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

Diagnosis: Pneumonia. 
Treatment: Inpatient Stay. 

The insurer denied coverage for inpatient stay. 

The denial is upheld. 

The patient has a history of hypertension (HTN), and sarcoidosis. Presented to the emergency department (ED) with complaints of fever, cough and some pleuritic chest pain (CP). The patient had been evaluated at an urgent care center for similar symptoms about 2 weeks ago and was prescribed a Z (Zithromax) pack. The patient's symptoms persisted so she went to her primary care provider (PCP) 2 days prior and was given Augmentin.  As patient's symptoms persisted, she presented to the emergency department.  Vital signs (V/S) at presentation were: Temperature 99.5, Heart Rate 96, Respiratory Rate 18, Blood Pressure 128/72, and Oxygen (O2) saturations at 97 % (percent). The patient was in no acute distress (NAD) and lungs were clear. The patient was alert and oriented.  Labs: white blood cell count (WBC) 16.2, hemoglobin 12.4 BUN [blood urea nitrogen]/ Creatinine 17/0.8 Electrolytes within normal limits. Troponin was negative and BNP (B-type natriuretic peptide) was normal. Chest x-ray revealed (CXR) right sided infiltrate. Computed tomography (CT) revealed small right upper lobe infiltrate. 

The patient was admitted to the hospital for community acquired pneumonia (CAP). The patient was started on intravenous (IV) Rocephin and Azithromycin. The patient started improving once treatment was started.  By the next day, the patient was afebrile and hemodynamically (HD) stable. Pleuritic pain had improved. Cough had improved. The patient denied any short of breath (SOB) or fever.  The patient was tolerating oral (PO) intake and wanted to go home. She was medically cleared for discharge home on PO Levaquin. 

This patient did not need acute inpatient hospitalization. She could have been placed in Observation status (which can be for up to 48 hours) while diagnostic testing and treatment initiated. The patient could have been started on intravenous (IV) antibiotics (Abx) for a few doses. The patient started improving soon after admission and by the next day had improved enough to be cleared for discharge home on PO Abx. This patient could have been managed in Observation unit. Patient remained afebrile and hemodynamically stable, was not hypoxic, and lungs were clear. She was tolerating PO and WBC had normalized after 24 hours. The patient has a mild pneumonia with a CURB (confusion, urea, respiratory rate and blood pressure) 65 score of Zero and a low pneumonia severity. 

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

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

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 

The insurer denied implant placement for tooth # 4 and # 5, and intravenous (IV)  sedation. 

The denial is overturned. 

The patient is a female who presented to the office of her dental provider for evaluation and treatment of teeth #4 and 5. Provided for review are previous letters of appeal and denial, a narrative from the provider explaining that the patient is in good health, full mouth radiographic images in the form of a panoramic radiograph of unknown date, two pages of American Dental Association (ADA) claim forms, and clinical notes. In question is the medical necessity of the planned treatment of implant placement for #4, 5, and intravenous (IV) sedation. 

The health plan's determination is overturned. 

The requested health service/treatment of implant placement for tooth #4 and #5 and IV sedation medically necessary for this patient. 

From the provided documentation the patient is missing teeth in the posterior site #4 and 5, which results the diagnosis of partial edentulism as well as diminished posterior support. With the diagnosis of partial edentulism as well as diminished posterior support the only therapy capable of addressing both diagnosis is that of implant therapy as it is anchored within the bone offering complete support stability and retention for a tooth prosthesis. Fixed partial dentures do not offer additional support and actually depend on the residual dentition to replace the missing tooth simply putting additional load on the residual teeth without replacing the loss. Removable partial dentures are tissue supported prosthesis and do not offer any support to the dentition as they are designed to become passive upon load. After the implants have integrated, they will require restorations in the form of abutments and crowns in order to complete the tooth replacement. As there are multiple dental implants to place along with grafting, the need for sedation is common. This is standard in tooth replacement involving implants. Hence the entire treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suicide attempt.
Treatment: Inpatient stay.
The insurer denied an inpatient stay. 
The health plan's determination is upheld.

This case involves a woman who presented to the emergency department (ED) for stabilization after she attempted to eat a castor bean and an apparent suicide attempt. The patient reportedly took three castor beans 7 hours prior to presentation, chewed them up, and spit them out. The patient apparently ordered the castor beans online with the intent of suicide. On arrival, she complained of nausea and vomiting. She continued to endorse suicidal ideation. The patient was placed on suicide precautions. She was given Zofran for nausea. The ED discussed the case with poison control, who recommended monitoring for 6 hours, at which point the patient can be medically cleared. Subsequently, they changed the recommendation to a 24-hour monitor.

