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

Diagnosis: Cardiac/Circulatory Problems
Treatment: Pharmacy/Prescription Drugs
The insurer denied: Praluent
The denial is: Upheld in whole

The patient is a male with a history of heterozygous familial hypercholesterolemia, coronary artery disease, aortic stenosis, aortic valve replacement and carotid artery disease. Per the appeal letter, multiple statins, including atorvastatin, rosuvastatin, simvastatin and pitavastatin, have either been ineffective or poorly tolerated. The doses tried were not provided. His most recent low density lipoprotein (LDL) cholesterol level was 191 milligrams per deciliter (mg/dl). The subject under review is the medical necessity for Praluent.

The health plan's determination is upheld in whole.

This patient has familial hypercholesterolemia and atherosclerotic cardiovascular disease. His most recent LDL cholesterol level of 191 mg/dl is more than three times his National Lipid Association goal level of less than 70 mg/dl. Per the appeal letter, he has been intolerant to multiple statins. However, the doses tried were not provided. Thus, it is not clear that he has complete statin intolerance. Per the 2017 Focused Update of the 2016 American College of Cardiology (ACC) Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk, ''A systematic approach to evaluation of possible statin-related adverse effects is critically important to encourage adherence to evidence-based statin treatment.... The approach to statin intolerance should include discontinuation of statin therapy until resolution of symptoms and subsequent rechallenge to verify recurrence of muscle-related symptoms. Whereas there is not a universally accepted definition of statin intolerance, most experts recommend that patients are documented to have unacceptable muscle-related symptoms that resolve with discontinuation of therapy and occur with rechallenge on at least 2 to 3 statins, preferably ones that use different metabolic pathways and have different lipophilicity, and 1 of which is prescribed at the lowest approved dose....Non-statin therapies are not considered to be an alternative to evidence-based statin therapy unless statin intolerance has been systematically and rigorously evaluated and documented.''
The most robust data regarding the improvement in cardiovascular outcomes that is seen with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors were derived from studies in patients treated with both a maximally tolerated statin and a PCSK9 inhibitor. For this reason, use of these agents in combination with a maximally tolerated statin whenever possible is recommended. 
Thus, based on the information available, true statin intolerance has not been established in this case.
Appeal type: Medical necessity
Decision: Overturned

Malpositioned Teeth
Dental/Orthodontic Procedure

The patient in question is a male. He has a Class I malocclusion with protrusive maxillary incisors. Tooth 9 has a history of trauma and has a large restoration. He has a treatment plan for 24 months of orthodontics to correct this malocclusion. This is the subject under review.

The health plan's determination is overturned. The Braces and Monthly Visit are medically necessary for this patient. 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. This is particularly important for this patient since tooth #9 has already been fractured once. If it is traumatized again it will likely result in more significant tooth damage. For this reason, the requested treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of Alzheimer's disease and hypothyroidism who was sent to the hospital via the cardiologist's office, for symptoms of hypertension and chest pain. She was evaluated in the cardiologist's office and found to have a blood pressure of 210/102 and reported nonradiating chest pain, pressure, and dizziness while ambulating. She also experienced mild shortness of breath that had been lasting for the past month. The episodes of chest pain occurred after walking for about 10 minutes.
On arrival in the hospital, the patient's blood pressures ranged from 168/72 -191/81. The heart rate was 51, the temperature was 36, and respirations were 15. A twelve-lead electrocardiogram (EKG) showed no evidence of ST-segment changes. Cardiac troponins showed negative values times three (x3).
Cardiology was contacted, and they recommended a 2 dimensional (D) echocardiogram, as well as a nuclear medicine stress test. It appears that the facility did not have the testing capability until three days later.
The laboratory studies were otherwise unremarkable, including normal electrolytes and renal function, and normal complete blood count (CBC). A chest x-ray showed no evidence of acute cardiopulmonary disease.
The patient's hypertension was treated with amlodipine and losartan. The patient also took hydrochlorothiazide at home, which was stopped.
Over the next two days, the weekend, the patient had no complaints, denied chest pain, or shortness of breath. Blood pressure improved to 115/65 and 125/67.
From the progress note, a 2D echocardiogram showed a normal ejection fraction, with no mention of wall motion abnormalities. The results of the stress test showed no evidence of inducible ischemia. The patient was deemed stable for discharge to home with primary care doctor and cardiologist follow-up. At issue is the medical necessity of an inpatient stay.
The health plan's determination is upheld. The requested health service/treatment of inpatient hospital admission for the above dates is not medically necessary for this patient. Care could have been provided at a lower level for this patient with chest pain with accelerated hypertension.
This patient did not have a severe hypertensive emergency that required antihypertensive infusions to satisfy any criteria for admission to the inpatient level of care. There was no evidence of end-organ damage, as the cardiac enzymes were normal, there were no EKG changes, there was normal renal function and no clear documented neurologic deficits.
There was is no indication for an inpatient hospital admission. Care could have been provided at a lower level than inpatient.
Appeal type: Medical necessity
Decision: Overturned

