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

Diagnosis: Motor vehicle accident
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

This patient presented to the emergency department (ED) following an accident in which he was a pedestrian reportedly struck by a car. He presented as a trauma patient to the ED. Vital signs identified elevated blood pressure and a heart rate of 107/minute. Glasgow coma score was 15/15. His evaluation included imaging with computed tomography (CT) scan of the head, cervical spine, chest, and abdomen/pelvis. These studies were normal. The patient was admitted for pain management. Overnight the patient received intravenous (IV) analgesia (Fentanyl). The following day the patient reported feeling better. Physical therapy evaluated the patient with the recommendation for use of crutches for ambulation. Diet was advanced and tolerated. He was considered to be stable for discharge the next day.

The submitted records do not support the medical necessity of inpatient admission for this patient.
This patient presented following an incident in which he was a pedestrian struck by a vehicle. There was no loss of consciousness at the scene of the injury, and he was awake, alert, and oriented with a Glasgow Coma Scale (GCS) of 15 at the time of hospital presentation. He had diffuse pain but was without identified injury based on the trauma work up. The patient was stable at the time of presentation and did not require surgical intervention. In this case the care and treatment provided could have safely been rendered with a lower level of care rather than an inpatient level of care. The lower level of care would allow for provision of IV fluid, IV pain medication, and overnight monitoring. The records support that this patient had an uncomplicated period. He remained hemodynamically stable without acute aberration of vital signs.
The patient was clinically stable and without acute injury at the time of ED presentation. He was monitored overnight and remained clinically stable with regard to vital signs. He was able to ambulate with crutches and tolerated a diet and was deemed clinically stable for discharge to his home. The care provided did not require an inpatient level of care and could have reasonably been rendered with a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope/Passing out
Treatment: Inpatient Hospital Stay.
The health plan denied the requested inpatient hospital stay.
The health plan's determination is upheld.

The patient is a male with history of chronic kidney disease (CKD), congestive heart failure (CHF), alcohol use disorder, pancreatitis and hypertension who presented with syncope. He was drinking all night prior to presentation and was also using cocaine. His sister called Emergency Medical Services (EMS) after she found him passing out multiple times. He was slightly hypotensive with a blood pressure (BP) of 86/49 millimeters of mercury (mmHg). He was given intravenous (IV) hydration. His blood pressure improved soon after being in the emergency room (ER). His labs showed mild acute kidney injury with a creatinine of 1.56 and a troponin of 0.047. An electrocardiogram (EKG) showed left ventricular hypertrophy and non-specific T-wave changes. A chest X-ray was unremarkable. The patient was admitted for syncope and an elevated troponin. The concern was neurocardiogenic syncope. He was started on intravenous (IV) hydration, telemetry monitoring, serial labs, blood work and pulse oximetry. He was observed and was subsequently discharged home after a cardiac etiology was ruled out.
At issue is the medical necessity for an inpatient hospital stay.

I uphold in whole, the health plan's determination of medical necessity.

The patient did not meet criteria for an inpatient admission. He was syncopating due to drinking all night. His presentation was consistent with intoxication rather than true syncope or having a cardiac etiology. He was briefly hypotensive, but his blood pressure improved soon after receiving IV hydration. Per Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 26th Edition Syncope ORG: M-340 (ISC) the inpatient admission was recommended for hemodynamic instability (persistent tachycardia, hydration despite observation level of care), cardiac findings (arrhythmias, ACS), severe or persistent dehydration, syncope leading to injury requiring hospitalization. [1] However he did not have any of these. His HEART (risk score for major cardiac events) score for acute coronary syndrome (ACS)/myocardial infarction (MI) was 3 with risk of major cardiac event only 0.9 - 1.7% and typically the admission is not recommended. [2] His TIMI (thrombosis in myocardial infarction) score was also low at 1, with 5% all cause mortality and no admission beyond an alternate level of care is recommended. [3] The patient was suitable for an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulnar neuropathy.
Treatment: 64718 [Neuroplasty and/or transposition; ulnar nerve at elbow] with modifier 80 [Assistant Surgeon], RT [Right side (used to identify procedures performed on the right side of the body)].

