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 abdominal pain. Pertinent history included gastroesophageal reflux disease. Initial vital signs revealed a temperature of 98.2oF (Fahrenheit), heart rate (HR) 92, blood pressure (BP) 135/67, respiratory rate (RR) 18, and pulse oximetry 98% on room air. Initial examination documented the patient as alert, oriented, and right upper quadrant tenderness. Initial serology revealed a white blood cell count (WBC) 5.9, HGB 12.0, platelets (Plt) 230, Na (sodium) 141, K (potassium) 4.0, blood urea nitrogen (BUN) 12, Cr (creatinine) 0.56, carbon dioxide (CO2) 26, Tbil (total bilirubin) 0.7, aspartate aminotransferase (AST) 533, alanine aminotransferase (ALT) 586, and alkaline phosphatase (ALP) 270. Right upper quadrant (RUQ) ultrasound revealed cholecystolithiasis with biliary colic and possibly cholecystitis. The patient was placed in the hospital thereafter with an impression of acute calculous cholecystitis. 

The inpatient stay was not medically necessary.
The patient presented with right upper quadrant pain without a fever or leukocytosis. Serology noted elevation of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and total bilirubin. Right upper quadrant (RUQ) ultrasound revealed cholelithiasis without ductal dilation. Treatment plan included intravenous fluids and empiric antibiotics. Following observation care, the patient improved without further issue or complication.

Yokoe et al. note the diagnostic criteria for acute cholecystitis was local signs of inflammation (eg. Murphy's sign or RUQ mass/pain/tenderness), Systemic signs of inflammation (eg. Fever, elevated C-reactive protein (CRP), elevated WBC), and Imaging findings characteristic of acute cholecystitis. Okamoto et al. note that patients diagnosed with acute calculous cholecystitis should be admitted to the hospital and provided with supportive care. Initial treatment includes monitoring of respiration and hemodynamics, administration of sufficient intravenous fluid, electrolyte infusion and/or electrolyte correction, and treatment with antimicrobials and analgesics. In this particular situation, the patient did not meet the aforementioned criteria for acute calculous cholecystitis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal bleeding. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a woman who was admitted to the hospital. She was a smoker and she presented to the emergency department for evaluation of vaginal bleeding and clots. She said that her symptoms started three weeks prior to presentation and her last menstrual period was reportedly at the end of last year. She stated that she was also having breast tenderness and thought that she may have been pregnant. Vital signs showed blood pressure 147/92, hearts heart rate 96, and temperature 97 Fahrenheit. On physical exam, heart was regular, breath sounds were normal and the abdomen had a large liver and spleen but was nontender. Labs showed glucose 99, sodium 139, potassium 4.2, creatinine 0.71, calcium 8.1, white blood cell count (WBC) 10.2, hemoglobin 6.9, and platelets 345. Pregnancy test was negative. The patient was admitted with vaginal bleeding, anemia, and concern for incomplete miscarriage. 

The inpatient hospital admission was not medically necessary. 

The reason is that the patient had no evidence of hemodynamic instability, tachycardia or low blood pressures, and was not complaining of palpitations or shortness of breath. In addition, there was no physical exam finding of acutely active bleeding or end organ ischemia. Patients with symptomatic anemia and evidence of hemodynamic instability are usually treated at the inpatient level of care, but these findings were not present in the case of this patient. 

The patient did not have evidence of active vaginal bleeding, end-organ ischemia, tachycardia, or hemodynamic instability. While she required a blood transfusion, this does not need to be done at the inpatient level of care in hemodynamically stable patients without evidence of acutely active bleeding. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness
Treatment: Transthoracic Echocardiograph (CPT 93306)
The insurer denied the Transthoracic Echocardiograph (CPT 93306)
The denial is overturned. 

The patient is a male. He has a past medical history of coronary artery disease, status post prior MI (myocardial infarction), status post PCI (percutaneous coronary intervention), diabetes mellitus, dyslipidemia and hypertension with hypertensive heart disease. He presented for cardiovascular evaluation. The patient was complaining of dizziness. An echocardiogram was requested.

Yes, the Transthoracic Echocardiograph (93306) is medically necessary.

