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

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

The patient is a male child who presented to the emergency department (ED) with elevated glucose, increased thirst, and urinary frequency. For the previous several months, he had been drinking and voiding more than usual and had unintentionally lost fifteen pounds. He also experienced some hair loss. A physician neighbor noted the symptoms could be associated with new onset diabetes and suggested testing his glucose at home. On the day of presentation to the ED, his blood sugar was 365 fasting and 410 a couple hours after breakfast. This prompted the ED visit. Vital signs included temperature 99.8, heart rate 77, respiratory rate 18, and blood pressure 121/75. Laboratory studies were obtained (sodium 135, potassium 4.0, carbon dioxide (CO2) 29, glucose 343) and he was treated with Humulin insulin and normal saline intravenous (IV) fluids.
Examination upon arrival to the pediatric floor included no acute distress, moist mucous membranes, no respiratory distress, benign abdomen, and non-focal neurologic exam. 

Acute inpatient admission was not medically necessary for this patient. He could have been safely managed at a lower level of care. This child presented to the ED with polyuria, polydipsia, weight loss, and hyperglycemia. Venous blood gas evaluation was indicative of moderate acidosis. Because he was a newly diagnosed patient with moderate acidosis, it was not unreasonable to monitor him in the hospital during correction of hyperglycemia, ketonuria, and acidosis. However, his clinical symptoms were mild and did not merit acute inpatient management. He could have been safely and appropriately managed at lower level of care in the hospital without jeopardizing his recovery and safe discharge.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uncontrolled Hyperglycemia.

Treatment inpatient admission.

The insurer denied coverage for inpatient admission.
The denial is overturned.

The patient has a medical history of asthma and obesity who was sent from a clinic to the Emergency Room (ER) for evaluation of a high fasting blood sugar. Accompanied by her mother, the patient presented in the ER with abdominal pain, weight loss and feeling thirsty. She was found to have a high blood glucose level (283).  Intravenous fluids were initiated, and insulin was administered. Endocrinology admitted the patient with a diagnosis of uncontrolled hyperglycemia.
	
Diabetes education consists of several components, nutritional counseling, self monitoring of blood glucose and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components. 

Practice patterns differ depending on the availability of educators etc. Whether a patient gets hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen.

The majority (75% [percent]) of medical centers in the US (United States) that treat new onset type 1 diabetes admit their patients. According to the ADA (American Diabetes Associatopm) statement on treatment of type 1 diabetes, hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education."  In type 1 diabetes, the initial hospitalization is to educate the patient and the family in self injection, drawing up and mixing of insulins, checking blood sugar, recognizing and responding to hyper and hypoglycemia, and evaluating ketosis, as well as nutrition education on carbohydrate counting because there is only one treatment option (insulin). Learning these skills is an overwhelming task for most patients and families and is the reason that this is done with a 2-3 day admission to the hospital. 

The patient had new onset diabetes and was admitted for new onset diabetes education including insulin administration 4 times a day blood glucose monitoring, nutrition education. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.  The request is medically necessary.

Based on the above, the medical necessity for the inpatient is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who presented to the hospital emergency department (ED) with complaint of left arm pain and numbness.  Vital signs were blood pressure (BP) 124/85, pulse 79, respirations 18, temperature 98.5oF (Fahrenheit), and pulse oximetry 99% on room air. Physical examination was unremarkable. Laboratory values were unremarkable. A Left upper extremity venous duplex was negative for acute disease. Brain computed tomography (CT) was negative for acute disease. Computed tomography angiography (CTA) of chest showed right lower lobe pulmonary artery thin linear filling defect with artery pruning suggestive of chronic pulmonary embolism.
The patient was admitted and started on intravenous heparin. 

The inpatient hospital admission was not medically necessary. This patient presented to the hospital with complaint of left arm pain and numbness for 1 day. CT imaging showed findings suggestive of a chronic pulmonary embolism in the right lower lobe. There was no evidence of hemodynamic instability. There was no evidence of other comorbid conditions such as congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD). There was no evidence of right ventricular dysfunction on echocardiogram. The patient did not require thrombolysis or vena cava filter placement. There was no evidence of severe pain requiring inpatient management. Based on review of the available medical records and Milliman Care Guidelines (MCG), none of the severity of illness criteria were present to support inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal-Constipation
Treatment: Pharmacy/prescription Drugs-Linzess
The health plan denied Linzess for this patient as medical necessity could not be established. 
The reviewer has overturned in whole the health plan's determination.

