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

Diagnosis: congestive heart failure
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male who was brought by Emergency Medical Services (EMS) to the emergency department (ED) of the hospital with shortness of breath that started the day prior after a fishing trip. The patient also was complaining of chest tightness and discomfort. There was sharp, reproducible point tenderness.
In another progress note, the chest pain was described as starting one hour ago prior to arrival to the ED, suddenly, in the center of the chest. It was reproducible, non-radiating to jaw or left arm, with associated shortness of breath and dizziness, and slightly relieved by sitting up. The patient also had foot bleeding without trauma to the foot.

The Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented with chest pain and shortness of breath. The patient ruled out for myocardial infarction (MI) with serial troponin, and his electrocardiogram (ECG) was not ischemic. His chest pain resolved and there was no additional work up done for his chest pain. His recent coronary angiography was unremarkable.
Based on the patient's chest pain, he did not meet indications for inpatient admission. A lower level of care would be more appropriate.
The patient had a history of congestive heart failure (CHF). His physical examination did not suggest CHF exacerbation. He had chronic lower extremity (LE) edema, most likely due to venous insufficiency. His jugular venous pressure (JVP) was normal, and he did not have crackles or wheezing. His CXR did not reveal CHF. He was treated with oral medications for his CHF. Inpatient admission for treatment of CHF was not medically necessary.
The patient was positive for COVID. However, he did not have fever, cough or rales. His O2 (oxygen) saturation upon presentation was 98% on room air. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

This adult male was hospitalized for atrial fibrillation. He presented to the emergency department for evaluation of palpitations. His past medical history is significant for known paroxysmal atrial fibrillation treated with anticoagulation and requiring electric cardioversions in the past, hypertension, dyslipidemia, and possible sleep apnea. The patient's vitals were stable. There was no ischemia, myocardial infarction (MI), congestive heart failure (CHF), cerebrovascular accident (CVA), or syncope. His Troponin panel was negative. Treatment included intravenous Cardizem and oral metoprolol. The patient had a transesophageal echocardiogram (TEE)-guided direct current (DC) cardioversion to sinus rhythm. Inpatient hospital admission is under review.

The requested health service was not medically necessary.

Based on the peer-reviewed medical literature, the documentation submitted for review do not establish the requested acute inpatient hospital stay as medically necessary for this patient. Criteria are not met, including hemodynamic instability, myocardial ischemia, syncope, altered mental status, dyspnea or hypoxemia, pulmonary edema, continuous cardiac monitoring is required for condition causing arrhythmia, such as serious electrolyte abnormality, any underlying medical condition requiring inpatient care like thyrotoxicosis or pneumonia, recent systemic embolic event like cerebrovascular accident, initiation of antiarrhythmic drug (AAD) therapy for patient at high risk for adverse effects like use of antiarrhythmic drug with proarrhythmic potential, low ejection fraction, congenital heart disease, valvular heart disease, prolonged QT interval (the duration of the ventricular action potential), significant sinus or atrioventricular (AV) node conduction disease, intolerable symptoms despite optimal outpatient treatment or elective or urgent cardioversion that cannot be done on an outpatient basis. In this particular case, none of these medically necessary criteria for inpatient stay were met. The care the patient received, including medication for ventricular rate control in hemodynamically stable patients followed by successful, uncomplicated electric cardioversion, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the standard of care, the requested inpatient level of care is not medically necessary for the dates of service for this member.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Orthodontic treatment.
The insurer denied orthodontic treatment.
The determination is upheld.

The patient is a male with a Class II Division 2 occlusion. He has a 5-millimeter (mm) overbite and 3-mm overjet. He has maxillary and mandibular crowing. His maxillary canines are displaced to the labial. He is treatment planned for 24 months of orthodontics to correct his malocclusion. At issue is the medical necessity of orthodontic treatment.

There is no medical reason to correct the patient's malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) This patient presents with none of those conditions. The patient has a slightly excessive overjet but this amount of overjet does not negatively affect oral health related quality of life. (2) If his teeth were aligned it would provide an 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: Overturned

Diagnosis: Chronic Low Back Pain

Treatment: Outpatient services 62323 x 1

The insurer denied coverage for outpatient services 62323 x 1

The denial is overturned.

