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

Diagnosis: Heart Disease. 
Treatment: Inpatient admission. 

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

The patient is a male. At the time of admission to the hospital, he had a past medical history significant for congenital heart block, status post (s/p) bi-ventricular pacemaker, non-ischemic cardiomyopathy with severely reduced ejection fraction (EF), and prior COVID infection. The patient presented due to congestive heart failure (CHF) exacerbation with worsening dyspnea on exertion, fatigue, and shortness of breath over several weeks. The patient was evaluated in the outpatient clinic and referred to the emergency department (ER). 

The patient was given intravenous (IV) Lasix. The patient was hemodynamically stable. His blood pressure was normal and oxygen saturation was 99%. Labs revealed creatinine of 1.39 and brain natriuretic peptide (BNP) was elevated at 541. Electrocardiogram (ECG) revealed normal sinus rhythm with ventricular pacing. Chest x-ray revealed resolution of pulmonary edema. He was admitted for congestive heart failure (CHF) exacerbation management. 

The next day, the patient underwent a right heart catheterization, which revealed normal pulmonary pressures. His orthostatic vitals were negative. A cardiopulmonary stress test was performed, revealing decrease exertional capacity. The patient was discharged home on medical therapy for congestive heart failure (CHF) with a plan for outpatient follow-up. 

No, the proposed inpatient admission was not medically necessary. 

This is a patient with known severe non-ischemic cardiomyopathy and congestive heart failure (CHF). He presented with worsening congestive heart failure (CHF) symptoms over several weeks. He was hemodynamically stable. He had normal oxygen saturation. He responded well to Lasix. Chest x-ray revealed resolution of pulmonary edema. Right heart catheterization revealed normal pulmonary pressures. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory Failure

Treatment Skilled Nursing Facility (SNF)

The insurer denied coverage for Skilled Nursing Facility (SNF)

The denial is upheld

This is the case of a female patient currently in an acute care hospital with a new tracheostomy from respiratory failure and is currently ventilator dependent. The patient is unable to be weaned from the ventilator. She also has a percutaneous endoscopic gastrostomy (PEG) tube placement for enteral tube feeding. The patient has unstageable pressure ulcers to coccyx, middle occipital area, and lumbar spine area, all of which require twice daily wound care. The treating physician has requested transfer to a subacute rehabilitation setting.  

The medical records document the patient's medical conditions (trach/PEG/multiple ulcers) that are more appropriately treated at a Long-Term Acute Care Hospital (LTACH) level of care. The recent left below knee amputation also makes functional mobility rehabilitation that much more complicated. An LTACH setting provides a greater opportunity for ventilator weaning while providing comprehensive rehabilitation therapies and skilled nursing care; all of which are medically necessary at this time.   

Based on the clinical information made available for review, the healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.  (Taken under consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based).

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, SNF level of care is not the most appropriate level of care for this patient at this time.

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, LTACH is the more appropriate level of care for this patient at this time.

The insurer's denial of coverage for the Skilled Nursing Facility (SNF) care admission to Affinity Skilled Living and Rehabilitation Center is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite. 
Treatment: Braces (Comprehensive Orthodontic Treatment) (Pre-Service). 

The insurer denied the Braces (Comprehensive Orthodontic Treatment). 
The denial is overturned. 

The patient is a female requesting orthodontic benefits. She has a class III skeletal occlusion. The lower lateral incisors are in crossbite. 

Yes, the proposed braces are medically necessary. 

The patient has both lower lateral incisors (teeth #23 and #26) in anterior crossbite. This means the lower teeth are outside of the upper teeth, which is backwards. This will, over time, contribute to trauma and/or breakage of teeth because the teeth are meshing incorrectly. This condition can also contribute to future temporomandibular problems (i.e., pain) because it places extra pressure on the temporomandibular joints and can cause premature breakdown. Orthodontic treatment is needed to correct the crossbite. There is gingival recession (gum loss) present. This is an automatic qualifier for treatment according to the handicapping index scale.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient was a female patient who had presented to the ED (emergency department) of the facility filing the appeal for the presenting complaints of emesis and diarrhea. The patient has the diagnosis of DM1 (diabetes mellitus type 1). The patient has no prior history of DKA (diabetic ketoacidosis). The patient also has a history of gastroparesis.

The patient reported that the diarrhea was non-bloody. The patient also reported that the many episodes of emesis were non-bloody. The last glucose was 256 on the patient's continual glucose monitoring device. There were no fevers reported. A urine dip for ketones was positive prior to arrival. The patient denied fever, chills, chest pain, shortness of breath, dysuria, headache, dizziness, or any tingling as per the provided record. A venous blood gas had a pH (power of hydrogen) of 7.461. The patient had an anion gap of 19. The lactic acid was 2.4. The betahydroxybutyrate was elevated at 3.60. The highest blood sugar in the ED (emergency department) was documented at 265. The BUN (blood urea nitrogen) was 22 and the creatinine was 0.97. The admitting diagnosis was diabetic gastroparesis.

No, inpatient hospital admission was not medically necessary. While the treatment provided was medically appropriate, the care was not rendered at a level at which was medically necessary.

The request for authorization of the hospital admission was not medically necessary. The clinical information sent shows that the patient was evaluated in the emergency room for high blood sugar. There was no documentation of high blood sugar with acid in the blood, very high blood sugar with confusion, significant dehydration (loss of body fluid), vomiting that would not stop despite treatment, unexplained fever or severe infection.

