Persius/hicric huggingface dataset:
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 who initially presented to the emergency department with concerns for abdominal pain and diarrhea. Pertinent history included ruptured ectopic pregnancy status/post (s/p) mini exploratory laparotomy and palpitations followed by an outpatient cardiologist. The patient was placed in the hospital thereafter with an impression of dehydration and proctocolitis. Treatment plan included intravenous fluids, clear liquid diet, cultures, empiric Zosyn, and consultations. 

No, the inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care. In this particular situation, the patient had a history of ruptured ectopic pregnancy status/post (s/p) mini exploratory laparotomy and presented with abdominal pain and diarrhea. An extensive evaluation was performed which found the patient to be afebrile, hemodynamically stable, without significant laboratory abnormalities, and with radiographic findings suggestive of proctocolitis. Treatment plan included intravenous fluids, symptom management, and additional diagnostic testing. Gastroenterology consultation was obtained who recommended discontinuation of antibiotics and performed a flexible sigmoidoscopy that was unremarkable. Multiple consultations were obtained, including neurology and cardiology, for dizziness and palpitations who essentially recommended outpatient follow-up. Following observation, the patient did not have a documented significant pathological process present that could only be managed at an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastric Ulcer.
Treatment: Sequential or repeat esophagogastroduodenoscopy (EGD).
The insurer denied the Sequential or repeat esophagogastroduodenoscopy (EGD).
The denial is upheld.

The patient is a female with epigastric pain, found to have hemorrhagic gastritis on esophagogastroduodenoscopy (EGD). The patient was treated with Pepcid. The patient recently presented with ongoing epigastric pain. The attending physician (AP) is requesting a follow up esophagogastroduodenoscopy (EGD).

No, the proposed treatment is not medically necessary.

The patient was found to have hemorrhagic gastritis and has failed treatment with Pepcid. There is no documentation that the patient has failed a proton pump inhibitor. There is no evidence of weight loss, vomiting, dysphagia or gastrointestinal (GI) bleeding.  As it is not standard of care to perform a follow up esophagogastroduodenoscopy (EGD) to assess for healing of hemorrhagic gastritis, and as esophagogastroduodenoscopy (EGD) is not medically necessary without failure of proton pump inhibitors, or worrisome symptoms of weight loss, vomiting, dysphagia or gastrointestinal (GI) bleeding, the proposed follow up esophagogastroduodenoscopy (EGD) was not medically necessary.

Yes, as above, as esophagogastroduodenoscopy is not medically necessary, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Surgical Services. 
The insurer denied microsurgery and hospital admission. 
The denial is overturned.

The patient is a female with bilateral lower extremity lymphedema secondary to treatment of cervical cancer and cellulitis.
The patient was diagnosed with cervical cancer and underwent trachelectomy one month later.
She developed lymphedema of the left lower extremity and lymphedema of the right lower extremity after a cellulitis infection.
The patient had been treated by a lymphedema therapist with catheter directed thrombolysis (CDT).
Radionuclide lymphoscintigraphy showed bilateral axillary and left supratrochlear lymph nodes. Minimal lymph nodes seen in the left inguinal region. No lymph nodes visualized elsewhere.
She had suction assisted protein lipectomy (SAPL) surgery on the right leg and SAPL surgery on the left leg.
The patient had improvement in lymphedema but had persistent swelling of the bilateral lower extremities.
The patient was recommended to undergo Vascularized Lymph Node Transfer and Lymphaticovenous Anastomosis surgery.
The issue at hand is whether or not the treatment, Vascularized Lymph Node Transfer and Lymphaticovenous Anastomosis surgery and hospital admission is likely to be more beneficial than any standard treatment or treatments for the patient's condition or disease.

The microsurgery and admission is likely to be more beneficial for this patient.
The patient has severe and chronic bilateral lower extremity lymphedema. The proposed treatment, Vascularized Lymph Node Transfer and Lymphaticovenous Anastomosis surgery and hospital admission is likely to be more beneficial than any standard treatment or treatments for the patient's condition. The patient had initial improvement in lymphedema but then had persistent swelling of the bilateral lower extremities. The treatment is supported by the literature, it is the appropriate treatment for this patient's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Surgical Services. 
The insurer denied microsurgery and hospital admission. 
The denial is overturned.