This patient has chronic low back pain with radicular symptoms. The patient has done Physical Therapy and a home exercise program.  The patient's medication trials include Naproxen, Gabapentin, duloxetine, baclofen and Lidocaine cream.  The patient's electromyelogram (EMG)/nerve conduction velocity (NCV) testing was normal. Magnetic resonance imaging (MRI) showed L (lumbar) 4-L5 disc bulge and spinal stenosis as well as degenerative changes at L5-S (sacral) 1. The patient had a prior epidural steroid injection (ESI) and achieved greater than 50% (percent) pain relief for more than 3 months.  The request is to repeat the injection.  

Evidence based clinical practice guidelines (1) support the use of epidural steroid injections without a one year limitation.  Similarly, the utility of Epidural Steroid Injections is supported by a Cochrane review (2).  There is no evidence-based guideline that limits therapy to 12 months.

The injection is medically reasonable and necessary.

Based on the above, the insurer's denial must be reversed. 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 outpatient services 62323 x 1 is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Constipation
Treatment: Motegrity
The insurer denied Motegrity.
The determination is upheld.


The patient is a female with slow-transit constipation. She has slow-transit constipation. She has failed magnesium citrate and lactulose with Miralax. She has failed Miralax, Senna, and Linzess together. Coverage is requested for Motegrity for the treatment of slow-transit constipation. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.
The request for Motegrity is not supported over the formulary alternative lubiprostone.  The American Gastroenterological Association Medical Position Statement on Constipation states that newer agents such as lubiprostone (Amitiza) should be used if non-pharmaceutical laxatives fail [1].  Lubiprostone has shown safety and efficacy for the treatment of constipation and associated symptoms including bloating and abdominal pain [2-7].  Motegrity has not demonstrated higher safety or efficacy than lubiprostone in a direct controlled comparison.  For these reasons, the request for Motegrity is not supported over the use of lubiprostone in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Left Foot Injury.
Treatment:  Inpatient admission.

The insurer denied Inpatient admission.  The denial is upheld.

The patient is a school-aged female. She was admitted after having stepped on a needle. She had been referred to a podiatrist, who scheduled outpatient removal of foreign body. The patient's parent was concerned it would be there for one week and felt that this was too long. There were no signs of infection noted on admission. The patient was admitted for surgical consultation.

The inpatient admission was not medically necessary.

Hospital admission was not indicated, as the surgery is typically performed outpatient. There were no signs of infection and, therefore, no need for inpatient antibiotics. As this could have been performed outpatient, inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pyelonephritis.
Treatment:  Inpatient stay.

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

The patient is a female with a history of pre-eclampsia, pyelonephritis, and polycystic kidney disease who returned to the hospital for the treatment of pyelonephritis after a urine culture resulted in quinolone-resistant ESBL (extended-spectrum beta-lactamases). She reported persistent left-sided abdominal pain, somewhat improved with ciprofloxacin, and denied further fevers, nausea, vomiting, or changes in stool.

The inpatient hospital admission was medically necessary for this patient. The patient required the administration of intravenous antibiotics beyond the observation period. She had acute pyelonephritis that was caused by quinolone-resistant ESBL organism requiring the administration of intravenous antibiotics, especially in the setting of structural kidney disease due to polycystic kidney disease. A lower level of care would not be appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Obesity.
treatment:  Gastric Restrictive Procedure/Surgery for Weight Loss and Associated Inpatient Stay.

The insurer denied Gastric Restrictive Procedure/Surgery for Weight Loss and Associated Inpatient Stay.  The health plan's determination is overturned. 

This patient is a man under consideration for bariatric surgery and associated hospital admission. He was 66 inches tall and weighed 236 lbs (pounds). This corresponds to a body mass index (BMI) of 37.6. The records indicate that he has been trying to lose weight for many years with nonsurgical weight loss diets, including a supervised diet program for the preceding 6-months.
The patient consulted and was enrolled in a multidisciplinary bariatric program. Thyroid stimulating hormone (TSH) is normal. The patient has been cleared for bariatric surgery from a mental health standpoint. He consulted with a registered dietician and has received nutritional counseling and education.