The inpatient stay is not medically necessary for this patient. The patient was medically cleared for discharge to an inpatient psychiatric unit within the observation timeframe. There is no evidence of cardiac arrhythmias, depressed respiratory status, depressed mental status, or seizures. The patient's discharge was delayed by awaiting psychiatric unit placement. There is no medical necessity for ongoing in-hospital/inpatient management of her condition beyond psychiatric care.
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 with a medical history of gastroesophageal reflux disease (GERD) and constipation. She presented to the emergency department with one day of bilateral lower abdominal pain, fever, nausea, and vomiting. Vital signs were notable for tachycardia with pulse rate of 108/minute and elevated blood pressure of 145/90. Physical examination was notable for soft abdomen with lower abdominal tenderness, mild guarding, and normal bowel sounds. Labs showed elevated white blood cell count of 17.2 with 82.6% (percent) neutrophils, and an unremarkable basic metabolic panel. Computed tomography scan of the abdomen and pelvis showed pancolitis and diverticulitis worse distally, acute sigmoid diverticulitis involving the proximal to mid-sigmoid colon with pericolonic inflammatory changes and fluid, no definite extraluminal air, hiatal hernia, and hepatomegaly with hepatic steatosis. She was treated with intravenous fluids and cefepime. 

The inpatient hospital admission is not medically necessary.
The medical necessity of the inpatient level of care is not supported, and the care provided could have been provided at a lower level of care. In patients with uncomplicated diverticulitis (without complications such as abscess or perforation, which were not documented in this case), 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. lower level of care is more appropriate when there are significant symptoms and leukocytosis, as in this case. However, there was no protracted fever or hypotension to suggest that intravenous antibiotics in the hospital were ineffective. There had been no definitive evidence of abscess on imaging. The patient improved on intravenous antibiotics (with resolution of leukocytosis, improvement in symptoms, and advancement of diet), and was appropriately discharged on oral antibiotics. No other cause for the inpatient level of care, such as peritonitis, toxic megacolon, bowel obstruction, sepsis, abscess, fistula, or other complication was documented. For these reasons, the inpatient level of care is not supported in this case, and the care provided could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient Hospital. 

The insurer denied Inpatient Stay. 
The denial is upheld. 

The patient was a female at time of presentation, with no significant past medical history who was three months postpartum. She came to the hospital for evaluation of abdominal pain, which started one week before her presentation. It was also reported that the patient has had some abdominal pain since her pregnancy, which was attributed to reflux. The pain was primarily located in the right upper quadrant. The patient denied fever, chills, nausea, vomiting, diarrhea, or constipation. The patient reported passing flatus and having bowel movements.
On exam, the patient was awake, alert, and oriented times three, and in mild distress due to pain. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. Breathing was nonlabored. Her abdomen was soft, with right upper quadrant tenderness and a positive Murphy's sign. It was non distended. The rest of the physical exam was unremarkable.
Her laboratory evaluation revealed that her white blood cell count was 6.83, hemoglobin was 12.6, hematocrit was 37.8, and platelets were 256. Sodium was 137, potassium was 3.9, chloride was 107, bicarbonate was 25, blood urea nitrogen (BUN) was 7, creatinine was 0.73, and glucose was 86. Calcium was 8.9. Her liver function tests were unremarkable.
This patient was admitted to the hospital with a diagnosis of acute cholecystitis. She was kept nothing by mouth (NPO) and was started on intravenous fluids. She underwent a laparoscopic cholecystectomy. Postoperatively, the patient's diet was advanced, and she tolerated it without difficulties. In the hospital, the patient remained in stable clinical condition and was discharged home.
At issue is the medical necessity of the Inpatient Stay.

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

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient.
Even though the patient had abdominal pain, there was no evidence of systemic signs of inflammation including fever, elevated white blood cell count, or C-reactive protein. Furthermore, there was no evidence of common bile duct disease. This patient had normal liver function tests and normal bilirubin. The patient remained hemodynamically stable and had no signs of severe or persistent dehydration, severe or persistent vomiting, or severe pain requiring acute inpatient management. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care. Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Therefore, the Inpatient Stay was not medically necessary
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gluteal abscess
Treatment: Inpatient stay

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

The patient is a male who was admitted for 3 weeks of gluteal pain and swelling. Of note, the patient had a prior drainage of gluteal abscess and treatment with antibiotics. The review of system was negative for additional clinical symptoms.
The patient was afebrile (Temperature of 37.4oCelsius). His blood pressure was 120/72, pulse rate of 101, respiratory rate of 18, and oxygen saturation of 100% on room air. Physical examination was remarkable for area of fluctuance over the left intergluteal cleft. The patient was admitted for left gluteal abscess. 

