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

Trauma/spinal cord injury
Inpatient hospital

Diagnosis: cauda equina syndrome 
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a male who presented to the emergency room via ambulance for low back pain. Emergency Provider note states that he had low back pain that got worse since Friday. He noticed urinary retention and only urinated once per day which was not normal. He also noticed numbness to the bilateral thigh and perianal area. He was admitted and he underwent a left microdiscectomy at L5-S1. There were no complications. Postop, and Neurosurgery states his discomfort and numbness he was feeling before surgery had diminished greatly. 

The Inpatient Emergency Hospital Admission was medically necessary for this patient. This patient had an obvious compression of the cauda equina with clinical cauda equina syndrome that required emergent surgery to which impatient care is medically necessary.
Inpatient admission is medically necessary for a patient with cauda equina syndrome (CES) and emergent surgery per Milliman Care Guidelines (MCG) Inpatient and Surgical Care, 22nd Edition for Lumbar Discectomy, Foraminotomy, or Laminotomy. Low back pain affects millions of people every year and, in most cases, it improves without surgery. But severe back pain can be a symptom of a serious condition that is not well known and is often misdiagnosed. Cauda equina syndrome (CES) occurs when the nerve roots of the cauda equina are compressed and disrupt motor and sensory function to the lower extremities and bladder. Patients with this syndrome are often admitted to the hospital as a medical emergency. CES can lead to incontinence and even permanent paralysis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain.
Treatment: Inpatient stay.

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

The patient is a male with a history of alcohol abuse, pancreatitis, perforated diverticulitis, and smoking who presented to the hospital with left-sided abdominal pain. He reported that the pain was constant and radiated to his left mid back. He also reported drinking up to six bottles of liquor and stated that the pain had been present since he left the hospital against medical advice. He reported no bloody vomiting. He denied chest pain and shortness of breath. Vital signs showed blood pressure 168/105, heart rate 110, and temperature 97.7 Fahrenheit. On physical exam, he was obese, heart was rapid, breath sounds were normal, and there was tenderness to palpation diffusely in the abdomen. His speech was slurred. Labs showed an ethanol level 300 and liver enzymes were also elevated. A computed tomography (CT) of the abdomen demonstrated pancreatic stranding. The patient was admitted with alcoholic pancreatitis.

Inpatient care was medically necessary. Acute pancreatitis is typically treated at the inpatient level care. Acute pancreatitis is considered a high acuity condition and associated with increased morbidity and mortality if not appropriately and closely managed, and concurrent alcohol abuse increases the risk of complications. Patients can develop pseudocysts and sepsis, and hemorrhage is also a complication. This patient was also having uncontrolled pain and required IV opioids for pain control. These patients need inpatient level of care.

The patient had acute pancreatitis, as explicitly diagnosed by the medical team, and he had increased pain requiring acute management. While he did not have hemodynamic instability, hypoxia, acute kidney injury, or severe electrolyte abnormalities, he did require inpatient pain management and monitoring due to the risk of acute alcohol withdrawal.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with previous history of CAD (coronary artery disease) and stenting. He presented with chest burning, similar to - but milder than - his previous MI (myocardial infarction). He underwent exercise stress test, which was positive for a small amount of ischemia.

The patient was admitted for elective cardiac catheterization. An RCA (right coronary artery) lesion was stented, and no complications were documented. He was observed overnight as acute care.

No, the Inpatient admission was not medically necessary.

This was an elective, uncomplicated catheterization and PCI (percutaneous coronary intervention) that was scheduled two weeks after a positive stress test. The patient was always hemodynamically stable with normal vital signs, normal EKG (electrocardiogram), normal LV (left ventricle) function, and no ectopy. The only care that was given after the uncomplicated radial catheterization was monitoring, IVF (intravenous fluids), and routine medications. This meets definition of outpatient care without any indication for a higher level. Many institutions protocols include a same day discharge.

Radial catheterization was developed with one of its advantages being the safety in early ambulation and discharge. The overnight stay for observation and telemetry does not change that determination. While possible, bleeding post radial artery intervention was not seen, nor does it require extended monitoring.