Given this patient's diagnosis, his current health condition and generally accepted guidelines for patient selection, the proposed laparoscopic sleeve gastrectomy and inpatient admission is medically necessary for this patient.
This patient has a body mass index (BMI) in excess of 35. He has successfully completed a multidisciplinary bariatric evaluation. He has had appropriate dietary counseling and has been cleared for bariatric surgery from a mental health standpoint. He has been granted medical clearance. He has attempted nonsurgical weight loss with refractory medically complicated obesity.
Laparoscopic sleeve gastrectomy is medically necessary for this patient per widely accepted guidelines as his body mass index (BMI) is in excess of 35, the patient has undergone evaluation by a multidisciplinary bariatric program and has been cleared for the proposed surgery from a mental health standpoint, per the enclosed psychological consultation and clearance.

An Inpatient level of care is consistent with the standard of care regarding performance of bariatric surgery such as sleeve gastrectomy. This period of inpatient stay allows for provision of IV (intravenous) fluid, analgesia, antiemetics, and appropriate monitoring during the period of diet advancement following gastric resection. The intensity of service associated with the management of the bariatric surgical patient warrants an inpatient designation and is consistent with the standard of medical / surgical care. A 1-day period of inpatient confinement is consistent with bariatric surgical standards for this patient. A lower level of care such as observation, rather than inpatient care, could jeopardize the health of this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Stab wounds.
Treatment:  Inpatient stay.

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

This patient is a woman, who presented as a level 1 trauma activation following an assault in which she sustained multiple stab wounds. Her injuries included a liver laceration and a traumatic abdominal evisceration involving omentum. She had also been stabbed in the right chest, right forearm, right anterior thigh, right posterior thigh, and right hand. She was hypotensive at the time of initial presentation. She was treated with emergent surgical exploration, hepatorrhaphy and abdominal wall repair. Her recovery was complicated by intra-abdominal bleeding that was treated with interventional angiography embolization of the celiac and hepatic artery and by the development of an abdominal abscess that required abdominal washout.

Inpatient Hospital Stay on the dates in question was not medically necessary for this patient. The patient was clinically/hemodynamically stable, she was tolerating a regular diet, was ambulatory and was tolerating oral medications. No further surgical interventions were anticipated, and she no longer required IV (intravenous) antibiotics.
This was a multi-injured patient who required emergent evaluation and treatment for major abdominal/thoracic injuries and repair of a complex laceration of the right hand/forearm. She required the coordinated care of multiple medical/surgical and ancillary disciplines to optimize her care and outcome. However, the records support that as of the date in question, she was stable for discharge from the inpatient hospital setting and could have received ongoing care/therapy with a lower level of care or in the outpatient setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: possible hip fracture

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.
 
Clinical practice guidelines (1) support admission when there are Red Flag symptoms.
This adult female did not have any Red Flags. She did have an area of lucency in the left intertrochanteric region suggestive of a nondisplaced fracture. She was unable to weight bear; she was unable to ambulate to the bathroom to do Activities of Daily living.  No Orthopedic consult was obtained to evaluate the need for surgery. She was assessed by physical therapy (PT) and felt would benefit from sub-acute rehabilitation (SAR).  She required transfer to a Skilled Nursing facility.

Casazza (2) reviewed concerning symptoms (Red Flags) that should prompt aggressive treatment.  The patient had motor weakness in being unable to ambulate and weight bear:

"Certain red flags should prompt aggressive treatment or referral to a spine specialist, whereas others are less concerning. Serious red flags include significant trauma related to age (i.e., injury related to a fall from a height or motor vehicle crash in a young patient, or from a minor fall or heavy lifting in a patient with osteoporosis or possible osteoporosis), major or progressive motor or sensory deficit, new-onset bowel or bladder incontinence or urinary retention, loss of anal sphincter tone, saddle anesthesia, history of cancer metastatic to bone, and suspected spinal infection. Without clinical signs of serious pathology, diagnostic imaging and laboratory testing often are not required."

The records do not support the need for an acute inpatient admission. The patient would benefit from SAR which did not require an acute inpatient admission.

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, 
Treatment: Consumer Directed Personal Care Assistance CDPCA services 9 hours per day, 7 days a week totaling 63 hours
The insurer denied coverage for: Consumer Directed Personal Care Assistance CDPCA services 9 hours per day, 7 days a week totaling 63 hours
The denial is: Overturned
This is an adult with chronic medical problems including dementia. The patient lives with  daughter and son-in-law and grandson. The patient's paid caregivers are the daughter and grandson. The plan approved Consumer Directed Personal Care Assistance (CDPCA) services 49 hours/week. The patient requested CDPCA services 9 hours per day, 7 days a week totaling 63 hours, denied by the insurer; leading to an external review. 

