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

Diagnosis: Rhinovirus infection
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female child who was referred from the clinic for anemia, normal ferritin, weight loss, and blood in the stool. She had a history of multiple viral illnesses, including respiratory syncytial virus (RSV), coronavirus disease (COVID), rotavirus enteritis, sapovirus, and influenza. She also had pneumonia and a urinary tract infection. In addition to the gastrointestinal (GI) losses and diarrhea from the illnesses, she also had a history of mild protein allergy and soy allergy. She was taking oat milk, but recently was not interested in solid foods. She had black tarry stools several days after stopping iron therapy followed by streaks of frank blood and mucous. She had fevers to 105 degrees Fahrenheit for four days, a runny nose, cough, and some leg swelling with prolonged standing. Admission orders included nutrition and gastroenterology consultation, allergy consultation, consideration for hematology consultation, additional lab work to include thyroid studies and nutrition labs, stool studies, calorie count, barrier creams for diaper dermatitis.
She remained on room air with congestion and a cough secondary to a Rhinovirus infection. The gastroenterology consultant suspected a persistent milk protein allergy. The hematology consultant was not concerned about the macrocytic anemia, recommending additional GI evaluation. Fecal occult blood was negative, ova and parasites testing was negative, elastase was pending. X-rays were obtained to evaluate the thigh swelling, with concerns for an occult fracture, revealing areas of lucency in the metaphysis possibly representing vitamin C deficiency. The allergy consultant recommended elimination diet (dairy and soy) with transition to an elemental formula, with low suspicion for serious immunodeficiency. She tolerated Elecare Jr for the duration of the hospital stay, demonstrating normalization of her stools and weight gain. She was cleared for discharge to follow-up with all consulting subspecialists. At issue is the medical necessity of an inpatient stay.
Yes. This young female child presented with a longstanding history of back-to-back viral infections, several requiring hospitalization, anemia, frank blood in her stool, history of milk protein and soy allergy, and cold symptoms. Testing was positive for Rhinovirus with no need for supplemental oxygen or bronchodilators. She was initially hospitalized for observation but was transitioned to acute inpatient status to allow for completion of her evaluation and demonstration of formula tolerance and weight gain. Overall, she failed outpatient management, ED (emergency department) management, and a lower level of care. Her hospital stay was most appropriate at an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with medical history of diverticulitis, coronary artery disease status post stent placement, diabetes mellitus, and hyperlipidemia. She presented to the emergency department with left lower quadrant abdominal pain for two days, syncope, and diarrhea. Vital signs were unremarkable. Physical examination was notable for soft abdomen with left lower quadrant tenderness. Labs showed elevated white blood cell count of 18.8, low hemoglobin of 11.3 and hematocrit of 35.7%, and low sodium of 131. Chest x-ray showed no acute findings. Computed tomography scan of the head showed no acute intracranial abnormality. Computed tomography scan of the abdomen and pelvis showed acute diverticulitis of the distal descending colon without abscess or pneumoperitoneum. 

The inpatient hospital admission was not medically necessary, and the care provided could have been provided at a lower level of care. The patient presented with symptomatic diverticulitis, without perforation or abscess. In patients with uncomplicated diverticulitis, outpatient management or observation is the standard of care. The safety and efficacy of outpatient management of acute uncomplicated diverticulitis has been demonstrated. A prospective randomized trial demonstrated that patients can be given intravenous antibiotics in the emergency department and then discharged with oral antibiotics. A systematic review of the literature underscored this. A lower level of care can be appropriate when there are significant symptoms and leukocytosis, as in this case. However, there was no documented protracted fever or hypotension to suggest that antibiotics in the hospital were ineffective. No other cause for the inpatient level of care, such as peritonitis, toxic megacolon, bowel obstruction, sepsis, fistula, or other complication was documented. No cardiac cause for syncope was found. For these reasons, the inpatient level of care is not supported in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity. 
Treatment: Mounjaro. 
The insurer denied coverage for Mounjaro. 
The denial is overturned. 

