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

Diagnosis: Class II malocclusion 
Treatment: Braces, Monthly Visits x 12, and Retainer
The insurer denied Braces, Monthly Visits x 12, and Retainer
The health plan's determination is overturned. 

The patient in question is a male. He has a Class II malocclusion with protrusive maxillary incisors. He has 6 millimeter (mm) overjet and a 4 mm deep bite. He has severe maxillary and mandibular crowding. Teeth 20 and 29 are impacted and unable to erupt due to crowding. 

Braces, Monthly Visits x 12, and Retainer are medically necessary for this patient.
Teeth number (#) 8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. Additionally, teeth 20 and 29 is impacted. Studies have shown almost 65 percent (%) of untreated impacted teeth will cause some kind of pathology. The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth. Given the proximity of the mandibular second premolars to the roots of the adjacent teeth, there is already concern that the mandibular first molars may be damaged, especially #30.
There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Additionally, overjets greater than 6mm are shown to negatively affect the oral health quality of life of patients. For these reasons, the requested treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nephrolithiasis
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a past medical history (PMH) of generalized anxiety disorder (GAD), attention deficit hyperactivity disorder (ADHD), and intracranial hypertension (HTN) who was admitted with complaints of (c/o) pelvic pain. Her vital signs were remarkable for tachycardia. The physical exam was unremarkable. Imaging studies, transvaginal ultrasound (TVUS) was unremarkable, a computed tomography (CT) scan of the abdomen/pelvis (A/P) showed a prominent right ureter to the level of a 4-millimeter (mm) calculus in the region of right ureterovesical junction (UVJ), computed tomography angiography (CTA) of the chest showed no large or central pulmonary embolism (PE). The patient was diagnosed with nephrolithiasis and mild metabolic acidosis and treated with intravenous fluids (IVF), pain control, and holding acetazolamide. Nephrology was consulted and recommended bicarbonate supplementation and biochemical work-up and decreased acetazolamide dose. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) pelvic pain and was incidentally found to have a mild metabolic acidosis secondary to prescribed acetazolamide. She was hemodynamically stable, there was no hypoxia, respiratory failure or distress, apnea, intentional overdose/exposure, disruptive/uncooperative behavior, other acute co-existing illness, fever, significant trauma, or unstable vital signs. In addition, the patient did not have evidence of decreased cardiac output, hypotension, or arrhythmias. She received observation, bicarbonate administration, IV fluids and nephrology evaluation, and this could have been safely provided at a lower level of care. The patient did not have a metabolic finding that is severe or persists despite observation care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment:  braces and monthly visits.
The insurer denied braces and monthly visits.
The determination is overturned.

The patient is a male presenting with a skeletal Class I malocclusion. He has minor spacing in the maxilla and mandible. He has an anterior crossbite and an anterior open bite affecting teeth 7-10. He is treatment planned for 30-36 months of orthodontic treatment to address the anterior crossbite and open bite. At issue is the medical necessity of braces and monthly visits.
Anterior open bite patients are among the most difficult patients to treat. (1) One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. (2) Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite. (3) Orthodontic treatment is medically necessary for this patient due to the side effect described in question (1), and the fact that this is not something that will self-correct without orthodontic intervention.
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 male with no significant medical history. He presented to the emergency department with abdominal pain, nausea, vomiting, and diarrhea for two days. Vital signs were unremarkable. Physical examination was notable for soft, nontender abdomen. Labs showed elevated white blood cell count of 14.3 and elevated bilirubin of 1.5. Computed tomography scan of the abdomen and pelvis showed sigmoid colon diverticulitis. He was treated with acetaminophen, famotidine, ceftriaxone, metronidazole, and intravenous fluids. 