The patient with known coronary artery disease, confirmed by prior cardiac catheterization, requiring stent placement for a previous myocardial infarction, as well as multiple risk factors, presented for a cardiac evaluation, complaining of a symptoms of dizziness. Dizziness is often a manifestation of cardiac disease, and may be related to cardiac arrhythmia, lack of perfusion, valvular disease, CHF (congestive heart failure), etc. Therefore, it would be consistent with the current standard of care to obtain an echocardiogram for evaluation of any underlying structural heart abnormalities. Therefore, the requested procedure meets the definition of medically necessary treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Foot Infection

Treatment: continued hospital admission

The insurer denied coverage for continued hospital admission.

The denial is upheld.

This is the case of a male patient with past medical history significant for diabetes mellitus, hypertension, hyperlipidemia, and statis post (s/p) right 4th toe amputation who initially presented to the Emergency Department (ED) with complaints of left foot pain. 
Vitals on presentation included: temperature 97.4 Fahrenheit (F), blood pressure 170/74, pulse 81, respiratory rate 18, oxygen (O2) saturation 100% (percent) on room air. Laboratory results included: white blood cell count (WBC) 7.5, hemoglobin (HGB)-10.9, hematocrit (HCT)-33.1, creatinine-1.88, glucose-368.  The patient was started empirically on intravenous (IV) antibiotics for possible left foot infection. Infectious Diseases consulted and recommended antibiotics (Unasyn). He underwent left lower extremity (LLE) angiogram, left percutaneous transluminal angioplasty (PTA). The patient was evaluated by multiple services including Nephrology, Neurology, Endocrinology, and Psychiatry. He remained afebrile, hemodynamically stable, and was discharged home.  

According to medical records, their clinical impression was "improved" despite intermittent confusion, which the wife stated has been present since recovery from COVID-19 (2019 Novel Coronovirus). Progress note indicated-"discharge (d/c) planning if cleared by neurology..." Another evaluation documents-"awake, aware, on phone, no pain, no shortness of breath (SOB), nor palp, feels well..." Similarly, Podiatry noted-"wounds are significantly improving..." Finally, Nephrology stated "no objection to discharge with outpatient renal and urology follow-up..." 

Based on the above findings, in a patient who remained afebrile and hemodynamically stable, documentation does not support need for continued stay in an acute level of care setting, during the period in question.   

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

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

Diagnosis: Generalized weakness.
Treatment: Inpatient admission. 
The insurer denied coverage for the inpatient admission. 
The denial is upheld. 

This is a male patient who presented to the hospital with complaints of generalized weakness.  The documentation indicated he does have diagnoses that include coronary heart disease, hypertension, hyperlipidemia, chronic kidney disease and diabetes.  He did undergo stenting at an outside facility due to left internal carotid artery stenosis.  The submitted documentation indicated he was seen the day prior to presentation with the same complaints and underwent a Computed Tomography (CT) of the head which was negative.  He was placed on antibiotics and discharged.  The physician indicated upon presentation the family was concerned due to severe weakness and low blood pressure.  The documentation indicated upon examination the patient had a heart rate of 52 with oxygen saturation at 100%.  Blood pressure was 135/61.  The documentation indicated he was alert and oriented x3.  It was recommended that he be admitted for generalized weakness and a urinary tract infection.  It was recommended he undergo treatment that includes hydration as well as a cardiology consultation for a follow-up regarding bradycardia.  The recommendation was made for multiple laboratory and diagnostic studies.  The laboratory studies revealed a blood urea nitrogen (BUN) of 38.  Blood glucose was 202.  The red blood cell count was 3.07 and hemoglobin was 9.3.  The urinalysis did not reveal any positive results.  The chest x-ray was normal.  The additional treatment included intravenous (IV) hydration and continued monitoring.  The following day the patient was discharged as there was no documentation of any further adverse events.  

The inpatient level of care (LOC) is not supported by the available documents. The patient was seen in the emergency department for generalized weakness. His vital signs were stable. His physical examination and laboratory results were non-diagnostic except for mild dehydration, which could have been treated with a status of observation without admission. 

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

Diagnosis: Class I Malocclusion
Treatment: Braces
The insurer denied Braces. The health plan's determination is upheld.