The inpatient hospital admission was medically necessary. The care could not have been safely rendered at the observation level of care.
The patient was admitted for a gluteal abscess that failed to respond to outpatient antibiotics and prior incision and drainage. Additionally, the patient presented with systemic inflammatory response syndrome (SIRS) /sepsis with the presence of tachycardia and leukocytosis. Furthermore, the patient warranted a repeat incision and drainage procedure with drain placement.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sepsis. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

The patient presented to the emergency room with complaints of altered mental status after being found unresponsive. The patient was treated with Narcan.  Vitals on presentation included: Temperature 99.8 Fahrenheit, Blood Pressure 100/60, Pulse 100, Respiratory Rate 18, oxygen (O2) saturation 95% (percent) on Room Air. Laboratory results included the following: white blood cell count (WBC) 20.2, HGB (hemoglobin)-17, HCT (hematocrit)-58, creatinine-1.78, potassium-3.0, glucose-275, urine toxicology negative. 

The patient was admitted for possible sepsis. He was empirically started on intravenous antibiotics (vancomycin and Zosyn). Cardiology impression was anaphylactic reaction to a "bee sting." Head CT (computed tomography) was normal and urine toxicology was negative. Neurology and Infectious Diseases consulted. The patient improved clinically, remained afebrile, and hemodynamically stable. He was discharged to continue management as an outpatient. 

According to documentation, the patient presented with change in mental status of unclear etiology. The patient was tachycardic, tachypneic, with multiple laboratory abnormalities including elevated white blood cell count (WBC), lactic acid, glucose, creatinine, hemoglobin, and low potassium. Based on the above findings in a patient with altered mental status, hospital admission was medically necessary for additional neurologic monitoring and diagnostic testing. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath/leg edema. 
Treatment: Inpatient stay. 

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

This case involves a man with congestive heart failure and hypertension, substance abuse, history of pulmonary embolism, left ventricular (LV) thrombus, and chronic kidney disease (CKD) who presented to the emergency department (ED) with shortness of breath and lower extremity edema. The patient has heroin and cocaine dependence and used the substances 1 day before arrival. The patient has had nonischemic cardiomyopathy for the past 6 years, with a fairly low ejection fraction of 20%, moderate to severe tricuspid regurgitation, and pulmonary hypertension 3 months before this presentation. The patient had a normal cardiac catheterization study. 
On arrival in the ED, the patient reported noncompliance with medical therapy, and reported intermittent chest pain without radiation. 

The inpatient hospital stay is not medically necessary for this patient. The patient has a known history of nonischemic cardiomyopathy, with heart catheterization performed just three months before this presentation, showing no evidence of coronary stenosis. He presented to the hospital with volume overload due to noncompliance with guideline-directed medical therapy for heart failure treatment. After initiating intravenous (IV) diuretics by the medical and cardiac team, the patient's symptoms rapidly improved. Both the chest x-ray and computed tomography angiography (CTA) of the chest showed mild pulmonary edema, and there is no documentation to support severe hypoxic respiratory failure. The leg edema is described as nearly resolved by 24 hours into the hospital stay. The diuretic therapy was converted to oral within 24 hours. There were no major electrolyte derangements. The medical team describes underlying chronic kidney disease stage III from a renal standpoint, which estimates the glomerular filtration rate  (GFR) between 30 and 60. The patient's GFR was 58 at the time of admission and around 60 at discharge. Therefore, there is no evidence of severely decompensated renal function contributing to the volume overload.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Caries

Treatment dental crowns for teeth #'s 7, 8, and 9

The insurer denied coverage for dental crowns for teeth #'s 7, 8, and 9

The denial is overturned 

Based on the submitted documentation which includes copies of panoramic and periapical radiographs, narrative letter from the dentist, dental charting and treatment records and insurer correspondence, it appears that this patient presented for comprehensive dental care.  Extensive caries was noted on teeth # 7, 8, 9 extending into the pulp. Endodontic therapy was recommended and completed with additional recommendation of full coverage crown restorations on these teeth. 