The inpatient hospital admission is not medically necessary. In patients with uncomplicated diverticulitis, outpatient management or observation is the standard of care. The safety and efficacy of outpatient management of acute uncomplicated diverticulitis has been demonstrated. A prospective randomized trial demonstrated that patients can be given intravenous antibiotics in the emergency department and then discharged with oral antibiotics. A systematic review of the literature underscored this. A lower level of care can be appropriate when there are not significant symptoms, as in this case. However, there was no documented protracted fever or hypotension to suggest that antibiotics in the hospital were ineffective. No other cause for the inpatient level of care, such as peritonitis, toxic megacolon, bowel obstruction, sepsis, fistula, or other complication was documented. For these reasons, the inpatient level of care is not supported in this case, and the care provided (including labs, observation, imaging, Infectious Disease consultation, and intravenous antibiotics) could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
Treatment: Inpatient Stay

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

The patient is a female with a history of asthma, smoking, diabetes, hyperlipidemia (HLD), obesity, and lupus. The patient also has a history of splenic infarct and was anticoagulated with apixaban. The patient presented to the hospital for peripheral vascular intervention. The patient underwent intervention: intravascular ultrasound (IVUS), angiography-guided DCB (drug-coated balloons) angioplasty of the proximal and distal superficial femoral artery (SFA). The patient was admitted for monitoring after the procedure. 

The inpatient hospital admission was not medically necessary for this patient.

The patient presented to the hospital for a scheduled elective procedure and intervention on her femoral artery. The patient previously underwent a diagnostic angiogram of her right leg, and it was found that the femoral artery had severe stenosis.

Upon presentation to the pre-procedure area on the day of the procedure, the patient was stable, with normal vital signs and an unremarkable physical examination. Her labs were stable. The procedure went as planned, and the patient's condition was stable.

After the procedure, the patient developed a small hematoma, which was managed conservatively. The patient also had mild vaginal bleeding without any significant blood loss. Her complete blood count (CBC) was stable.

Based on the above, the patient presented with an elective procedure done under mild anesthesia; the patient underwent the procedure as planned, and the post-procedure period was not complicated by serious problems warranting an inpatient level of care. A lower level would be more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginitis
Treatment: Genitourinary Pathogen Nucleic Acid Detection Testing
The insurer denied Genitourinary Pathogen Nucleic Acid Detection Testing.
The determination is upheld.

The patient is a female with vaginitis. She had Sureswab NAAT [nucleic acid amplification] vaginal testing 81513, 87481 and this testing is under review for medical necessity.

The requested health service/treatment of Genitourinary Pathogen Nucleic Acid Detection Testing is not medically necessary for this patient.

Vaginitis is diagnosed with a series of standardized clinical tests, such as bacterial culture, physical examination, microscopy, and/or vaginal potential hydrogen (pH). In addition, direct deoxyribonucleic acid (DNA) probe assays to detect the DNA of candida, Gardnerella vaginalis, and Trichomonas vaginalis in vaginal fluid specimens may also be beneficial.

However, molecular diagnostic testing for vaginitis with nucleic acid amplification (NAAT) under current procedural terminology (CPT) 87481 or subsequent quantification testing for bacterial vaginiosis (BV) or vaginal candidiasis are not medically necessary. These are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature in the English language. Multipathogen panels are not currently recommended or under her plan unless all pathogens tested in the panel meet requirement criteria. The testing listed under 81513 is not identified as widely used.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fall
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a past medical history (PMH) of uncontrolled diabetes mellitus (DM) and chronic pain who was admitted with complaints of (c/o) a fall associated with neck pain and generalized weakness, but no loss of consciousness (LOC) or head trauma. His vital signs were unremarkable. The physical exam was notable for no focal deficits, no apparent distress (NAD). Lab work was notable for hyperglycemia. Imaging studies were notable for a normal chest x-ray (CXR) and pelvic radiograph. The patient was diagnosed with a fall secondary to generalized weakness from dehydration versus medication-related and treated with physical therapy (PT)/occupational therapy (OT), radiological work-up, and insulin. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o weakness after a fall. The patient received a diagnostic imaging workup, which showed no acute fractures and had a normal neurological examination. The patient was diagnosed with weakness, likely secondary to dehydration versus polypharmacy, not an acute medical illness and without complications such as fracture. Observation provides an ideal setting for care coordination and discharge planning and an opportunity for assessment by a physician, physical therapist, social worker, and care manager for these types of patients. These patients receive focused interventions in mobility, gait training, and functional status improvements. Overall, this patient had neither severe acute pathology nor the need for acute surgical intervention. For the hyperglycemia, the patient was hemodynamically stable, responded to insulin therapy, and there was no diabetic ketoacidosis (DKA), acute mental status change, end stage renal disease (ESRD), sepsis, acute cerebrovascular accident (CVA), acute myocardial infarction (MI) or significant complications, and did not have any evidence of acidosis as the patient had a normal serum bicarbonate and potential hydrogen (pH). Hyperglycemic patients presenting to the ED with a blood glucose less than (<) 600 can be appropriately managed at a lower level of care. The patient was diagnosed with falls secondary to weakness for which they were treated with diagnostic imaging work-up and non-surgical treatment modalities, including physical therapy, endocrinology consultation and pain control, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nasal congestion/obstruction
Treatment: Nasal surgery
The insurer denied Nasal surgery.
The determination is overturned.