The insurer denied the 64718 [Neuroplasty and/or transposition; ulnar nerve at elbow] with modifier 80 [Assistant Surgeon], RT [Right side (used to identify procedures performed on the right side of the body)].  The denial is upheld.

The patient is a male who presented with numbness and tingling in the fourth and fifth digit of the right hand with weakness in abduction. Electromyography (EMG) showed ulnar neuropathy. The patient underwent decompression and external neural lysis of the right ulnar nerve at the elbow.

No, the proposed 64718 with modifier 80, RT (right side) was not medically necessary.

The patient is being billed for assistant surgeon services. The operative report does not mention any specific portions of the procedure that the assistant was involved in. With regards to standards in billing practices, assistant surgeon fees should be considered only when there is an adequate documentation of their role in the procedure. In this setting, there is no documentation of this, and it is not possible to know the work effort that was performed by the assistant based upon the operative report. Therefore, the use of an assistant was not medically necessary.

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

There is limited documentation to support the need for use of an assistant in this surgery, and, therefore, it is not supported by the documentation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Crisis
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male with diagnosis of sickle cell crisis with review for inpatient hospital admission.
The patient presented with history of sickle cell disease, glaucoma, constipation, and reflux due to severe chest and right upper arm pain.  This is consistent with a prior vaso-occlusive cell crisis and the patient had not responded to treatment with Tylenol at home.  On examination the patient had tenderness to the sternum.  Laboratory evaluation demonstrated white blood cell count of 13.9, hemoglobin 10.9, and sinus rhythm on EKG (electrocardiogram) was noted.  Chest radiograph was negative for acute pulmonary disease.  The patient was administered IV (intravenous) fluids, IV (intravenous) morphine and ibuprofen.  The patient was admitted and managed for pain.  No fevers.

The proposed treatment at an inpatient level of care would not be considered medically necessary.
In this case the patient was admitted with a vaso-occlusive pain crisis and remained in the hospital for 24 hours.  The patient was managed with IV (intravenous) narcotics.  His pain resolved.  Clinical indications for inpatient level of care admission for a patient with sickle cell complications include the patient having stroke, seizure, other significant central nervous system event, acute chest syndrome, need for oxygen, fever/infection, or persistent pain that cannot be managed in an observation level of care and timeframe.  In this case there is no evidence of any significant sickle cell complication to include aplastic crisis, priapism, hyphema, acute chest syndrome, severe infection or any other treatment that would be deemed medically necessary and inpatient level of care such as prolonged oxygen requirement, prolonged parenteral narcotic requirement, exchange transfusion or any other treatment requiring inpatient level of care.  As such, this patient could have been safely and effectively managed at a lower level of care such as observation.

Yes; the health plan determined the safe and effective level care for this patient based on the clinical information provided.  In this case the plan made a correct assessment that inpatient level of care would not be considered medically necessary given the patient's presentation, short stay, resolution of pain symptoms and other clinical factors to differentiate observation level of care versus inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder/Seizures. 
Treatment: Inpatient Hospital. 

The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld. 

The patient is a woman with a history of seizures, sarcoidosis, multiple mental health problems, tobacco use, and asthma. She presented to the emergency room reporting two seizures over the past several days, stuffy nose, and watery eyes. The vital signs were normal, and the patient was alert and oriented x 3. The physical exam was unremarkable, and other than a subtherapeutic valproic acid level, the labs were non-contributory. The chest x-ray was negative for acute changes. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. A dose of intravenous antibiotics was administered, and the patient was admitted for further treatment and evaluation. 
Upon admission, the patient was treated with her usual home oral medications. The following day, an electroencephalogram (EEG) was abnormal, showing a few sharp wave discharges in the right temporal region that were "potentially" epileptogenic. The remainder of the stay was clinically uneventful, and the patient was discharged.
At issue is the medical necessity for the inpatient stay. 

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

No, the requested health service/treatment of inpatient stay was not medically necessary for this patient. 

