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

Diagnosis: Difficulty breathing, fever, diarrhea, cough. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is a toddler male child born prematurely at 35-weeks' gestation that was taken to the ED (emergency room) with three-day history of dry cough, runny nose, tactile temperature treated with Tylenol, and decreased appetite. He developed difficulty breathing one-day prior to presentation. He was initially taken to urgent care, and then referred to the ED (emergency department). 

The patient's vital signs included temperature 99.3, heart rate 170, respiratory rate 34 with 99% saturation in room air. Examination was significant for crying, not consolable by the mother, subcostal retractions, moist mucous membranes, mild bilateral rhonchi, mild end-expiratory wheezing, and non-focal neurologic exam. Respiratory panel was positive for RSV (respiratory syncytial virus). Chest x-ray revealed prominent broncho-vascular markings at the hila, suggestive of reactive airways disease. He was treated with DuoNeb and prednisolone. Upon re-evaluation, he was able to take a bottle but continued to cry and exhibit retractions. He later spiked a fever to 101.6.
The patient was admitted for further management. Admission orders included nasal suctioning, diet for age, albuterol, and routine vital signs with respiratory monitoring. He improved overnight and was deemed stable for discharge the next day to continue with albuterol every four hours to follow-up with his pediatrician. 

The Inpatient Hospital Admission was not medically necessary. 

This young male child presented with increased work of breathing, cough, and fever. Testing was positive for RSV (respiratory syncytial virus), and he was diagnosed with RSV (respiratory syncytial virus) bronchiolitis. He was given a trial dose of albuterol (with Atrovent) in the ED (emergency department) with presumed positive response. He continued to receive albuterol with sufficient resolution of symptoms that he was deemed stable for discharge the day after admission. While it was not unreasonable to monitor him in the hospital for improvement versus decompensation, he was overall hemodynamically stable with no need for supplemental oxygen and no evidence of impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiolitis
Treatment: Hospital admission
The insurer denied coverage for hospital admission
The denial is overturned

This is an infant who had a worsening nonproductive cough. The infant had nasal congestion and an upper respiratory infection for six days. The infant had been using saline nebulizer treatments at home, but the symptoms became worse, and the mother decided to bring the child to the emergency room (ER) when the child had episodes of post-tussive vomiting and was not able to tolerate oral fluids. Two weeks prior to this illness the infant was seen in the urgent care and referred to the ER with a rhinovirus infection.

In the ER the infant was noted to have increased work of breathing and increased nasal secretions. The infant was in respiratory distress with a respiratory rate of 46 and the pulse oximeter was 94% (percent) on room air. The infant was placed on oxygen and was administered a STAT (urgent) treatment with albuterol via a nebulizer. Due to intolerance to oral fluids, the infant was started on IV (intravenous) fluid supplementation. A respiratory viral panel was positive for Respiratory Syncytial Virus (RSV). When the breathing failed to improve with treatment, and the infant continued to require oxygen supplementation the decision was made to admit the infant to the hospital for ongoing treatment with a diagnosis of bronchiolitis.

The insurer has denied the medical admission as being not medically necessary.

The patient was treated appropriately in the ER for coughing, hypoxemia and increased work of breathing. The increased work of breathing and wheezing did not respond to treatment with bronchodilators, nasal sprays and suctioning. The decision to admit with a diagnosis of bronchiolitis for continued treatment with 3% hypertonic saline and albuterol was medically indicated and this infant could not have been safely discharged home. The child's young age placed the child at high risk for ongoing respiratory distress.

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 hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse. 
Treatment: Inpatient Rehabilitation. 

The insurer denied coverage for inpatient rehabilitation. 

The denial is overturned. 
 