The patient is a female who was diagnosed with cervical cancer. She underwent pelvic surgery for cervical cancer which caused her to initially experience lymphedema in bilateral lower extremities. She had multiple swelling episodes of her left and right lower extremity with multiple cellulitis flares.  The patient started to undergo conservative therapy for lymphedema with weekly decongestive therapy, manual lymphatic massage, custom compression stockings, self- manual lymphatic drainage and compression pump. Despite conservative therapies, the patient suffers persistent lymphedema in bilateral lower extremities. She was diagnosed with stage II lymphedema of the right lower extremity and stage I on the left lower extremity. The diagnosis was confirmed by lymphoscintigraphy. The patient underwent suction assisted lipectomy on the right leg and on the left leg. The surgeries successfully improved her leg volume and functional capacity. However, the patient still required constant compression. The provider is requesting stage 2 of lymphedema surgery with vascularized lymph node transfer (VLNT) and laser vein ablation (LVA) with a 3 night inpatient hospital stay for the surgeries.

The proposed health service and treatment of VLNT, LVA and the associated hospital stay is likely to be more beneficial than any standard treatment or treatments for the health plan's life threatening or disabling condition or disease.
The patient has well documented chronic lymphedema of bilateral lower extremity as a result of pelvic surgery for cervical cancer. She has exhausted all available conservative therapies for the treatment of bilateral lower extremity lymphedema and has had success with stage one of surgical treatment of lymphedema with liposuction.
VLNT is a well-established method for the surgical management of refractory extremity lymphedema. There are myriad studies documenting the benefits of the procedure for the treatment of lymphedema. No other alternative treatment exist for the treatment of this patient's condition. In addition, the patient has had a long standing history with lymphedema and she has exhausted all available treatment. This patient will likely benefit from the procedure with an improvement in her quality of life.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Surgical Services. 
The insurer denied microsurgery and hospital admission. 
The denial is overturned.

The patient is a female who has a history of bilateral lower extremity lymphedema, She also has a history of bilateral hip dysplasia, requiring two surgeries at early age to remove hardware. She experienced cellulitis after hardware removal. Her lymphedema symptoms started and involve both legs below the knees and feet with the left worse than the right. She underwent bilateral saphenous vein ablation without improvement, The patient complains of easy bruisability, difficulty walking, working out and work-related job duties as a magnetic resonance imaging (MRI) /x-ray tech due to stretching and tearing of the swollen skin of her lower extremities. She has experienced multiple bouts of cellulitis. requiring intravenous (IV) antibiotics and hospital admission related to lymphedema. She has also tried physical therapy, lymphatic massage, and compression garments without significant improvement. Physical examination notes leg asymmetry left leg larger than right, with pitting edema of the legs and feet. There is a surgical plan to undergo bilateral lymphatic venous anastomosis and lymphoscintigraphy in 3 staged procedures. The subject under review is whether the microsurgery is likely to be more beneficial than any standard treatment for the patient's life.

Yes. The patient has failed all reasonable conservative treatments (physical therapy, lymphatic massage, and compression garments). She has activity limitations and has required IV antibiotics for cellulitis. She has significant functional limitations due to her lymphedema. Surgery is the only treatment that can improve her condition. A 2020 Consensus Document of the International Society of Lymphology (Lymphology. 2020;53(1):3-19) states: "Lymphatic-venous (or lymphovenous) anastomoses (LVA) are currently in use at many centers around the world. These procedures have undergone confirmation of long-term patency (in some cases more than 25 years) and demonstration of improved lymphatic transport (by objective physiologic measurements of long-term efficacy)."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic sinusitis.
Treatment: Sinus surgery.

The insurer denied coverage for sinus surgery.  The denial is overturned.

The patient who has a history of right sided chronic sinusitis. Odontogenic origin is suspected. His medical treatment has included multiple courses of antibiotics, nasal rinses, steroids and azelastine. Right sided nasal edema and pus is noted. There is a history of diabetes. The provider is requesting functional endoscopic sinus surgery (FESS) procedures. All records were reviewed.

The health plan did not act reasonably and with sound medical judgment and in the best interest of the patient as the sinus surgery is medically necessary. This is considering the clinical standards of the plan, the information provided for review concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations.

The sinus surgery is considered medically necessary for this patient. The patient has chronic sinusitis that has failed maximal medical therapy including multiple courses of antibiotics.

There is a sinus CT (computed tomography scan) reporting pan sinus disease on the right after medical therapy. The infection is likely to be related to tooth pathology. Surgical therapy would involve addressing both the sinuses and teeth. Allergies would not be a cause of this problem. Therefore, based on the information provided for review and consistent with scientific literature and the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines, the requested FESS sinus surgery is medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for sinus surgery is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Diagnostic Testing. 
The insurer denied esophagogastroduodenoscopy (EGD). 
The denial is upheld.