The patient is a female with a history of nasal congestion/obstruction with symptoms improved with modified Cottle maneuver. Based on the submitted medical records/treating physical statements, she has received multiple treatments including intranasal corticosteroids, oral antihistamines, intranasal anticholinergic medications, in the past without sustained improvement in symptoms. The clinical exam/nasal endoscopy exam was consistent with turbinate hypertrophy, septal swell bodies, and stenosis of the nasal valve/nasal valve collapse. The patient's otolaryngologist requested insurance approval for the Vivaer procedure/repair of nasal valve collapse. The health plan denied excision/destruction intranasal lesion/internal approach for nasal swell bodies and VivAer procedure. At issue is the medical necessity of the requested nasal surgery.
The proposed health service/treatment is medically necessary. The patient has received standard treatments to date without sufficient improvement in symptoms. The patient has received a thorough workup including physical examination and appropriate standard medical treatment for treatment of nasal congestion/obstruction. The patient has undergone maximal medical therapy including undergoing treatment with intranasal corticosteroids, and oral antihistamines without sufficient improvement in symptoms. Clinical examination confirmed that the patient had nasal valve stenosis/nasal swell bodies contributing to the patient's symptoms of nasal congestion. The ViVaer is used to coagulate soft tissue in the nasal airway to strategically treat nasal airway obstruction by shrinking submucosal tissue and is an appropriate next step in treatment for this patient. VivAer received Food and Drug Administration (FDA) approval for this indication in 2017. There is sufficient clinical trials and peer reviewed literature to support the benefits of the procedure in appropriate patients.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral Infection
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male child with a medical history significant for a febrile seizure who presented to the emergency department (ED) with a four-day history of congestion and progressively worsening cough, decreased appetite, one-day history of refusing fluids with one episode of post-tussive emesis, decreased wet diapers, fever to 102.5 degrees Fahrenheit, and increased sleepiness. The examination was significant for dry oral mucosa, sunken eyes, tachycardia, clear lungs, benign abdomen, no rashes, non-focal neurologic exam.
Respiratory viral panel was positive for parainfluenza. A chest x-ray was unremarkable. He was treated with two normal saline boluses, maintenance intravenous (IV) fluids, and ibuprofen prior to admission for ongoing care.
Admission orders included maintenance IV fluids, encourage fluids by mouth, acetaminophen/ibuprofen as needed, monitor urine output, follow-up cultures. He had some low-grade fever but was otherwise hemodynamically stable. He had no signs of respiratory distress. His appetite improved and he was able to tolerate fluids by mouth. He was deemed stable for discharge to follow-up with his pediatrician in one to two days.
Inpatient admission was not medically necessary for this patient.
Acute viral syndrome is a diagnostic term for viral infection with no clear etiology. Symptoms include fever, sore throat, headache, injected sclera, nasal congestion, rhinorrhea, diffuse body aches, nausea and vomiting, diarrhea, abdominal pain, and rash. The onset is rapid, with the illness lasting several days. Treatment is typically symptomatic, including antipyretics, fluids, and rest. There is some risk for secondary bacterial infection, but typically affected individuals recover without sequelae.
This young male child presented with congestion, cough, fever. He was moderately dehydrated upon presentation, requiring two IV fluid boluses followed by maintenance IV fluids. Testing revealed metabolic acidosis consistent with dehydration and viral testing positive for parainfluenza. While it was reasonable to monitor this child in the hospital to monitor fluid balance and resolution of dehydration, he was overall hemodynamically stable with no evidence of impending hypovolemic shock or significant metabolic derangements. He did not require acute inpatient admission and could have been safely managed at lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hypertension
Treatment: emergency room
The insurer denied the emergency room visit.
The health plan's determination is upheld. 