The patient has chronic idiopathic constipation. She presented with a bowel movement every 3-4 days, as well as episodic nausea and vomiting. She has failed Metamucil, Benefiber, Miralax, suppositories, and over the counter laxatives. She is on suboxone. The medical necessity is requested for Linzess 72 micrograms (mcg) for oral administration O(R) Capsules for the treatment of chronic idiopathic constipation.

Yes, the medical necessity of Linzess is supported in this case. The patient has chronic idiopathic constipation and opioid use as well. The American Gastroenterological Association Medical Position Statement on Constipation states that when first-line laxatives fail, a newer agent such as Linzess should be considered [1]. In multicenter, randomized, blinded, placebo-controlled Phase III clinical trials, Linzess significantly increased weekly spontaneous bowel movements in patients with chronic constipation of multiple types [2,3]. Current medical literature also supports the use of Linzess for non-targeted treatment of opioid -induced constipation [4]. American Gastroenterological Association guidelines for opioid-induced constipation recommend the use of laxatives over fiber [5]. This patient has failed Metamucil, Benefiber, Miralax, suppositories, and over the counter laxatives, and she is also on suboxone. The medical necessity of Linzess is supported in this patient.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems
Dental/Orthodontic procedure

Diagnosis: Class I occlusion
Treatment: Braces
The insurer denied braces. The health plan's determination is upheld.

The patient in question is a female with a Class I occlusion. She presents with a 4-millimeter (mm) overbite and 3mm overjet. She has maxillary and mandibular crowing. She is treatment planned for orthodontics (Braces) to correct her malocclusion. This is the subject of this review.

Braces are not medically necessary for this patient. She is crowded but no teeth are impacted. Her cephalometric radiograph shows the lower incisors not contacting the palate in occlusion. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) on this patient. There are no anterior crossbites present.
There is no medical reason to correct her malocclusion with braces. While the patient has crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient's overjet is more than ideal but her overjet would not affect oral health related quality of life unless it was greater than 6 mm. If her teeth were aligned, it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular disorder - speech problems
Treatment: Durable Medical Equipment (DME) - Speech Generating Device (SGD)
The health plan denied the SGD as not medically necessary.
The reviewer has overturned in whole the health plan's determination. 

The patient has a medical history significant for severe dysarthria and anarthria following cerebrovascular accident (CVA).

The requested augmentative and alternative communication (AAC) device is medically necessary for this patient.

The patient suffered bihemispheric strokes and despite 2 months of speech therapy has had minimal verbal improvement. Records note that the patient's "verbal productions have not improved sufficiently to meet her daily communication needs." Documentation notes that further verbal improvement is not expected. Documentation also notes that "cognitive abilities are at the same level as before her CVA and she therefore needs a device to allow her to communicate as she once could." Per the Speech Language Pathologist (SLP), "...attention, memory, and nonverbal problem-solving skills appear within functional limits. This is demonstrated by her sustained attention, recall of detail, and ability to independently communicate using the SGD [Speech Generating Device]." The patient has been appropriately evaluated for the use of AAC device. Documentation shows that she has successfully trialed AAC devices and that the "SC tablet [an iPad-based SGD] was selected as the best option.." as the patient and her family were able to quickly learn this device. Additionally, "SC Tablet is the least costly SGD option available on the market today and was selected as the best option..."

An SLP with training in AAC devices conducted a formal evaluation of the patient's abilities. The formal evaluation included a written report which described current communication impairment including type, severity, language skills, cognitive ability, and anticipated course of impairment. It also included a technological assessment of the patient's basic daily communication needs and whether these needs could be met by other modes of communication. Additionally, there was a description of the functional communication goals expected to be achieved and treatment options with rationale for select of a specific device. The treatment plan also included a training schedule. Furthermore, the patient trialed the device on multiple dates and "was able to type words and sentences using the keyboard, and to utilize predictive spelling features to facilitate speed and efficiency of communication." Lastly the formal report documented the history of the AAC usage within all the environments in which the device had been used. Additionally, there is documentation by speech therapy that supports the patient has the cognitive and physical abilities necessary to use the selected device, the patient's speech impairment will benefit from use of selected device and that the device has not been selected primarily for the convenience of the patient/patient's family.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary.
The reviewer has upheld in whole the health plan's determination.