The patient is a male patient who has a history of Barrett's esophagus. He has prior esophagogastroduodenoscopy (EGD) procedures. Prior EGD reports are not provided. It is not known if the patient has long or short segment Barrett's esophagus. His Prague circumferential and maximal extent (C&M) classification of Barrett's is unknown. The medical records state the patient has Barrett's esophagus without dysplasia. The attending provider did an EGD to follow up on this patient's Barrett's Esophagus. At issue is if the EGD was medically necessary.

The health plan's determination is upheld.

The requested health service/treatment of gastric service (sequential or periodic esophagogastroduodenoscopy or EGD) is not medically necessary for this patient.
Barrett's esophagus (BE) is the metaplastic transformation of the esophageal squamous mucosa to intestinal columnar mucosa. It is the only known premalignant lesion for esophageal adenocarcinoma (EAC). BE is thought in most cases to sequentially pass through stages of non-dysplastic BE, low-grade dysplasia, and high-grade dysplasia (HGD) before becoming EAC.
The diagnosis of BE is made when columnar-appearing mucosa is seen proximal to the gastroesophageal junction (defined as the proximal extent of gastric folds) and confirmed by pathology. The Prague criteria should be used not only to aid in the identification of patients with BE (because it uses landmarks with high interobserver agreement) but also to grade the endoscopic extent of BE (by recording the circumferential and maximal lengths). Because neoplasia can be patchy and is not reliably detected by standard white-light endoscopy, 4-quadrant biopsies are taken every 1-2 centimeter (cm) over the entire extent of BE.
According to the updated American College of Gastroenterology (ACG) clinical guidelines for the diagnosis and management of patients with Barrett's esophagus published in 2022:
Length of Non dysplastic Barrett's esophagus segment should be considered when surveillance intervals are assigned, with longer intervals reserved for segments less than 3 cm.
Therefore, longer segments of BE (greater than or equal to [>=]3 cm) are surveyed on a 3-year interval and shorter segments of BE (less than [<] 3 cm) are surveyed on a 5-year interval (quality of evidence: moderate; strength of recommendation: strong).
Since there is no description of the length of this patient's Barrett's esophagus based on the Prague classification and since he does not have dysplasia, the EGD was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood Disorders. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male with a history of hypertension, diabetes, metastatic lung cancer, and stroke. He presented to the emergency room after a significant drop in his hemoglobin was noted in an office visit that day. He had no complaints otherwise. The vital signs were normal, and he was alert and in no acute distress. The physical exam was unremarkable, and the stool was negative for occult blood. Labs were notable for a hemoglobin of 6.3 grams per deciliter (g/dL) and a creatinine of 1.3 milligrams per deciliter (mg/dL). The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. A transfusion of packed red blood cells (RBCs) was administered. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with his usual home medications except his antiplatelet agents were held. An additional unit of packed cells was administered. The following day, the computed tomography (CT) scan of the chest, abdomen, and pelvis showed improvement of the previously noted pleural effusion. An upper endoscopy was performed and revealed two non-bleeding duodenal ulcers. The remainder of the stay was clinically uneventful, and the patient was discharged.

The subject under review is the medical necessity for the inpatient stay.

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 patient was asymptomatic and other than the noted drop in hemoglobin on admission, there was no evidence of active bleeding. The services provided - blood transfusions, oral medications, and esophagogastroduodenoscopy (EGD) - were not particularly complicated and were not at the acute inpatient level of intensity. Therefore, based on the standard of care, and the peer reviewed literature cited below, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

The following review is based on the patient appeal letter only. There are no medical records provided. The patient presented to the emergency department with a one-day history of lower abdominal pain with associated nausea and vomiting. The patient was diagnosed with appendicitis. There are no laboratory results available. Results of imaging is not available. The patient underwent surgery after one day of conservative management. An operative report is not available and there were no reported complications in the patient appeal letter. Admission may be necessary for patients with severe systemic illness [example (eg), sepsis], poorly controlled comorbidities [eg, chronic obstructive pulmonary disease (COPD), chronic heart failure], or complications from the procedure (eg, infection, bleeding) that require more than 24 hours of postoperative care. There is no indication as to why an inpatient admission was medically necessary. Peer-reviewed literature also indicates that laparoscopic appendectomy can successfully be performed as an outpatient procedure in those with uncomplicated appendicitis. Therefore, the requested inpatient hospital stay is not medically necessary.