This is an adult patient with a history of obesity. This request is for Mounjaro. The patient's body mass index (BMI) was 33.02; weight was 203 pounds (lbs). Several months later, the patient's BMI was 33.09; weight was 205 lbs. Per the visit note, the patient was status post Roux-en-Y gastric bypass (RYGB) and has a history of lymphedema. The patient had stopped Ozempic (patient reported not finding it too effective for weight loss). The plan was to start Mounjaro. Per the visit note, the patient was on Mounjaro 15 milligrams (mg). Most recently, the patient's body mass index (BMI) was 29.54; weight was 183 lbs. 
The requested medication Mounjaro (Tirzepatide) is Food and Drug Administration (FDA) approved for treating adults with type 2 diabetes. It is a glucagon-like peptide-1 (GLP-1) and gastric inhibitory polypeptide (GIP) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1c as well as weight loss [1-3]. Although the medication is only FDA-approved for type II diabetes, it is safe and effective in treating obesity [4,5]. The standard of care is based on multiple societal guidelines [6-11] recommending treatment of obesity with medications that are effective for obesity. The patient has failed other treatments for obesity and has lost weight with the requested medication. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary. 

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

The medical necessity for Mounjaro 10 milligrams (mg) / 0.5 milliliter (ml) (2 ml per month) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chronic uveitis

Treatment: J7312, Ozurdex

The insurer denied coverage for J7312, Ozurdex.

The denial is overturned.


This is an adult patient with visual acuities 20/40 (pinhole to 20/30) in the right eye (OD) and 20/150 (pinhole to 20/40) in the left eye (OS). Examination showed band keratopathy status post removal both eyes (OU), rare pigment cell right eye (OD) and 1+ cell left eye (OS).

On follow up, the patient was noted to be on methotrexate, Humira, and difluprednate.  Visual acuities were 20/30 (pinhole to 20/25) right eye (OD) and 20/80 (pinhole to 20/40) left eye (OS).  The patient was noted to have a diagnosis of uveitis in both eyes (OU) and had cystoid macular edema flare left eye (OS).

The patient has chronic inflammation/uveitis with macular edema and has failed multiple steroid treatments including difluprednate and prednisolone drops, Triescence, as well as immunosuppressive therapies such as methotrexate and Humira.  Due to persistent and recurrent macular edema, Ozurdex is medically necessary to improve the macular edema due to chronic uveitis, and to improve vision and function.  Ozurdex has been shown to be safe and effective for the treatment of macular edema secondary to uveitis (Massa 2019, Ratra 2018).

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 best interest of the patient. The medical necessity for J7312, Ozurdex services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastritis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient had a history of a cerebrovascular accident (CVA), diabetes, and hypertension. The patient was transferred from the nursing home after having coffee ground vomiting. The patient was afebrile and the vital signs were stable. The abdominal exam was benign. The hemoglobin was 15.1. A computed tomography (CT) scan was negative for acute disease. An endoscopy revealed gastritis. Proton pump inhibitor (PPI) therapy was given. There was no active bleeding after being admitted to the hospital. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-180 for Upper Gastrointestinal (GI) bleeding. Clinical indications for admission include hemodynamic instability, ongoing active bleeding, peptic ulcer with high-risk endoscopic features such as a visible vessel, variceal bleeding, severe coagulopathy, severe anemia with signs of cardiac ischemia, bowel obstruction, peritoneal signs, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient vomited coffee grounds but was not actively bleeding during the admission. PPI therapy and intravenous (IV) hydration could have been given with observation care and then the endoscopy performed as an ambulatory procedure. The patient was not actively bleeding and did not have any high-risk endoscopic features. The patient did not meet MCG criteria for admission for Upper GI Bleeding. 

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 inpatient hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, nausea, vomiting and left flank pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is an adult female who presented to the emergency department (ED) with complaints of fever, nausea, vomiting and left flank pain. The patient was previously seen in the emergency department (ED) two days earlier and discharged on oral antibiotics. The patient was afebrile. The patient's potassium (K) was 3.3, Magnesium (Mg) 1.3 on presentation. Urine was cloudy with white blood cell (WBC) count 57. Urine culture grew Klebsiella. Computed tomography (CT) showed mild left hydronephrosis/ perinephric stranding, renal cysts, calculi in renal cortex. The patient was given intravenous fluids, intravenous medications in the emergency room and was admitted. She improved with treatment; urine culture returned negative for urinary tract infection. She was stable for discharge home on oral antibiotics. 