The patient is a very young female with a medical history significant for severe early childhood caries. The treatment plan was carried out in under general anesthesia to alleviate situational anxiety reduce her medical risk, and provide the most appropriate environment for her to receive proper care. 

The health plan denied the general anesthesia as not medically necessary. The health plan's determination is overturned. Per the provided records, the patient was having severe pain and had not been eating well. She had eight teeth that required restorations, including four pulpotomies, four stainless steel crowns, and four surgical extractions. Due to the patient's age, extent of treatment that was needed and her inability to tolerate treatment in the office setting, general anesthesia was medically necessary and would be considered the standard of care.

The provided treatment was in line with the current recommendations provided by the American Academy of Pediatric Dentistry. The only appropriate option for this child's proper and compassionate care was to complete her treatment safely under general anesthesia in the hospital setting, which is what was done.
Appeal type: Medical necessity
Decision: Upheld

Malpositioned Teeth
Dental/Orthodontic Procedure

The patient is a male with Class II malocclusion, moderate maxillary crowding and moderate mandibular crowding. There is also moderate overbite and severe overjet. The proposed treatment is braces. This is under review.

The health plan's determination is upheld. Braces are not medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score an 18 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9-millimeter (mm) or greater and underbite 3.5mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Increased swelling and discomfort in both legs for 10 days 
Treatment: Inpatient admission 

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

Yes, the inpatient admission is "medically necessary". 

The patient is a female at the time of admission to the hospital, with a past medical history significant for HTN (hypertension), edema and right leg DVT (deep vein thrombosis), who presented to the ER with complaints of worsening LE (lower extremity) edema and erythema. Patient was previously on anticoagulation, but it was recently held. The patient also had a chronic oozing ulcer on left LE. Her BP (blood pressure) was severely elevated at 208/93. Her physical examination was significant for ill-appearing female, with regular rate and rhythm with systolic murmur on cardiac examination, rales on pulmonary examination, and bilateral grade four edema. Chest X-ray revealed vascular congestion, consistent with CHF (congestive heart failure). 

The patient was admitted for management of CHF, hypertensive urgency and DVT. Repeat LE Doppler scan revealed left greater saphenous vein DVT, which was new. Echocardiogram revealed preserved EF (ejection fraction). Patient was diuresed with Lasix and BP regimen was intensified for better BP control. She was discharged home with a plan for outpatient follow-up. 

The patient presented with symptoms of acute CHF (congestive heart failure) exacerbation and DVT. Her blood pressure was severely elevated, consistent with hypertensive urgency. She required IV diuresis and escalation of her hypertension medical regimen. Also a new onset DVT was diagnosed, and the patient was re-started on anticoagulation. Given this presentation, acute CHF, hypertensive urgency, as well as her co-morbid conditions, it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: s/p Cardiac Catheterization And Percutaneous.
Coronary Intervention.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. 
The denial is overturned. 

Yes, the Inpatient Admission is "medically necessary".

The patient is a female at the time of admission to the hospital, with a past medical history significant for HTN (hypertension), dyslipidemia, diabetes mellitus type 2, asthma, bipolar disorder, CAD (coronary artery disease), s/p (status post) prior STEMI (ST elevation myocardial infarction) with PCI (percutaneous coronary intervention) of LAD (left anterior descending artery), complicated by cardiogenic shock, ischemic cardiomyopathy, who presented for staged angioplasty of RCA (right coronary artery) and LCX (left circumflex coronary artery) lesions. PCI was performed, however, during the procedure there was dissection of the proximal LCX artery, requiring additional stenting. The procedure was further complicated by severe bradycardia and hypotension, requiring atropine and epinephrine injections. Due to hemodynamic instability, the patient was admitted to inpatient setting. Post PCI troponin was elevated at 0.57, consistent with peri-procedural MI (myocardial infarction). The patient was treated with antiplatelet therapy and medical therapy for CAD was continued. She was discharged home.