The patient was admitted to the hospital and on the day prior to admission the patient was treated and released from an outside hospital for the diagnosis of esophagitis. The patient presented with upper abdominal/chest pain associated with vomiting x (times) 4 episodes. The patient described the vomitus as dark blood. On admission, the patient had a normal pulse and mean arterial blood pressure. The abdominal exam had no significant findings. On labs, his hemoglobin (hgb) was normal at 14.8. In the History and Physical, the vomitus was described as bright red blood. The patient was admitted due to ongoing chest pain and prescribed intravenous (IV) Proton-pump inhibitors (PPI) and as needed (PRN) Dilaudid. On the second day of admission, the patient was without complaints and had no further bloody emesis. They tried to advance the patient's diet to clear liquids, but he had chest burning and nausea. Carafate was added, and a repeat hgb was 13.7 with hydration. He had an esophagogastroduodenoscopy (EGD), which revealed esophagitis and gastritis. The patient was discharged soon after procedure.

The inpatient stay was not medically necessary for this patient.

The patient did not meet Milliman Care Guidelines (MCG) criteria for admission. Specifically, there was no evidence of hemodynamic instability, ongoing active bleeding, need for mechanical ventilation, high risk endoscopic stigmata on endoscopy, or irreversible coagulopathy.

In addition, based on the AIMS65 score (Upper gastrointestinal [GI] bleeding mortality risk) the patient had 0 points resulting in a predicted 0.3% (percent) in-hospital mortality. Additionally he had a Glasgow-Blatchford Score (Screening tool for acute upper gastrointestinal bleeding [UGIB]) of 0, indicating a "low risk" GI bleed and is highly sensitive (99.6% in a retrospective study) for predicting which patients do not require any "medical intervention": blood transfusion, endoscopy, or surgery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Premature newborn.
Treatment: Inpatient stay.

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

The male patient was born at 33.3 weeks-estimated gestation age by Cesarean section. The mother was a Gravida 3 now Para 3 whose pregnancy was complicated by pre-eclampsia, diabetes mellitus (Type 1), poly-cystic ovary syndrome, sleep apnea, hypothyroidism, Herpes Simplex Virus (Type 1), intrauterine growth restriction, and sleep apnea.

The neonate's birth weight was 1530 grams, and the one- and five-minute Apgar scores were 9 and 8, respectively. He received Continuous Positive Airway Pressure (CPAP) for his respiratory distress at two minutes of age but was discontinued prior to transfer from the delivery room. The infant was taken to the Neonatal Intensive Care Unit (NICU) for further stabilization and management of prematurity.

The Inpatient Hospital Admission for this patient on the dates in question was not medically necessary.

The neonate was being observed for desaturations while feeding, which were not documented in the medical record and secondary to failing a car seat challenge and lack of the request for a car bed. The provider's of medical care did not document the degree of desaturation and/or any interventions for the desaturations during feedings-which require continued inpatient care. In addition, the car bed could have been requested earlier and made readily available for the infant's discharge.

Although it is medically necessary for this neonate to have a car bed for discharge, there was a delay in requesting the car bed until the day of discharge. The infant had two failed car seat challenges previously. At that time, arrangements could have been made for a car bed so that when the neonate fulfilled other discharge criteria, the discharge could have been accomplished.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck swelling.
Treatment: Inpatient stay.

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

This is the case of a male who presented to the emergency department (ED) with right sided neck swelling for 3 days. He had difficulty turning the neck to the right due to the swelling and subsequently developed fever. The review of symptoms (ROS) was positive for neck pain/discomfort and nasal congestion. There was no difficulty breathing, nausea, vomiting, or chills. Oral intake was normal.

Emergency department (ED) vitals were T (temperature) 37.1oC (Celsius), heart rate (HR) 77, respiratory rate (RR) 18, blood pressure (BP) 84/44, and O2 (oxygen) saturation 100% on room air. Physical exam was remarkable for 3+ tonsilar enlargement R>L (right greater than left) without visible exudate. There was right sided swelling of the neck which was tender to palpation, but normal range of motion (ROM). Labs showed an elevated white blood cell count (WBC)15.6, PLT (platelet) 413, and lactate dehydrogenase (LDH) 266. Monospot and COVID tests were both negative. A computed tomography (CT) of the neck showed palatine tonsillar enlargement R>L (2.1 centimeter (cm) x 2.0 cm) with associated lymphadenopathy of the upper cervical chain, without abscess formation. The patient was started on intravenous fluids (IVF) and intravenous (IV) Clindamycin, and was admitted to the hospital for further management. 