The Uniform Assessment System (UAS) report is dated 12/13/22. The patient's cognitive skills are described as moderately impaired. The patient is total dependent to maximal assistance for completing much of her Instrumental Activities of Daily Living (IADL's) tasks including meal preparation, ordinary housework and shopping. The patient also requires maximal assistance for bathing, personal hygiene, dressing and toilet use. Extensive assistance is needed for eating and toilet transfer. Limited assistance is needed for locomotion and ambulation. The patient is independent for bed mobility. The patient is frequently incontinent of bladder and bowel. There have been no reported falls over the prior 90 days. 

The patient's condition and functional deficits are  at a level or unpredictable as to require the requested CDPCA services 9 hours per day, 7 days a week totaling 63 hours. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by the requested  63 hours/week. 

The healthcare plan did not act reasonably, with sound medical judgment and in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based). 

From a physical medicine and rehabilitation perspective, the requested consumer directed personal care assistance (CDPCA) services, 9 hours per day, 7 days per week (Monday through Sunday), for a total of 63 hours per week is medically necessary.  

Based on the above, the insurer's denial must be reversed. 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 consumer directed personal care assistance services, 9 hours per day, 7 days per week (Monday through Sunday), for a total of 63 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient has a past medical history significant for breast cancer, hypertension, diabetes mellitus, lymphedema, and obesity who presented to the emergency department with complaints of fever, shortness of breath, nausea, and vomiting. 

Vitals on presentation included: Temperature (T) 102.7 Fahrenheit (F), blood pressure (BP) 152/93, heart rate (HR) 126, respiratory rate (RR) 20, and oxygen (O2) saturation 94% on Room Air. Laboratory results included the following: white blood cell count (WBC) 17.8, hemoglobin (HGB) 13.6, creatinine 0.54, lactic acid 1.29, and glucose 183. 

The patient was started empirically on intravenous (IV) antibiotics for possible pneumonia (vancomycin and Levaquin). Infectious Diseases consulted and recommended continuation of antibiotics. Chest x-ray (CXR) showed patchy perihilar and left greater than right lower lobe atelectasis and/or infiltrate. Viral panel showed human rhinovirus. The patient remained improved clinically, remained afebrile and hemodynamically stable. The patient was discharged to continue outpatient management on oral antibiotics.

According to documentation, the patient presented with respiratory symptoms. The patient was initially febrile (102.7 F), tachycardic (heart rate of 126), and laboratory results were notable for leukocytosis (WBC 17.8) and elevated glucose. Additionally, the patient's CXR showed abnormalities. Based on these findings in a patient with a history of breast cancer, hospital admission was medically necessary.

Based on the above, the insurer's denial must be reversed. 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 the full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee pain.

Treatment: Knee device.

The insurer denied coverage for knee device.

The denial is upheld.
 
The requested knee system is an implantable shock absorber or unloader device proposed to relieve pain in people who are unwilling or ineligible to undergo a total knee replacement. It is a new approach on a long-standing principle, i.e. (that is), to unload the medial compartment and hence reduce pain. 

The facts are the studies completed were under the IRB (Institutional Review Board). There were low numbers of patients evaluated for approximately two years. This was a nonrandomized study using a historical control who underwent high tibial ostomy.(Diduch et al.)  The device is not standard of care nor utilized by the practicing orthopedic community. There are no guidelines nor recommendations made with regard to application. 

The clinical records show presence of knee pain, which was intermittent. The positive physical finding was medial knee pain. The imaging studies showed the joint space was not narrowed. The magnetic resonance imaging (MRI) showed a macerated tear to meniscus with osteoarthritis. 

The treatment recommendations for meniscal pathology and underlying osteoarthritis do not include recommendation for any implant. She clearly is not a candidate for arthroplasty based upon her activity level, physical examination and treatments provided. 

There is no indication for an osteotomy nor any other procedure. 

The facts are no treatments were provided aside from a cortisone injection. The proposed procedure is not accepted as standard of care. There are no extenuating factors to substantiate the recommendation of this "new" device.

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 a knee device is not substantiated.