for a transient ischemic attack (TIA). 
Treatment: Inpatient admission. 

The insurer denied coverage for the inpatient admission. 

The denial is upheld. 

This is a male patient with a past medical history of asthma, anxiety, and depression. The patient was brought to the hospital by emergency medical services. He was brought in for an episode of left sided numbness and weakness. He stated he was cleaning his room when he got a phone call so he laid on the bed with his right leg over his left leg. After he finished his phone call, he noted left lower extremity numbness and weakness. He stated he thought his left lower extremity fell asleep from laying on his right leg. He then noticed left upper extremity and left facial numbness and weakness. He stated he could not move the left side of his body. The patient's daughter noticed a facial droop. 

The patient was completely asymptomatic in the emergency department. The symptoms had resolved once emergency medical services had arrived and helped him into a chair. He denied fever, chills, cough, congestion, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, dysuria, headaches, and dizziness. The physical examination revealed his sensation was intact and motor function was intact. He had no weakness or pronator drift. His coordination was normal. There was noted to be a concern for a transient ischemic attack (TIA). The patient had no facial droop and had a resolution of his left-sided weakness and numbness. He was pending a Neurology consultation. He underwent a Computed Tomography (CT) scan of the head revealing multifocal low-attenuated lesions. The Magnetic Resonance Imaging (MRI) of the brain and Magnetic Resonance Angiogram (MRA) of the head revealed moderate chronic white matter microvascular ischemia, including bilateral chronic appearing lacunar infarcts. He was admitted for a transient ischemic attack work-up. He underwent a transesophageal echocardiogram (TEE), which was normal. He was discharged and was to follow-up with neuro-immunology. 

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

The inpatient admission was not considered medically necessary for this patient. MRI of the brain and CT of the head showed chronic changes consistent with stroke but no evidence of acute stroke or hemorrhage. Vascular work up for TIA etiology, including TEE was normal. Care provided, including diagnostic imaging, could have been performed in the emergency department setting and at an observation level of care. Therefore, the inpatient admission was not medically necessary. 

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.