This is the case of a male with increasing neck swelling for 3 days prior to admission and report of subjective fever. Evaluation in the ED showed normal vital signs. There was no difficulty breathing or swallowing, and the patient was eating and drinking typically. CT scan showed lymphadenopathy without abscess formation. The patient's condition improved with IVF and IV antibiotics, and the patient was transitioned to oral antibiotics prior to discharge home. 

The inpatient hospitalization was not medically necessary. This case could have been safely managed at a lower level of care. This patient did not demonstrate difficulty breathing or require respiratory support. He did not have nausea, vomiting, or inability to tolerate oral intake. The vital signs were stable. Therefore, observation with discharge home could have been an appropriate course of management.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Inpatient Stay. 

The insurer denied inpatient stay. 
The denial is overturned. 

The patient is a male who presented to the emergency department (ED) with a 2-day history of runny nose and difficulty breathing that started the day of presentation. There was no fever or known ill contacts. The patient attends daycare. Vitals were temperature (T) 98.0 Fahrenheit (F), heart rate (HR) 145, respiratory rate (RR) 60, oxygen (O2) saturation was 91% on room air. Exam was notable for tachypnea with retractions and wheezing. The patient was positive for rhinovirus. Complete blood count (CBC) and comprehensive metabolic panel (CMP) were within normal limits; chest x-ray was unremarkable. The patient was treated with intramuscular (IM) Decadron, albuterol nebulizer x 3, and intravenous fluid (IVF) bolus. Oxygen levels remained 89-90% on room air with slight retractions, so the decision was made to admit to the hospital for supplemental oxygen and respiratory support. At issue is whether the inpatient hospitalization is considered medically necessary.

The health plan's determination is overturned.

The requested inpatient hospitalization is considered medically necessary for this patient. This patient presented to the ED with acute respiratory distress secondary to reactive airway disease (RAD) exacerbation.  Upon arrival to the ED, he had tachypnea=60 and hypoxemia=91% on room air.  Despite treatment with nebulizers, steroids, and IVF, the patient remained symptomatic with oxygen levels of 89-90% on room air.   Safe discharge home was not possible, as this patient required supplemental oxygen and vital sign monitoring at the inpatient level of care.  He also required inpatient level of care for treatment and monitoring to ensure no additional respiratory decompensation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Oligodontia.
Treatment:  D6010, implant placement for tooth 12, 13, 14, 15, 18, 19, 2, 20, 21, 3, 30, 31, 4; D4263 adding bone at one mouth site, tooth 10; D7140 removal of tooth or tooth root, tooth 29.

The insurer denied coverage for D6010, implant placement for tooth 12, 13, 14, 15, 18, 19, 2, 20, 21, 3, 30, 31, 4; D4263 adding bone at one mouth site, tooth 10; D7140 removal of tooth or tooth root, tooth 29.  The denial is upheld.

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants, a bone graft and extraction of a tooth. The dentist is requesting implants over removable partial dentures presumably due to patients reported dysphagia, gag reflex and nausea. 

Upon review of the objective documentation which primarily consists of a panoramic radiograph, the patient exhibits oligodontia in both the maxilla and mandible. Regarding endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include conventional removable dentures. Further, the documentation provided does not objectively support, justify, or substantiate the requested treatment. Therefore, as removable dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of partial dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary. In regard to the extraction of #29, as per the submitted radiograph this tooth has been extracted and is no longer present.
 
An appropriate alternative standard of care treatment would be conventional removable dentures, and the medical documentation provided does not substantiate a limitation that would preclude the patient using removable partial dentures. Therefore, as other acceptable alternative treatments are appropriate, and the documentation provided does not support the recommended treatment this renders the endosteal implants and associated services not medically necessary.

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

The insurer's denial of coverage for the D6010, implant placement for tooth 12, 13, 14, 15, 18, 19, 2, 20, 21, 3, 30, 31, 4; D4263 adding bone at one mouth site, tooth 10; D7140 removal of tooth or tooth root, tooth 29 is upheld. Medical Necessity is not substantiated.