Upon review of radiographs, it supports the recommended treatment. Each of the teeth 7, 8, and 9 are endodontically treated.  There is ample coronal structure remaining.  These teeth will have adequate residual coronal structure for support of crowns and adequate residual periodontal alveolar bone height.  The standard of care in general dental practice would be placement of crowns on endodontically treated teeth which would have an excellent long-term prognosis with the recommended treatment.

Overturn denial and approve coverage for dental crowns for teeth # 7, 8 and 9 as medically necessary as the radiographic documentation supports this service, and this service would be a standard of care in general dental practice.

Dental crowns for teeth's # 7, 8 and 9 is considered medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for dental crowns for teeth #'s 7, 8, and 9 is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Generalized Periodontal Pocketing

Treatment D4341 - periodontal root planning/scaling per quad and D4342 - periodontal root planning 1-3 teeth per quad

The insurer denied coverage for D4341 - periodontal root planning/scaling per quad and D4342 - periodontal root planning 1-3 teeth per quad

The denial is upheld

Based on the submitted documentation which includes copies of periodontal charting, full mouth series radiographs, and insurer correspondence, it appears that this patient presented for evaluation for dental services and periodontal therapy. The dentist reported periodontal chartings indicating 3-5 mm (millimeters) with focal 6 mm depth readings. The recommended treatment was scaling and root planning in the upper and lower right quadrants. 

Upon review of the submitted documentation, there is minimal if any loss of alveolar bone height affecting these teeth. Although there is evidence of radiographic calculus the increased pocket depths likely represent pseudopocketing due to superficial calculus accumulation and poor oral hygiene.  There is minimal significant periodontal probing with no periodontal probing over 6mm depth. The insurer has correctly applied the clinical criteria in denying scaling and root planning services.

Uphold denial of coverage for D4341 - periodontal root planning/ scaling per quad and D4342 -periodontal root planning 1-3 teeth per quad performed as not medically necessary as the clinical and radiographic documentation does not support or substantiate scaling and root planning services.

The health care plan acted reasonably and with sound medical judgement and in 1
the best interest of the patient.

The insurer's denial of coverage for D4341 - periodontal root planning/scaling per quad and D4342 - periodontal root planning 1-3 teeth per quad performed is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Infection (pyelonephritis), During
Pregnancy
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female with no significant history. She presented to the hospital with pelvic pain, dysuria and noted to be pregnant. She was admitted for pyelonephritis.

The patient was started on fluids and antibiotics. The patient was initiated on pain medication including PCA (patient-controlled analgesia) pump and converted to oral medication and subsequently discharged.

No, the Inpatient admission was not medically necessary.
Based on available data, the patient did not have persistent hemodynamic instability, Vomiting that is severe or persistent, Altered mental status that is severe or persistent, Persistence or worsening of clinical findings despite observation care treatment, Parenteral antibiotics needed beyond observation care treatment, pregnancy of 24 weeks' gestation or beyond or Immunocompromised state. Based on available data there were no urinary system finding that requires invasive procedure, acute renal failure nor treatment, or monitoring requiring inpatient admission. Based on available data inpatient level of care was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of Breath, Wheezing, Coughing and Chest Tightness. 
Treatment: Inpatient Admission. 

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

The patient is a female with a history of moderate persistent asthma. She presented to the ED (emergency department) for severe progressively worsening dyspnea, cough, and wheezing, which persisted despite using her albuterol inhaler. 

On exam, the patient was tachycardic, tachypneic with prolonged expiration, retractions, decreased air movement and wheezing. The patient was given multiple duo-nebulizers, albuterol nebulizer, and dexamethasone. Upon serial monitoring, the patient had severe persistent tachypnea and wheezing consistent with failure to achieve symptom improvement. 

The health plan denied coverage of the inpatient admission on that basis of no documentation of unresolved wheezing with cyanosis, change in mental status, or a chronic health condition with an abnormal heart rate, increased work of breathing with an oxygen level below 96%. 

Yes, the Inpatient admission was medically necessary. 

The patient did not exhibit improvement after several bronchodilator treatments in the ED (emergency department), as demonstrated by continued wheezing and tachypnea. Decreased air movement, wheezing, prolonged expiration, tachypnea, respiratory distress, and retractions were noted on exam. SpO2 (pulse oximetry) was 93% at one point. Inpatient admission with interventions including continued bronchodilator treatment and steroids was appropriate, given the patient's status asthmaticus and need for frequent, scheduled bronchodilators. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

The inpatient admission was appropriate.