The letter of appeal was carefully considered, but it offered no evidence to support a higher level of care. The only care that was provided was telemetry, which is frequently performed in observation and outpatient status. The patient was admitted for monitoring and routine post-Cath care; neither required an inpatient level of care. There was no "complex" care that was required in this patient's care, post-catheterization. While there was always a potential for an adverse event, one did not happen, and no actual treatment was needed. The appeal letter it referenced that care could not be safely provided in a lower level of care, but no support was provided for that statement.

Milliman criteria requirements for ACS (acute coronary syndrome) do not apply, as the patient did not meet criteria to support that diagnosis. It is incorrect to label the presentation of this case as unstable angina. The patient's EKG (electrocardiogram) showed no acute changes, and no acute medical treatment was given for ACS (acute coronary syndrome).

All of the testing and therapy that were provided would have been appropriate, safe and guidelines-consistent in an outpatient setting. Thus, inpatient level of care was not medically necessary.

The denial was consistent with guidelines and usual community care. Post-cardiac care as described in this patient's case is routinely performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems-Teeth Spacing problem. 
Treatment: Dental/Orthodontic Procedure-Braces. 

The health plan denied the requested orthodontic treatment plan. 
The health plan's determination is upheld. 

The patient is a male with maxillary and mandibular crowding. Teeth #6 and #11 have erupted labial within the arch due to lack of space. He has moderate overbite and is Class II. The patient was treatment planned for 18-24 months of comprehensive orthodontics to align the teeth and correct the bite, but the plan was denied due to lack of medical necessity. 

At issue is the medical necessity of the requested orthodontic treatment plan. 

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

Teeth #6 and #11 are crowded but they have erupted successfully. There are no indications of gingival recession or pathology from the tooth position of #6 or #11. It is not as if the teeth were so crowded that they were prevented from erupting, which left untreated could damage the roots of other permanent teeth [1] leading to more invasive and expensive procedures than orthodontic treatment. 

While the patient has crowded teeth, there is no indication supplied of a functional impairment due to the position of his teeth. There is no evidence of wear or periodontal recession, and no narrative of potential tooth pain has been supplied. If his teeth were corrected it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. Furthermore, Class II malocclusions may be corrected in adulthood [2], so it is not as if he will lose the ability to correct his malocclusion, should he choose to do so as an adult. For these reasons, treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System/Chronic Obstructive Lung Disease/COPD
Treatment: Inpatient Hospital
The health plan denied the inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a history of hypertension (HTN), asthma/ chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), chronic kidney disease (CKD), renal cell carcinoma (RCC) status post nephrectomy, benign prostatic hyperplasia (BPH), glaucoma, and dementia who presented with worsening dyspnea that had been present for months and had progressed to the point where he could only walk a half block before stopping.
In the emergency department (ED), his temperature was 97.3 Fahrenheit (F), with a blood pressure (BP) of 109/72 millimeters of mercury (mmHg), a heart rate (HR) of 97 beats per minute (bpm), a respiratory rate (RR) of 16/minute, and an oxygen saturation of 98% on room air (RA). He appeared comfortable, breathing comfortably with mild wheeze, and was alert and oriented. A chest x-ray (CXR) was clear.
He was diagnosed with a COPD flare and started on nebulized bronchodilators and Prednisone. The next day he was feeling much better and was discharged with a course of Prednisone.
At issue is the medical necessity of the inpatient stay.

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

I do not think an inpatient admission was medically necessary. The patient was short of breath and was diagnosed with a COPD exacerbation. There were no additional or alternative diagnoses to explain his symptoms. He did not have severe disease at presentation with no major organ dysfunction, respiratory distress, or severe gas exchange abnormality. Routine scoring systems would suggest his risk of worsening or needing the intensive care unit (ICU) care was low. Based on lack of severity at presentation, low chance of worsening, and absence of other concerning diagnoses, I do not think he needed inpatient testing, monitoring, or treatment. He improved with observation care during an observation care time frame. Given all of this, I think an observation admission would have been reasonable, but I do not think he needed an inpatient admission. He did not meet any of the provided inpatient admission criteria.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: Braces
The insurer denied the braces. 
The denial is overturned. 

The patient is a female. The request is for orthodontic benefits.

Yes, the braces are medically necessary.