This adult was admitted to this inpatient substance rehabilitation treatment facility for substance rehabilitation treatment. He reportedly was using 1 bag per day of phenylcyclohexyl piperidine (PCP) and cocaine, and also using Xanax 1 mg (milligrams) per day. He also had depression and sleeping problems. He was agitated, anxious, had garbled speech, flat affect, sleeping problems, and had cravings. He had past unsuccessful treatments due to multiple past episodes. He attended group and individual therapy. 

The medical records provided enough specific evidence to support that he required this level of care. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case this patient was considered in need of 24-hour substance rehabilitation treatment as he lacked coping skills and substance-free social supports to remain abstinent in an ambulatory setting as evidenced by the fact that he had no significant abstinence time reported despite past treatment episodes. His longest abstinence reportedly was 2 weeks. 

According to the Level of Care Determination (LOCADTR) he met criteria for inpatient substance rehabilitation treatment as he reportedly was using large amounts of multiple substances or serious use including PCP, cocaine, and Xanax and he was considered a medical risk for medical consequences and also for overdose. He had negative consequences due to use including a Driving While Intoxicated (DWI) which put him and others at risk of harm. He lacked the motivation, insight, coping skills, relapse prevention skills, and ability to identify relapse triggers, and lacked sober supports as his wife also reportedly uses. He required inpatient substance rehabilitation treatment and needed to learn better coping skills, identification of relapse triggers, increase sober supports, improve motivation, learn relapse prevention skills, and maintain abstinence.  Without this structured and supervised therapeutic inpatient substance rehabilitation treatment, he likely would have relapsed quickly as evidenced by his past history of relapsing after past treatments and also due to his inability to remain abstinent more than 3 weeks. He was considered at risk for medical issues due to multiple serious substances of use and he also was at risk of overdose. 

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 inpatient rehab admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dense breasts
Treatment: Breast MRI (magnetic resonance imaging) Without/ With Contrast
The insurer denied: Breast MRI Without/ With Contrast
The denial is upheld

The patient is an adult female who has dense to extremely dense breasts on mammogram. She had several ultrasounds in conjunction that were normal. She underwent breast MRI (magnetic resonance imaging) testing due to the density of her breasts. This was normal. The breast MRI (magnetic resonance imaging) is denied as not medically necessary. This is being appealed. 

The proposed treatment is not "medically necessary". 

According to the American College of Obstetrics and Gynecology, "Women with dense breasts (Breast Imaging Reporting and Data System [BI-RADS] category 3 and 4) have a modestly increased risk of breast cancer and experience reduced sensitivity of mammography to detect breast cancer. Although categories have been established, the assessment of breast density is subjective and based on the opinion of the radiologist. In women with heterogeneously dense or extremely dense breasts, digital mammography has been shown to be more effective compared with film mammography for breast cancer screening. Numerous states have passed legislation that require health care providers to inform women of the modest increased risk of breast cancer and reduced sensitivity of mammography, and several states require practitioners to discuss supplemental tests to screening mammography for women with dense breasts. Current published evidence does not demonstrate meaningful outcome benefits (e.g., reduction in breast cancer mortality) with supplemental tests (e.g., ultrasonography and magnetic resonance imaging) to screening mammography or with alternative screening modalities (e.g., breast tomosynthesis or thermography) in women with dense breasts who do not have additional risk factors. Evidence is lacking to advocate for additional testing until there are clinically validated data that indicate improved screening outcomes." 
The USPSTF (United States Preventive Services Task Force) concludes that the current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, DBT (digital breast tomosynthesis), or other methods in women identified to have dense breasts on an otherwise negative screening mammogram. 
In review of the information provided, the patient has had screening mammograms with the findings of dense to extremely dense breasts. She had ultrasounds in 2018 and 2019 which were negative. In the record provided there is not a strong family history of breast cancer or any genetic abnormalities. The literature does not support the use of MRI (magnetic resonance imaging) as an adjunct in the evaluation of dense breasts. Several national organizations conclude that there is not sufficient evidence from peer reviewed literature to support this testing, as described above. Therefore, this is not a standard of medical practice and would be considered a convenience rather than necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The health plan's determination is upheld.