The patient with known complex CAD, presented for management of obstructive disease of the LCX and RCA and PCI was performed. The procedure was complicated by coronary dissection with resultant hypotension and bradycardia, requiring the use of IV vasoactive agents (atropine and epinephrine). The procedure was further complicated by peri-procedural myocardial infarction, as evidence by the acute elevation in troponin levels. It would be consistent with the current standard of care that this patient, after this complex PCI with the complications as described above, as well as evidence of hemodynamic instability, be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiovascular
Treatment: Inpatient hospital stay
Issue: Medical necessity 
The health plan's determination is upheld in whole. Inpatient stay was not medically necessary for this patient.
The patient has a history of hypertension, hyperlipidemia, and coronary artery disease (CAD) who presented to the Hospital for staged percutaneous coronary intervention (PCI) of the left anterior descending (LAD) coronary artery. Six weeks before, the patient had undergone coronary angiography for non-ST elevation myocardial infarction (NSTEMI) and was found to have obstructive CAD involving an obtuse marginal (OM) branch of the left circumflex (LCx) artery and the left posterior descending artery (LPDA). The angiography images also documented proximal and mid LAD stenoses. The OM and LPDA stenoses were felt to be the culprit stenoses for the patient's NSTEMI, and underwent treatment with stent placements of these respective vessels. The patient had recovered well from that PCI procedure vs. the NSTEMI. Patient reported dizziness and a feeling of head  spinning when bent over. The patient did not report any recent chest pain, shortness of breath, dyspnea, or syncope. The procedure was successfully carried out  and 2 drug eluting stents (DES) were placed to treat the proximal and mid LAD stenoses as well as the in-stent stenosis of a previously placed mid-LAD stent. The patient tolerated the procedure well, experienced no procedural complications, was admitted overnight, and was discharged to home the following day.
Per medical literature review, there are no recent national guidelines to help guide clinicians, hospitals, and other entities regarding same day discharge for stable outpatients undergoing PCI procedures. Several meta-analyses and studies referenced below documented a relatively low rate of major complications such as death, myocardial infarction, access site complications, and rehospitalizations in patients who underwent PCI and same day discharge from the hospital. The complication rates in these reviews list comparable or near comparable levels of these complications among post-PCI patients undergoing same day discharge or overnight observation with next day discharge. Lastly, a study reviewing PCI registry data which compared characteristics of patients with same day discharge with patients who underwent overnight observation with next day discharge found that age, access site, complexity, and number of lesions stented did not preclude same day discharge.
Based on the patient's lack of reported chest pain, shortness of breath, and syncope prior to the PCI, the success of the LAD PCI procedure itself, the lack of complications documented during and immediately after that procedure, the lack of recent national guidelines regarding same day discharge of outpatients undergoing PCI, and the comparably low rates of complications and readmission rates documented by meta-analyses and reviews on this topic regarding patients undergoing same day discharge vs. overnight observation after PCI, inpatient admission for this patient was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uremia  
Treatment: Inpatient admission  

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

The is a male patient with a medical history of hypertension, seizure, brain aneurysm status post clipping, coronary artery disease, myocardial infarction status post stent placement, cerebrovascular accident, psychiatric disease, and end-stage renal disease on dialysis.  The patient presented to the Emergency Department (ED) with complaints of mild chest discomfort, having an unwitnessed seizure and missing dialysis. The patient was not assigned to a dialysis center.  The patient went from the emergency room to the emergency room to get dialyzed.  The patient was non-compliant with his treatment.  It was reported that the patient went to a dialysis center and was told he needed to be registered; he was being sent from hospital to hospital for them to accept him.  It was also noted that he had been having more seizures despite the fact he was taking his medication every day.  The patient's blood pressure was 159/87 and his pulse rate was 97.  The patient was admitted to the hospital for uremia.  The patient underwent an electrocardiogram (EKG) and chest x-ray both were reported normal. Neurology was consulted.  A computed tomography (CT) scan of the head without contrast revealed postoperative changes with a left-sided craniotomy defect and aneurysm clipping; there were areas of encephalomalacia in the left temporal lobe, right cerebellar hemisphere, and left ganglia.  It was reported that the patient intermittently refused dialysis during this inpatient stay and was noncompliant with his home medications.  The patient underwent a repair of a right inguinal hernia with mesh and a fistulogram with supervision and interpretation of fistulogram gram, venous PTA with supervision and interpretation of pre-and post-angioplasty films as the clinical evaluation of the fistula showed the evidence of diminished inflow.  The social worker implemented setting up a dialysis center but because of his noncompliance with dialysis and medications they were refusing the patient placement.  The patient left against medical advice (AMA).  