The patient in question is a male with a Class I occlusion with 4 millimeter (mm) overbite and 5 mm overjet. He has moderate maxillary crowding. He is treatment planned for 24-30 months of orthodontics (Braces) to correct his malocclusion.

Braces are not medically necessary for this patient. The patient has minor crowding. His overbite is deep but there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient.
There is no medical reason to correct his malocclusion with braces. While the patient has some crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient's overjet is slightly more than ideal but his overjet would not affect oral health related quality of life unless it was greater than 6mm. If his teeth were aligned it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. Therefore, braces are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems-Teeth spacing problem
Treatment: Dental/Orthodontic Procedure-Braces
The health plan denied the treatment of Braces as not medically necessary. The reviewer has upheld in whole the health plan's determination.

The patient in question has a Class II occlusion with 2 millimeter (mm) overjet and 8 mm overbite. The maxillary and mandibular arches have moderate crowding. He is treatment planned for 24-30 months of orthodontics with elastics to correct his malocclusion. At issue is the medical necessity of the treatment plan of Braces.
The patient has minimal crowding. His bite is deep but there is no indication of damage to the incisors or the palate in the photographs, and his cephalometric radiograph show the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs provided there is severe soft tissue damage (or any soft tissue damage) on this patient.
There is no medical reason to correct his malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Although the narrative indicates a posterior crossbite, the supplied photos do not show any crossbites. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 6mm overjet, but this amount of overjet does not affect oral health related quality of life. If his teeth were aligned it would provide a minor esthetic improvement, but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nasal Papilloma Excision
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient underwent functional endoscopic sinus surgery. There were no intraoperative complications. Postoperatively, he underwent an episode in which he became lightheaded pale and diaphoretic, with bradypnea and bradycardia. He was treated with intravenous fluid and given juice, water and pretzels and his symptoms resolved. He was admitted to be monitored for bleeding. No significant postoperative bleeding during recovery was documented. He was stable with no documented bleeding and was discharged. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. Based upon the clinical information provided, the patient developed a transient episode of lightheadedness with diaphoresis, bradypnea with bradycardia in the post anesthesia care unit that resolved. It was documented that he was admitted postoperatively to monitor for bleeding, but there was no postoperative bleeding.
Patients recover in the recovery unit until they have met post-anesthesia care unit (PACU) discharge criteria. The criteria for discharge from phase 1 to phase 2 of PACU are often based on the (modified) Aldrete score, which includes adequate activity, circulation, consciousness, oxygen saturation, and maintenance of respiration. An episode of bradycardia/bradypnea responded to fluids with juice and pretzels. There was no bleeding documented in the PACU and the patient remained stable. In a review of a cohort of 94 patients by Arqhtani et al (2020) vasovagal syncope was common in a cohort of 94 patients who underwent nasal septoplasty. Therefore, the requested inpatient stay is not clinically appropriate/medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraine without aura, intractable, with status migrainosus. 

Treatment: Sumatriptan-naproxen tablet. 

The insurer denied coverage for sumatriptan-naproxen tablet. 

The denial is overturned. 

This is a female patient with a history of migraine without aura, intractable, with status migrainosus. The patient writes that she has suffered from migraines for many years and Treximet [sumatriptan-naproxen] relieves her migraines within an hour. This was denied by the insurer.  She has tried Imitrex, Relpax, Maxalt and Naprosyn - all with insufficient benefit. 

There is no evidence in the medical record that the formulary drugs will cause an adverse reaction - they are just not effective. She has tried Imitrex, Relpax, Maxalt and Naprosyn - all with insufficient benefit. 

Treximet has proven more effective than the formulary alternatives in this patient. There is evidence that Treximet is more effective and better tolerated than its components. 

The insurer's denial of coverage for sumatriptan-naproxen tablet is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, rheumatoid arthritis, diabetes mellitus, hypertension, peripheral neuropathy and severe obesity. 

Treatment: Personal Care Aide (PCA) Level 2 Services live-in per diem, 24 hours per day, 7 days per week. 

The insurer denied coverage for PCA Level 2 Services live-in per diem, 24 hours per day, 7 days per week. 

The denial is overturned. 