The patient is a male who presented to the emergency department (ED) with chest and abdominal pain of 1-day duration. At the time of presentation, the patient was without fever, his heart rate was 96 beats per minute and his blood pressure was 161/93 millimeters of mercury (mmHg). He was tender in the right upper quadrant. The white blood cell count (WBC) count was elevated at 11.9 thousand (K). The complete metabolic panel identified normal liver enzymes. The ultrasound and computed tomography (CT) scan showed no gallstones and no ductal dilatation.
He was admitted to the hospital and initially treated with intravenous (IV) fluid and antiemetics. A cardiology consultation was obtained. He was treated with a laparoscopic cholecystectomy. The operative dictation records completion of the procedure without complication.
The patient was treated with post-surgical monitoring, IV fluids, IV analgesia, antibiotics, and antiemetics. The immediate post-surgical recovery was uncomplicated. Following surgery he had a normal temperature and normal vital signs. The patient's diet was advanced and his pain was controlled with oral medications. The patient remained clinically stable and he was discharged from the inpatient setting.

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

An inpatient level of care was not medically necessary for the patient. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. There is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring an inpatient admission. While the initial WBC count was elevated, his serum transaminases were normal and the imaging did not identify acute cholecystitis.
The treatment plan in this case included surgery. The progress notes state that the patient was stable for discharge from the hospital following surgery. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered at an alternate level of care. 
An alternate level of care would have provided for ED assessment, perioperative care and monitoring, provision of IV antibiotics and fluid, imaging as performed, follow up laboratory data, surgery, and overnight care. This patient underwent an uncomplicated laparoscopic cholecystectomy procedure. There were no peri-operative complications or other clinical issues. He remained stable and was suitable for discharge from the hospital following the initial recovery period.

The health plan's determination is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Dementia. 
Treatment: Increase in personal care aide (PCA) services: 12 hours per day, 7 days per week, for a total of 84 hours per week. 

The insurer denied coverage for increase in personal care aide (PCA) services: 12 hours per day, 7 days per week, for a total of 84 hours per week. 

The denial is modified. 

This is an elderly patient with progressive dementia. She lives alone in a private residence. The insurer approved personal care aide (PCA) 3 hours/day, 3 days/week for a total of 9 hours/week and the request is for PCA 12 hours/day, 7 days/week, for a total of 84 hours/week. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition was described as "moderately impaired- decisions consistently poor or unsafe; cues/supervision required at all times."  She is totally dependent to maximal assistance for much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  However, she requires only limited assistance for bathing, lower body dressing and toilet use. She is otherwise independent to supervision for personal hygiene, upper body dressing, eating, bed mobility, locomotion, toilet transfer and ambulation. She is also continent of bowel and bladder. The patient's clinical condition, limited physical impairments and independent mobility do not support the medical necessity of the requested PCA 12 hours/day, 7 days/ week, (84 hours/week).  However, increasing the PCA to 3 hours/day, 7 days/week is clinically appropriate. This physician would agree the patient may benefit from additional monitoring; particularly due to her cognitive deficits and wandering. However, safety monitoring under personal care services does not include monitoring an individual (with dementia) when no other Level I or Level II personal care services task is being provided.  Based on the enclosed documents reviewed, the patient's health and safety can be more appropriately provided and maintained by increasing PCA to 3 hours/day, 7 days/week. 