Per Milliman Care Guidelines (MCG) Health (27th) Urinary Tract Infection, RRG, the patient fails to meet clinical indications for admission to inpatient care but does meet guidelines for observation care. (dehydration, ability to tolerate outpatient treatment regimen uncertain).

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System-Pneumonia
Treatment: Inpatient hospital stay
The health plan has denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient has a medical history of type 2 diabetes mellitus, hypertension, and hyperlipidemia, and was admitted for pneumonia with symptoms of fevers for two weeks and syncope on the day of admission. The chest x-ray and the computed tomography (CT) scan of the chest did not demonstrate a complicated pleural effusion. He was treated with antibiotics (Ceftriaxone & Azithromycin), acetaminophen, and intravenous fluids with an improvement in his condition. His syncope work-up was negative and felt to be secondary to vasovagal.

The requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient.
Based upon the severity of illness and intensity of required therapy, the inpatient level of care was not medically necessary. This patient with a medical history of type 2 diabetes mellitus, hypertension, and hyperlipidemia, was admitted for pneumonia with symptoms of fevers for two weeks and syncope on the day of admission. As per the clinical documentation, in the emergency room although the patient was febrile (39 degrees Celsius), he was hemodynamically stable, with a respiratory rate of 18 breaths per minute, an oxygen saturation of 95 percent (%) on room air, was in no acute distress and had normal breath sounds on auscultation of the chest. He was treated with antibiotics (Ceftriaxone & Azithromycin), acetaminophen, and intravenous fluids. On a progress note the next day the patient was afebrile, remained hemodynamically stable, had an oxygen saturation of 99% on room air and was clear to auscultation bilaterally. He was alert, awake and oriented throughout his stay, he did not have documentation of hypoxia or hypoxemia, he had a normal pulmonary effort without a sustained respiratory rate greater than or equal to (>=) 30, he did not require invasive or non-invasive ventilatory support, he did not have documented immunosuppressed state, bacteremia, or dehydration. The chest x-ray did not demonstrate a complicated pleural effusion. His CURB-65 (Estimates mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment.) score was 0 and Pneumonia severity index (PSI) score was class 2, putting him at lower risk for adverse outcomes and lower level of care treatment would be appropriate. In addition, there was no documentation that he had failed outpatient therapy or required isolation that could not be performed outside the inpatient hospital setting. Although he presented with syncope, it was felt to be secondary to a vasovagal episode and throughout the hospitalization he did not have further syncope, any arrythmias or hypotension. Therefore, the requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain. 
Treatment: Inpatient stay. 
The insurer denied coverage for the inpatient stay. 
The determination is overturned. 

The patient is a female with a medical history of recent diverticulitis, gastroesophageal reflux disease (GERD), diabetes mellitus, chronic obstructive pulmonary disease, Graves' disease, asthma, hypertension, deep venous thrombosis, rheumatoid arthritis, Sjogren's syndrome, and psoriatic arthritis. She presented to the emergency department with lower abdominal pain. She had previously been discharged on ciprofloxacin and metronidazole for the treatment of diverticulitis. She had a decreased appetite, and had small bowel movements but felt incomplete evacuation.  A computed tomography scan of the abdomen and pelvis showed mild pericolonic fat stranding involving the sigmoid colon deep in the pelvis without interval worsening, no abscess or perforation; findings may represent mild diverticulitis again, or exaggerated appearance of inflammation due to the redundant bowel which also has significant diverticulosis, and stable uncomplicated nephrolithiasis. She was treated with intravenous fluids, hydromorphone, ondansetron, acetaminophen, and meropenem. 
A colorectal surgery consultation concluded she had no need for acute surgical intervention, and recommended continued intravenous antibiotics, serial abdominal exams, and outpatient follow-up. An infectious disease consultation noted recurrent diverticulitis, and recommended stopping Zosyn, and starting ertapenem, gastroenterology evaluation and pulmonology evaluation for pulmonary nodule. She was discharged on oral vancomycin, with a plan for gastroenterology and colorectal surgery follow-up. At issue is the medical necessity for the inpatient level of care.
The inpatient level of care is medically necessary in this case. The patient presented with abdominal pain and imaging findings consistent with diverticulitis. Despite antibiotic therapy, she had persistent symptoms, including abdominal pain[1-4]. She had explosive diarrhea and a finding of Clostridioides difficile infection. She was at risk for complications of diverticulitis such as perforation, and at risk for complications of Clostridioides difficile such as sepsis and toxic megacolon; discharge would not have been appropriate until she was on oral vancomycin therapy for the treatment of Clostridioides difficile with response [5-8]. She had improvement with only mild pain, and improvement in diarrhea; discharge then became appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dental issues
Treatment: Surgical Placement of Implant Body: Endosteal Implant on Tooth 03 and Tooth 04 and Surgical Placement of Implant Body: Endosteal Implant on Tooth 12 and Tooth 13
The insurer denied Surgical Placement of Implant Body: Endosteal Implant on Tooth 03 and Tooth 04 and Surgical Placement of Implant Body: Endosteal Implant on Tooth 12 and Tooth 13
The health plan's determination is overturned. 