This is a female patient with a past medical history of osteoarthritis, rheumatoid arthritis, diabetes mellitus, hypertension, peripheral neuropathy and severe obesity.  Per the New York State Department of Health's Uniform Assessment System (UAS-NY) report, the patient lives alone on the second floor of a three bedroom apartment, which has elevator access. 
 
Needs are: 
- Maximal assistance for meal preparation, ordinary housework, managing stairs, shopping, transportation, bathing, dressing her lower body and toilet use; 
- Extensive Assistance for managing medications, personal hygiene, dressing her upper body, walking, toilet transfer, bed mobility and locomotion; 
- Limited assistance for managing finances and eating; 
Cognition:  No impairment. 
- Continence:  She is frequently bladder incontinent but has complete bowel   continence. The patient uses pull ups for her incontinence. 

The patient uses an assistive device for locomotion indoors. The patient reported a fall, and she had a bruise on her face and legs. The patient's son helped her after the fall. The patient has a supportive family, and they are involved in all aspects of her care. The patient's son visits regularly and assists her with shopping. 

An increase to personal care aide (PCA) level 2 services live-in per diem, 24 hours per day, 7 days per week is being requested. 

The patient has urinary incontinence as well as extensive needs for assistance with all activities of daily living (ADLs) including bed mobility, transfer, locomotion and toilet use.  She has had an informal caregiver who filled in hours and is leaving. The patient is unable to manage her incontinence without assistance, and the same is true for toileting. The patient's locomotion and toileting have required more assistance. 

The provision of diapers and other Durable Medical Equipment (DME) is not by itself adequate for prevention of pressure sores. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. The patient has scheduled and unscheduled needs that support 24-hour care. 

The insurer's denial of coverage for the requested PCA Level 2 Services live-in per diem, 24 hours per day, 7 days per week is overturned.  Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Reyvow. 
The denial is overturned in whole.

The patient is a female with a longstanding history of migraine headaches. She has been under the care of a neurologist for at least six years (based on medical records) provided for review.
A note from a consult indicated that the patient had been seen for a headache evaluation on that date. The patient reported onset of headaches in her teenage years. The patient's headache frequency gradually increased over the years. With regard to acute treatments the records indicated that the patient had been ""on many different regimens of triptans including the Imitrex injections and Zomig nasal spray--all were not effective"). At the time of that visit the patient was prescribed a combination of eletriptan/dexamethasone/phenergan for the acute treatment of migraines.

At a follow-up visit the notes indicated that "Ubrelvy did not seem to help her headaches at all and Nurtec response has been variable. She has found Reyvow helpful when she takes it towards the end of the day and likes the fact that it makes her "sleep better" which she finds helpful when she has a migraine". At the time of that visit samples of Nurtec were given. The patient has since been prescribed Reyvow for the acute treatment of her migraines.

The health plan's determination is overturned.

In this case the patient is noted to have a history of aortic stenosis. While the rest of her cardiac history was not fully detailed the records provided for review, it would be within the generally accepted standards of practice to avoid the use of triptan agents.
As was noted in a recent review: "triptans are vasoconstrictors and these effects may increase the risk of serious ischemic events in patients who have underlying cardiovascular (CV) diseases or risk factors for CV disease" (Dodick et al 2020).
As such given the patient's history of aortic stenosis trials of almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan tablet, rizatriptan ODT, sumatriptan-naproxen, sumatriptan tablet, sumatriptan nasal spray, zolmitriptan ODT, zolmitriptan tablet would not be appropriate.
The records provided for review also indicated that the patient had trialed Ubrelvy but that the drug had not been effective for her condition (acute treatment of migraine).
The requested drug is a Selective 5-hydroxytryptamine (5-HT1F) receptor agonist which is noted to not carry the same cardiovascular risks that are associated with triptans (Rubio-Beltran et al. 2018).
In this setting the requested non-formulary drug would be a more appropriate clinical choice (given the patient's failure of the plan's non-triptan preferred agent).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: anterior crossbite
Treatment: Braces
The insurer denied braces. The health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on tooth #7. She presents with a Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for 24-30 months of braces to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity.

Braces are medically necessary for this patient.
This patient presents with an anterior crossbite on tooth 7, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.
If left untreated the damage that will occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, braces are deemed medically necessary.