Based on the above, the insurer's denial must be modified. 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 an increase in personal care aide (PCA) services: 12 hours per day, 7 days per week, for a total of 84 hours per week services is not substantiated. However, increasing PCA to 3 hours/day, 7 days/week (21 hours/week) is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 
This adult patient with a past medical history of hypertension presented to the hospital with chest pain radiating to the left jaw and left arm. On arrival to the hospital, vital signs were stable (blood pressure 129/87, Pulse 72).  Physical examination revealed no major abnormality. A 12-lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST (interval on an ECG) or T wave (interval on an ECG) abnormalities. Serum troponin levels were not elevated (< (less than) 0.01). The patient has had similar symptoms in the past and was evaluated in the emergency department and by the cardiologist. Previous stress testing was negative. The patient was admitted to the hospital for treatment and discharged the following day without additional testing. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. The pretest probability of coronary artery disease was low. Utilizing the HEART (history, ECG anomalies, the patient's age, any risk factors present, and elevated Troponin score), the patient was considered low risk. Utilizing the thrombolysis in myocardial infarction (TIMI) risk score, the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days. Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care.

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

Diagnosis: Dental Problems/Other/Dental Issues
Treatment: Dental/Orthodontic Procedure/Other/all white glass crown tooth 9
The health plan denied the requested all white glass crown tooth 9 as not medically necessary. The health plan's determination is upheld.

The patient is a female who presented to the office for evaluation and treatment of tooth #9. Provided for review are previous letters of appeal and denial, full mouth radiographic images, and one page of American Dental Association (ADA) claim forms. 
In question is the medical necessity of the requested health service/treatment of a white glass crown for tooth # (number) 9.

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

No, the requested health service/treatment of all white glass crown for tooth #9 is not medically necessary for this patient. A direct restoration is most appropriate in this case, as there is minimal involvement of decay or missing tooth structure on tooth #9.
The current decay/affected tooth structure is less than one third of the crown and is indicated for a direct restoration and not preparation of the remaining healthy unaffected tooth structure as there is not any indication to place more than a class III restoration (direct restoration). The requested treatment of crown #9 is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Oppositional defiant disorder (ODD)

Treatment: Inpatient care

The insurer denied coverage for Inpatient care

The denial is modified.

 
This teenager was admitted to inpatient mental health treatment due to mood and behavioral symptoms including mood swings, emotional dysregulation, oppositional defiant behavior, agitation, property destruction, self-injurious behavior including hitting self, lying, stealing, using profanities, talking about drugs, disrespectful behavior towards others, physical altercations, risky behaviors, impulsive behaviors, and difficulty following rules. He had a diagnosis of Oppositional Defiant Disorder (ODD) and attention-deficit/hyperactivity disorder (ADHD). He took Risperidone and Lamictal and attended group, individual, and family therapy. 

The Milliman Care Guidelines (MCG) Residential-Behavioral Health Level of Care- Psychiatry Child/Adolescent guidelines report that one needs to have continued danger to self or others, moderately or severe psychiatric or behavioral symptoms requiring 24-hour daily treatment, or serious dysfunction in daily living. The InterQual Behavioral Health Child/Adolescent Psychiatry Inpatient Level of Care residential treatment guidelines reports that one still has psychiatric or behavioral symptoms that put the patient at high risk for hospitalization if not in this 24-hour treatment, that they still have psychiatric or behavioral symptoms that are improving or expected to improve but they are not clinically stable yet. It also states that one could still have symptoms including disorganized behavior, command auditory hallucinations decreasing in frequency, delinquent behavior, still have a major depressive episode with certain symptoms including hopelessness, have high risk sexual behavior, eating disorder symptoms requiring 24-hour treatment, hypomanic symptoms associated with poor impulse control, or psychomotor agitation. 

In this case this patient did have continued reported psychiatric symptoms that were improving or expected to improve but were not clinically stable yet. He was considered at risk for worsened behavioral and mood symptoms if not in this inpatient therapeutic supervised and structured residential treatment due to his limited coping skills and problems solving skills, limited ability to regulate his emotions, and risky and impulsive behavior putting himself and others at risk including agitation, property destruction, self-injurious behavior including hitting self, stealing, physical altercations, risky behaviors, impulsive behaviors, and difficulty following rules. 

Based on the above, the insurer's denial must be modified. 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 residential mental health treatment is partially substantiated but the insurer's denial is upheld in part.