Tooth #9, the upper left central incisor, is in crossbite with the lower front teeth, meaning it is inside of the lower teeth, which is backwards to what it should be. Normally the upper teeth are outside of the lower teeth. This is not a healthy situation. The tooth will ultimately be traumatized to the point of loosening and/or fracturing. The lower teeth could also suffer the same fate. The only way to correct this problem is with orthodontic treatment.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a history of seizure disorder treated with levetiracetam and alcohol use disorder. He presented to the emergency ward after a seizure. He reported non-compliance with medication.

The requested inpatient admission was not medically necessary.

The patient had a pre-existing diagnosis of seizure disorder. The patient had a breakthrough seizure due to non-compliance with anticonvulsant therapy. He had a normal neurological examination and normal imaging of his brain and spinal cord. There were no recurrent events and no need for treatment at an acute inpatient level of care. The clinical evaluation, diagnostic studies, monitoring and treatment, including orthopedic treatment, could have been safely and effectively provided at a lower level of care.


At presentation, CT (computed tomography) brain and CT (computed tomography) cervical spine were negative for any acute pathology. The patient was evaluated and treated for clavicular fracture, restarted on Keppra and discharged home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male who presented to the emergency room with fevers for three days. In the emergency room, the patient received Tylenol for fever, intravenous (IV) fluids and intravenous (IV) antibiotics. The patient was admitted to acute in hospital level of care for the management of pneumonia.

No, the proposed inpatient admission was not medically necessary. 

The patient's condition improved significantly with emergency room care. The patient was hemodynamically stable. The patient was tolerating oral diet. The patient was ambulating. The patient could have been safely and effectively be treated as an outpatient. The acute in-hospital level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Toothache. 
Treatment: A white glass with high gold content crown (code D2750) for tooth 19. 

The insurer denied coverage for a white glass with high gold content crown (code D2750) for tooth 19. 

The denial is upheld. 

This is a female patient who presented with a complaint of pain with cold in the tooth #19 area. The treatment plan included a new crown on tooth #19. The insurer has denied coverage for a white glass with high gold content crown (code D2750) for tooth #19 as not medically necessary, stating that, in brief, the clinical circumstance does not meet the insurer's criteria for approval of this service for medical necessity due to insufficient documentation and that the radiographs do not indicate recurrent decay or other findings that would necessitate replacement of the preexisting crown. 

The objective documentation provided for review is the radiographs and clinical notes. There is no periodontal charting provided for review. The radiographs indicate a stable intact restoration on tooth #19. There does not appear to be any radiographic change or pathology that would necessitate replacement of the existing restoration. A clinical note states, specifically referring to tooth #19, "19 looks fine, crown on 18 is failing." The treating doctor noted that tooth #19 appears to be without pathology aside from some gingival recession. The documentation provided fails to substantiate the recommended dental service as enumerated above and therefore, it is deemed not medically necessary. 

The requested service, white glass with high gold content crown (code D2750) for tooth 19 is not considered medically necessary for this patient. 

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

The carrier's denial of coverage for a white glass with high gold content crown (code D2750) for tooth 19 should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient, is a male. He has a past medical history significant for HTN (hypertension), dyslipidemia, diabetes, who was evaluated for palpitations and lightheadedness episodes, which have been present for six years, and had an MCOT (mobile cardiac outpatient telemetry), which revealed possible non-sustained ventricular tachycardia and supraventricular tachycardia. He was then referred to the ER (emergency room) for evaluation.

The patient was hemodynamically stable. He underwent a cardiac catheterization, which revealed no obstructive coronary disease. An echocardiogram revealed no significant valvular disease, and normal LV (left ventricle) systolic function. Cardiac MRI (magnetic resonance image) was recommended, but patient could not complete the study due to anxiety. The strips from outpatient monitor were reviewed by EP (electrophysiology) specialist and were determined to be consistent with SVT (supraventricular tachycardia) rather than VT (ventricular tachycardia). EP (electrophysiology) study was performed and ablation of SVT (supraventricular tachycardia) was performed. The patient was discharged home with a plan for outpatient follow-up. There were no documented complications for any of his cardiac procedures.

No, the Inpatient admission was not medically necessary.