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

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

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

This male presented with possible seizure. He became lightheaded and fell to the floor.   He complained of neck and right shoulder pain.  

The patient's vital signs were stable.  His temperature was 96.4.  His exam was unremarkable.  His labs were remarkable for white blood cell count of 16.1 with 16% bandemia and potassium of 2.8.  The patient's head computed tomography showed no acute disease.  His cervical spine computed tomography showed status post anterior cervical discectomy and fusion at C5 (fifth cervical spine vertebra) and C6 (sixth cervical spine vertebra),and no acute fracture.  The patient received Keppra in the emergency room and was admitted. The plan of care included electroencephalography (EEG) and magnetic resonance image of the brain and neck.  

The patient's brain magnetic resonance image showed no acute infarct.  Cervical spine magnetic resonance image showed degenerative changes and muscular strain/injury.  His potassium was replaced.  Leukocytosis was trending down.  There were no signs of sepsis, and no active bleeding.  The plan was for an electroencephalography.  The patient was undergoing Epilepsy Monitoring Unit (EMU) monitoring.  Epilepsy Monitoring Unit (EMU) was completed. There was no evidence of seizure.  Plan was for shoulder arthroscopy.  A Dilaudid patient controlled analgesia (PCA ) was started for shoulder pain.  Surgery was performed.  

The patient remained on the Dilaudid patient controlled analgesia.  The Plan was for discharge once the patient's pain improved and he could be on oral intake.  The Dilaudid patient controlled analgesia was discontinued.  The patient was cleared for discharge.

No, the proposed inpatient hospital admission was not medically necessary.
This patient was admitted after possible seizure.  The plan denied inpatient admission because the patient did not have a seizure associated with severe problems.  He was hemodynamically stable.  His evaluation did not reveal a brain disorder, infection, metabolic disorder, or arrhythmia.  He underwent prolonged monitoring for seizure, which was negative.  The patient also complained of neck and shoulder pain.  There was no acute fracture.  His shoulder pain persisted and the patient remained hospitalized after seizure workup for management of shoulder pain and arthroscopy.  He was discharged after oral pain medications were restarted.  Acute inpatient admission was not medically necessary.  The patient was clinically stable.  He did not have recurrent seizure activity.  Arthroscopy is an ambulatory procedure.  The patient had not failed an observation level of care and there were no acute findings that required intervention at an acute inpatient level of care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath, lower extremity swelling.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.


The patient has a history of cardiomyopathy with mild to moderately reduced left ventricular ejection fraction (LVEF), poorly controlled diabetes mellitus type 2, chronic left lower extremity venous ulcer, hypertension, peripheral vascular disease, who presented to the emergency department (ED) for evaluation of worsening shortness of breath, cough, orthopnea, and lower extremity swelling. A chest x-ray demonstrated pulmonary edema. The B-type natriuretic peptide was significantly elevated at 9,010 picograms per milliliter (pg/ml). An electrocardiogram (ECG) was negative for ischemic changes. The patient was admitted under an inpatient level of care for evaluation and treatment of acute systolic heart failure with volume overload and evaluation for left lower extremity (LLE) cellulitis. The patient responded well to twice daily intravenous (IV) Lasix and remained hemodynamically stable during his hospitalization. His heart failure medical therapy was adjusted which included adding an evidence-based beta-blocker as well as daily oral diuretic at the time of discharge. At issue is the medical necessity of an inpatient level of care.

Inpatient admission was medically necessary for optimal patient outcomes in this case. 

This patient presented with signs and symptoms of significant volume overload highlighted by orthopnea, pulmonary edema, severe leg edema, elevated B-type natriuretic peptide (BNP) requiring twice daily intravenous (IV) Lasix for adequate diuresis which had not resolved completely at the time of discharge based on the documentation provided. Given the severity of this patient's volume overload and high BNP which is predictive of increased risk for future adverse cardiac events including mortality and heart failure readmission, inpatient level of care was medically appropriate, necessary and in the best interest for the safety of this patient which is supported by peer-reviewed medical literature and expert consensus guidelines on acute heart failure management (1-3). Based on the patient's marked degree of volume overload, high BNP level predictive of increased risk for adverse cardiac events, inpatient level of care was medically appropriate, necessary, and in the best interest for the safety of this patient.