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. The subtherapeutic anti-seizure medication readily explained the reported seizures in the previous days before admission. There was no hemodynamic instability, mental status changes, focal neurologic abnormalities, or metabolic disarray. The stuffed nose and watery eyes were not clinically worrisome. Therefore, based on the standard of care, and the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary, and the patient could have been managed at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic low back pain
Treatment: Procedure code 64555 - Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
The insurer denied the Procedure code 64555 - Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
The denial is upheld.

The patient is a male with low back and buttocks pain.  He is not considered a good candidate for surgery at this time.  Pain is rated 8/10.  Physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs) help some.  The patient is taking Percocet as needed for pain.  Examination is significant for axial loading and negative straight leg raise.  Magnetic resonance imaging (MRI) of the lumbar spine shows a congenital canal narrowing with lumbar disc bulges and degenerative changes.  Mild canal and foraminal stenosis is seen throughout the lower lumbar region, slightly worse from prior study.  

Request for the Sprint peripheral nerve stimulation (PNS) was denied as not medically necessary.

No, the proposed treatment is not medically necessary.
As discussed in the article by Gilmore et al., "Although the results presented here are promising and consistent with previous studies of percutaneous PNS (peripheral nerve stimulation) for other types of pain, 80, 81, 83-97 this study has limitations, which should be considered in interpretation of the results. In particular, the population size was limited (number = 9) and did not include a control group or explore placebo effect; additional studies could help confirm these results in a larger population of patients, including studies that might compare the effects of percutaneous PNS (peripheral nerve stimulation) to other standard interventional approaches used for patients with chronic LBP (low back pain). Because chronic LBP (low back pain) can include a heterogeneous population (eg, facetogenic, discogenic, arthritic, or myofascial pain) and the selection criteria for inclusion in this study were broad, additional studies and analyses of larger populations, including larger, prospective multicenter case series studies, may determine LBP (low back pain) subtypes or characteristics that are more likely to benefit from percutaneous PNS (peripheral nerve stimulation), as well as if specific types of diagnostic tests or imaging are predictive of success."


Sprint peripheral nerve stimulation (PNS) has limited studies addressing treatment of chronic back pain only.  There is insufficient or inconclusive evidence published in peer-reviewed medical literature to evaluate the therapeutic value of peripheral nerve stimulation (PNS). There are no well-designed and well-conducted studies.  There is inconclusive evidence published in peer-reviewed medical literature that the service improves net health outcomes.  The service under consideration is not as beneficial as any established alternatives.  As such, the proposed treatment is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Obesity.
Treatment:  Weight loss surgery.

The insurer denied weight loss surgery. The health plan's determination is overturned.

The patient is a woman who has medically complicated morbid obesity. Her weight was 233 lbs (pounds). She is 65 inches tall. This corresponds to a body mass index (BMI) of 38.1. The records indicate that the patient has been significantly overweight for many years. She has attempted weight loss with conventional diet programs. The patient has comorbid health conditions of osteoarthritis and hypertension. The patient is prescribed the antihypertensive medication Cozaar for hypertension.

The patient sought bariatric surgical evaluation and was enrolled in a comprehensive, multidisciplinary, bariatric program. 

The requested weight loss surgery is medically necessary for this patient. The current standard of care for successful candidacy for bariatric surgery such as laparoscopic sleeve gastrectomy are: BMI of 40 or a BMI of 35 in association with weight related comorbid illnesses such as hypertension, diabetes, sleep apnea, osteoarthritis, etc. There must also be documentation of prior nonsurgical attempts at weight loss, nutritional counseling/education, mental health clearance for the proposed surgery, and commitment for long term follow up post bariatric surgery.

In this case, the patient has a body mass index of 38.1 with comorbid, weight related conditions of osteoarthritis and hypertension. She has successfully completed a comprehensive multidisciplinary evaluation that includes surgical, psychological and nutritional components. The proposed bariatric operation is medically necessary for this patient and is consistent with nationally recognized standards.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: tongue squamous cell carcinoma.
Treatment: Proton beam therapy.
The insurer denied proton beam therapy. 
The health plan's determination is upheld. 