Per the MCG guidelines, clinical indications for admission to inpatient care is dependent on several criteria including hemodynamic instability, cardiac arrhythmias of immediate concern, altered mental status that is persistent, uremic findings that persist despite observation care treatment, respiratory findings, clinically significant metabolic or electrolyte abnormalities that persists despite observation care treatment, infection, or urgent treatment of renal failure that is necessary on an inpatient basis. Upon review of the medical records, the patient did not fit any of these criteria, and subsequently.  

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System 
Inpatient hospital 

Diagnosis: Seizure 
Treatment: Inpatient hospital stay 

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

The patient is a man with history of gastroesophageal reflux disease (GERD), hypertension, pseudotumor cerebri, glaucoma coronary artery disease status/post (s/p) percutaneous coronary intervention (PCI) to left anterior descending (LAD) who presented to the emergency department (ED) with the complaint of a seizure. The patient was at a barbershop three days prior and reportedly his arm became stiff. He began to have seizure like movements and was urinary incontinent. The patient is now coming in for an evaluation. 

The acute inpatient hospitalization was not medically necessary for the patient. An MRI, EEG and neurologic evaluation would have been appropriate at a lower level of care or as an outpatient. Patients who return to their baseline after a seizure do not require an inpatient hospitalization in the absence of structural or metabolic causes or have another indication for admission. This patient had a normal CT, MRI, and EEG. There was not hemodynamic instability noted. His care could have been accomplished at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Genitourinary/Kidney Disorder
Inpatient hospital

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

This is the case of a female with past medical history significant for nephrolithiasis in addition to being 12 weeks pregnant who presented to the emergency department with right flank pain without fevers, chills, headaches, nausea, vomiting, or dysuria. On presentation, she was afebrile with blood pressure 123/75, heart rate 87, respiratory rate 16, and oxygen saturation of 100% on room air. Exam otherwise noted flank tenderness. Labs resulted with white blood cell (WBC) 10.8, Hemoglobin (HGB) 11.7, platelets 172, and basic metabolic panel within normal limits. Urinalysis was positive for urinary tract infection. 

The inpatient stay was not medically necessary. This is a patient with a history of nephrolithiasis who presented with right flank pain and a positive urinalysis in the setting of being 19 weeks pregnant. She was afebrile without leukocytosis on presentation, without nephrolithiasis or hydronephrosis, without vomiting or other abnormal labs, and remained hemodynamically stable throughout her course. It is unclear in the absence of hemodynamic instability, with normal renal imaging, and with WBC of 10.8 without associated renal failure or nephrolithiasis why this patient was not safe to care for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Heart Failure.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Stay.  The determination is upheld.

This is a patient with a history of hypertension, hyperlipidemia, coronary artery disease, coronary artery bypass graft surgery, aortic valve replacement and congestive heart failure with a left ventricular ejection fraction of 24%.  He presented to the hospital for the scheduled implantation of a dual chamber implantable cardioverter defibrillator for the primary prevention of sudden cardiac death.  He had no complaints upon presentation.  The procedure was uncomplicated.  Post-procedure the patient was admitted to the hospital.  He was discharged the next day.  The medical necessity of an inpatient admission is at issue.

An inpatient stay was not medically necessary.  This patient presented for an elective implantable cardioverter defibrillator (ICD) placement.  He was hemodynamically stable, and the procedure was uncomplicated.  While admission for overnight observation after this procedure is still the preferred approach for many implanting physicians, this can generally safely be accomplished at a lower level of care than inpatient; an inpatient admission is not medically necessary for the vast majority of patients.  Same day discharge after ICD implantation is an increasingly common practice and has been shown to be feasible and safe in most cases, with no increase in death, readmission or procedural complications when compared to patients who were admitted overnight.