The patient is a male with a history of hyperlipidemia who presented to the Emergency Department (ED) requesting a refill of his simvastatin. He was evaluated and treated. He reported being in the process of establishing with a new PCP (primary care provider) due to recently moving to the area. His review of systems was negative. His vital signs were within normal limits except for mildly elevated blood pressure. His physical exam was remarkable for a slight systolic ejection murmur. His prescription was refilled and he was given a rapid primary care follow up.

The ED visit was not medically necessary.
The patient presented to the Emergency Department without any physical complaints, requesting a refill of medication for hyperlipidemia. The patient reported being on the medication for many years. He had no history of coronary artery disease. Treatment with statin is based on a 10-year coronary vascular disease risk assessment and repeat low density lipoprotein (LDL) testing is not indicated unless there is a clinically significant change in the patient's status (2). There is no indication that the patient or the treating physician felt there was a life or limb-threatening condition present at the time of the visit. No lab tests or imaging were performed. His medications were refilled and he was referred to a primary care clinic. The patient could have received care in an urgent care or a primary care office.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: knee osteoarthritis
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

This case describes a female patient with a history of advanced right knee osteoarthritis. She failed all conservative treatment modalities for this condition and opted to undergo elective right total knee replacement surgery. The surgery was successful with no documented complications. The patient progressed well with post-surgical physical therapy and was deemed stable for discharge home. 

The inpatient hospital admission was not medically necessary for this patient. The records show that this patient failed conservative treatment for advanced right knee osteoarthritis and underwent right total knee replacement surgery. The surgery was successful with no documented complications. The patient was admitted for inpatient hospital care after the operation. She ambulated 100 feet with supervised physical therapy and was deemed stable for discharge home the following day. There were no signs of post-operative infection or excessive bleeding that would require an inpatient hospital admission. There were no clinical signs of deep vein thrombosis for this patient. Based upon the documentation in the records, the medical necessity of the inpatient hospital admission is not established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a patient with a medical history of human immunodeficiency virus (HIV) not on therapy, asthma, syphilis and substance abuse who was admitted for possible pneumonia with symptoms of shortness of breath, cough, chills and fever. The chest imaging did not demonstrate evidence of an empyema/abscess/necrotizing pneumonia. He was seen by the infectious disease consultant, and they determined he had no indications to treat pneumonia and his imaging demonstrated old markings. He did not have any decompensation of his comorbidities, did not require supplemental oxygen for hypoxia/hypoxemia and had not failed outpatient treatment. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of Inpatient hospital admission was not medically necessary for this patient. Based upon the severity of illness, intensity of required therapy and criteria provided, the inpatient level of care was not medically necessary. This patient with a medical history of HIV not on therapy, asthma, syphilis and substance abuse was admitted for possible pneumonia with symptoms of shortness of breath, cough, chills and fever. As per the clinical documentation, on admission, although the patient was febrile (38.9 C), he was hemodynamically stable, with a respiratory rate of 16 breaths per minute, oxygen saturation 99 percent (%) on room air, had a normal pulmonary effort, was not in respiratory distress and did not have stridor, wheezing, rhonchi or rales on auscultation of the chest. His chest x-ray demonstrated no acute cardiopulmonary process. His computed tomography (CT) scan of the chest did not demonstrate evidence of an empyema/abscess/necrotizing pneumonia but did demonstrate numerous foci of nodularity in lung fields possibly due to an atypical pneumonia or malignancy, underlying chronic changes in the lung fields also noted, and opacities at pulmonic apices suspicious for post inflammatory changes. He was seen by the infectious disease consultant, and they determined he had no indications to treat pneumonia and his imaging demonstrated old markings. He was alert, awake and oriented throughout his stay, he did not have a documented bacteremia, or severe persistent dehydration, he was able to take oral medications and feeds and his CURB-65 (confusion, uremia, respiratory rate, blood pressure (BP), age greater than or equal to (>=) 65 years) score was 0 and Pneumonia Severity Index score was a risk class 1 and outpatient treatment would be considered reasonable. In addition, he did not have any decompensation of his comorbidities, did not require supplemental oxygen for hypoxia/hypoxemia and had not failed outpatient treatment. Therefore, the requested health service/treatment of inpatient hospital admission was not medically necessary for this patient.