The patient was diagnosed with SVT (supraventricular tachycardia) on outpatient monitor and was referred for further evaluation and treatment. The patient had symptoms of SVT (supraventricular tachycardia) present for several years.  There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. Diagnostic cardiac catheterization was performed without complications and revealed no obstructive coronary artery disease. EP (electrophysiology) study was performed and his SVT (supraventricular tachycardia) was ablated without compilations. Usually no acute inpatient admission is required, unless there is evidence of access site bleeding or other complications, such as periprocedural MI (myocardial infarction), tamponade, AV (atrioventricular) block, hemodynamic or electric instability. None of these complications were documented for this patient. Thus the medical record does not support medical necessity for acute inpatient care, and care during this admission could have been provided at a lower level of care setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foot Disorder. 
Treatment: Orthotics. 
The insurer denied orthotics for medical necessity. 
The denial was upheld. 

The patient is a male who has been treated for worsening foot pain bilaterally for over 1 year. He has pain after walking as little as 1-2 blocks and he avoids activities with his friends due to the pain in his feet. He is currently doing home therapy for his feet with stretching and strengthening exercises. He was prescribed custom molded orthotics.
At issue is the medical necessity of the Foot inserts.
The health plan's determination of medical necessity is upheld in whole.
No, the requested health service/treatment of Foot inserts is not medically necessary for this patient.
The treatment documented for this patient was home therapy for his feet with stretching and strengthening exercises. He was then prescribed custom molded orthotics. There is no documentation of conservative measures being tried for this patient.  Custom molded orthotics are not a first line treatment.   Custom molded orthotics are recommended after failure of improvement with other conservative treatments such as physical therapy, strapping, anti-inflammatory medication, activity modification, shoe modification, or over-the-counter inserts. This patient has not tried conservative treatment, other than home stretching exercises.  The medical necessity of custom molded orthotics for this patient, based on the research and standards or care is not justified.
Therefore, the health treatment of Foot inserts is not considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke
Treatment: Non-Emergency Ground and Air Ambulance Transportation
The insurer denied the Non-Emergency Ground and Air Ambulance Transportation.
The denial is upheld. 

The patient is a male.  There was a past history of hypertension, heart disease, diabetes, polysubstance abuse and seizure disorder. The patient was hospitalized in his home state with bilateral brainstem acute ischemic strokes resulting bulbar weakness, tetraplegia and dysphagia.  He was on mechanical ventilation.  A tracheostomy was placed.  A gastrostomy tube was placed at some unspecified point.  His hospitalization course was complicated by multiple medical conditions, including severe sepsis likely due to aspiration pneumonia.  He developed left leg venous thrombotic disease with bilateral pulmonary emboli and was started on anticoagulation.  He subsequently developed a small bleeding duodenal ulcer.  His anticoagulation was discontinued and inferior vena cava filters were placed, with two filters required due to an anatomical variation with a bifurcated vena cava.  He was essentially dependent for self-care and mobility per physical and occupational therapy notes.
	
The patient was tolerating ventilator weaning trials with tracheostomy capping and nasal cannula oxygenation.  He was tolerating some oral feeds but was on cyclic tube feeds via his gastrostomy to complement his oral intake, which was poor.  He was on dronabinol.  He had been deemed competent to make decisions.
	
The patient was transported via ground and air ambulance to another state to attend an acute inpatient rehabilitation program.

No, the proposed Non-Emergency Ground and Air Ambulance Transportation was not medically necessary.

The patient was hospitalized in his state of residence, following a severe neurological event, i.e., a bilateral brainstem stroke.  The stroke resulted in severe functional sequelae rendering him essentially dependent for all care and mobility.  There were also multiple medical complications, including sepsis, blood clots and gastrointestinal bleeding.  He received extensive care at multiple local acute hospitals to stabilize his condition.  Once he was sufficiently medically stabilized, he was an appropriate candidate for post-acute care.  His health and functional impairments following his stroke warranted a transition to a rehabilitation facility where his residual issues could be addressed and treated.  There were, however, appropriate facilities for this rehabilitation within the patient's residential state, such that air ambulance transportation to another state would not have been necessary.  This would have also kept the patient closer to facilities where his physicians who had been treating the patient were present.  In the event of a need for a return to an acute hospital setting, this would have allowed for better continuity of care.  There was no medical necessity for the patient to travel out of state for his rehabilitation.