The patient is a female with dental issues who has been denied Surgical Placement of Implant Body: Endosteal Implant on Tooth 03 and Tooth 04 and Surgical Placement of Implant Body: Endosteal Implant on Tooth 12 and Tooth 13. 

The Surgical Placement of Implant Body: Endosteal Implant on Tooth 03 and Tooth 04 and Surgical Placement of Implant Body: Endosteal Implant on Tooth 12 and Tooth 13 is medically necessary for this patient.
The options to restore a function are a partial denture or implants. Implants are the best choice. A partial denture has been shown to lead to the loss of adjacent teeth and have less chewing efficiency than implants. Implants are the standard of care and much more efficient than a partial. They are the closest thing to natural teeth, preserve the bone and are not susceptible to caries. The requested treatment is the standard of care and a superior restoration.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female. She was hospitalized from for 
elective cardiac catheterization. Her past medical history includes subclinical coronary artery disease by elevated computed tomography (CT) coronary calcium score of 2087. Coronary angiography revealed severe single-vessel coronary artery disease (CAD) and she underwent successful percutaneous coronary intervention (PCI) to the mid-left anterior descending artery (LAD) on the same day. There were no procedural complications, and the patient was discharged to home following day. The requested coverage for inpatient admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The inpatient admission was not medically necessary.

Based on the peer-reviewed medical literature, there was not a medical need for the requested acute inpatient hospital stay, because the severity of this patient's illness did not meet the 
intensity of service for inpatient hospital stay. In this particular case, the patient underwent planned left heart catheterization (LHC) followed by successful and uncomplicated percutaneous coronary intervention (PCI) with stenting of the left anterior descending artery (LAD) on the same day. The information provided does not support the medical necessity for admission after her successful and uncomplicated coronary intervention. PCI (percutaneous coronary intervention) procedures are routinely performed in the ambulatory setting with overnight observation. There is no documentation of unstable medical conditions like acute coronary syndrome/acute myocardial infarction (ACS/AMI), cerebral vascular accident (CVA), contrast nephropathy, acutely decompensated congestive heart failure (CHF), life-threatening cardiac arrhythmia; procedural complications like acute coronary perforation; vascular access complication requiring surgery; or other medical instability or acute care needs that would require acute inpatient management. Therefore, based on the submitted information and the current published medical literature, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol abuse
treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

This case involves a man with coronary artery disease who presents to the hospital with chest pain. He was evaluated for acute coronary syndrome earlier in the day, left Against Medical Advice (AMA), went home, drank 2.5 pints of vodka and some beer, and then returned to the hospital for alcohol detoxification. He had complained of non-radiating chest pain for several days. He also complained of hematemesis and dark stools for three days. 

Based on the provided documentation, there is no clinical indication for an inpatient hospital admission. The patient presented to the hospital intoxicated after leaving the hospital Against Medical Advice, and upon return, requested to be detoxed. Vital signs remained stable throughout the hospital stay. The initial calculated Clinical Institute Withdrawal Assessment (CIWA) score was 13; however, the subsequent CIWA scores are 0. The patient was on the scheduled CIWA Scale protocol and showed no hemodynamic instability, delirium tremens, or seizures. Based on admission criteria for alcohol withdrawal, a lower level of care is appropriate.
Regarding the complaint of possible upper gastrointestinal (GI) bleed, the patient's vital signs remained stable; hemoglobin remained unchanged. No emergent endoscopic procedures were completed, as there was no hemodynamic instability or continued melanic stools. No blood transfusions were indicated. Therefore, a lower level of care was appropriate.