This is a man with a left base tongue squamous cell carcinoma post resection and neck node dissection with negative margins. The tumor was HPV (human papillomavirus) 16+. Radiation therapy is recommended to decrease his risk of recurrence and proton beam approach is being requested. 

Proton beam radiation therapy is not considered medically appropriate nor necessary for this patient and his squamous cell carcinoma of the base of tongue. There are lack of any significant clinical trials completed and published in peer reviewed journals supporting the benefits and safety of proton beam radiation therapy as compared to conventional standard of care photon beam radiation therapy with intensity modulated radiation therapy (IMRT). Until the ongoing clinical trials accrue patients and mature to evaluation and published in peer reviewed journals showing a significant benefit for patients with this clinical scenario, the requested proton beam radiation therapy is not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Pain, Fever, Swelling
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient with no significant past medical history (PMH) and a past surgical history (PSH) that included silicone breast implant placement and mastopexy. She presented to the emergency department (ED) with reported bilateral breast pain, redness, swelling (left greater than right) and fever. She reported that she was in contact with the surgeon who performed her surgery and was told only to continue pain medication. The patient presented to the ED when the pain was no longer manageable with pain medication. The physical exam revealed left breast erythema surrounding the scarring and a crusting lesion/ulcer on her superior nipple with serosanguinous drainage, swelling, tenderness to palpation and long suture material that remained. Additionally, yellowish bloody discharge was seen on her shirt. In the ED, she was treated with intravenous (IV) Unasyn 1.5 grams (gm), by mouth (PO) Tylenol 975 milligrams (mg), and she was evaluated in consult by Plastic Surgery who recommended "...admission to Plastic Surgery service with intravenous (IV) antibiotics and pain management..." The decision was made to admit her as an inpatient with a plan of care that included IV antibiotics, pain management, continued Plastic Surgery evaluations and vital sign monitoring.
On the denied dates of service, the patient was tachycardic up to 108 beats per minute with reported breast pain (6/10), itchiness and persistent left breast erythema. She continued to receive inpatient treatment that included IV antibiotics, pain management, antipruritics, breast/nipple erythema and drainage monitoring. She was deemed medically stable by her attending and consulting physicians for discharge to home with antibiotics, wound care instructions and to follow-up with Plastic Surgery. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. This patient had signs and symptoms of a breast implant infection. At presentation, she had early signs of sepsis and warranted close monitoring and IV antibiotics in a supervised health care setting. The progress notes document improvement of symptoms. The pain had resolved and redness was improving.
According to Milliman Care Guidelines (MCG) General Admission Criteria: "General Criteria: Observation Care. Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically, it is 48-hours or less, but can be up to 72-hours in certain situations." The patient clearly had responded to treatment and did not require an inpatient admission; care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

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


The patient has a history of hypertension (HTN), prediabetes, and obstructive sleep apnea, on continuous positive airway pressure (CPAP), who presented to the emergency room (ER) with palpitations associated with upper back pain and left hand tingling. Paramedics noted her heart rate to be 180 beats per minute (bpm). She was given 6 milligrams (mg) than 12 milligrams (mg) of intravenous adenosine with restoration of normal sinus rhythm. In the emergency room, her blood pressure was 164/86 and pulse 111 bpm. An electrocardiogram (EKG) showed sinus tachycardia.
She was admitted to telemetry and ruled out for a myocardial infarction with negative troponin levels. A nuclear stress test was performed which was negative. She was discharged home. At issue is the medical necessity of an inpatient stay,
An inpatient stay was not medically necessary for this patient. She could have been managed at a lower level of care. The patient presented with palpitations and supraventricular tachycardia (SVT). However, she was hemodynamically stable in the emergency room, having been treated with intravenous adenosine by the paramedics in the field. She remained stable throughout her hospitalization with no evidence for acute coronary syndrome or recurrent arrhythmia.
Per current guidelines, including Milliman guidelines (reference one below), inpatient admission is indicated for patients with SVT and hemodynamic instability, persistent tachycardia, congestive heart failure, myocardial ischemia, altered mental status, medication toxicity, or other underlying medical condition requiring hospitalization. The patient did not have any of these conditions. Therefore, an inpatient stay was not medically necessary.