Despite the patient's presentation the care as provided could have been rendered in its entirety at a lower level of care. The patient has diabetic gastroparesis with episodes of emesis. However, the patient did not show evidence of a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. The patient showed no evidence of dehydration on laboratory studies. The patient had improved with treatment delivered in the ED (emergency department). As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth decay.
Treatment: D2791--All Metal Crown (Tooth #30, #31); D3330--Nerve Treatment on Molar Tooth (Tooth #30, #31).
The insurer denied the D2791--All Metal Crown (Tooth #30, #31); D3330--Nerve Treatment on Molar Tooth (Tooth #30, #31).
The denial is overturned. 

The patient is a female requesting root canal therapy and crowns on teeth #30 and #31. The patient has severe decay into both nerves and will need crowns to restore both teeth.

Yes, the proposed metal crowns (D2791) on teeth #30 and #31 and nerve treatment of a molar tooth (D3330) on teeth #30 and #31 are medically necessary.
Teeth #30 and #31 are functioning teeth and need the treatments described (root canals and crowns).  The denial is based upon the need to keep (i.e., treat) any abutment teeth for bridges or partial dentures, both of which the patient does not have or need. However, the patient has severe tooth decay extending into the nerves of these teeth. These two teeth are fully functional and with the treatments described, will remain fully functional for many years. It is within the standard of care to restore functional teeth. The treatments requested, root canals and crowns, are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep impinging overbite
Treatment: D8080 Comprehensive Orthodontic Treatment of the Adolescent Dentition, Pre-service
The insurer denied the D8080 Comprehensive Orthodontic Treatment of the Adolescent Dentition, Pre-service
The denial is overturned. 

The patient is a male.  The request is for dental benefits for orthodontic treatment (braces).  Orthodontic records were created including x-rays and photos. The patient's clinical exam reveals mild spacing, slight protrusion of upper teeth, deep impinging overbite with tissue damage.  

The Health plan denied the treatment because the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) Index.  The provider appealed because the patient presents with a deep impinging overbite with tissue damage- - an automatic qualifier for orthodontic therapy on the Handicapping Labio-Lingual Deviation (HLD) index.

Yes, the proposed treatment of orthodontic therapy (braces) is medically necessary.
As evident on the photos, the patient has a deep impinging over-bite of almost 100 percent  with damage to the gums on the upper anterior palate. The imprint of the lower incisors are visible within the folds of the rugae present on the upper palate; this shows the impact to the area.

The extent of the over-bite is significant; if left untreated, it  will continue to cause damage to the upper gum tissue as well as discomfort to the patient. This will adversely affect the patient's ability to have optimal chewing function as well as difficulty with speech.  Long term, the patient may experience gum recession, strained facial muscles and ultimately jaw pain.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The claimant is a male with a past medical history significant for diabetes, apathy, and hypertension.  He is status post a Jones fracture nonunion with a cavovarus foot correction.  This was corrected by transferring his tibial tendon a Dwyer osteotomy and resection of his fifth metatarsal base. He presented to the emergency room complaining of right lower extremity swelling and a ulceration.  He believes it may have been caused by a new orthotics prescribed after his surgery.  He was noted to have an erythematous ulcer with 2 ulcerations and lateral and medial ulcer there was erythema and signs of infection.  He had an erythrocyte sedimentation rate of 65.  Initial white blood cell count was 10.5 this was improving on IV(intravenous) antibiotics received in the emergency room.  He was placed on vancomycin and cefepime.  He was evaluated by podiatry a debridement was performed dressings were ordered and he was deemed stable for discharge

Failure to receive inpatient care for a diabetic ulcer suspected of bone infection can lead to limb loss without prompt and appropriate treatment and diagnosis this often requires inpatient hospital admission and is not appropriate to be managed as an outpatient in severe cases this can lead to sepsis and death
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dyspnea on exertion, abnormal electrocardiogram
and stress test
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient is a male.  The patient has a past medical history significant for hypertension, diabetes, metastatic prostate cancer, laryngeal cancer, and anemia.  The patient presented for evaluation of dyspnea on exertion, as well as abnormal electrocardiogram (ECG) and stress test. 

The patient underwent a coronary angiogram, which revealed severe three vessel coronary artery disease. After the diagnostic procedure options of coronary artery  bypass grafting surgery (CABG) and high risk percutaneous coronary intervention (PCI) were discussed with the patient, and he chose to proceed with the percutaneous revascularization. Impella assisted high risk percutaneous coronary intervention (PCI) on left anterior descending (LAD) and ramus intermedius was performed and Impella device was removed. The patient was admitted for monitoring after the procedure. He was hemodynamically stable. The course was complicated by a decrease in hemoglobin to as low as 6.1 grams per deciliter (gm/dL) and he required transfusion as well as intravenous iron supplementation and additional imaging (computed tomography scan to rule out retroperitoneal hematoma). The patient was discharged home with a plan for outpatient follow-up.

Yes, the proposed inpatient admission was medically necessary.

The patient was diagnosed with severe multi-vessel coronary artery disease and underwent a complex percutaneous coronary intervention (PCI) with the use of atherectomy, Impella hemodynamic support. This type of high risk percutaneous coronary intervention is usually performed in an inpatient setting, due to high risk of complications and necessary monitoring. Furthermore, the patient's course was complicated by severe anemia, suggestive of bleeding complication and he required necessary monitoring, imaging and transfusion.  Given the patient's condition, course post procedure, as well as complexity of his procedure, 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: sepsis/HCAP (healthcare-associated pneumonia)

Treatment: full hospital admission

The insurer denied coverage for full hospital admission

The denial is overturned.

This is an adult female patient who was 3 days post-op for total knee arthroplasty. Other past medical history includes asthma, obesity, obstructive sleep apnea (OSA), and neck malignancy (unknown primary). The patient presented to the Emergency Department (ED) with complaints of fever, chills, and cough. She also reported having some shortness of breath (SOB) on exertion. At presentation to the ER, the patient had temperature 102 degrees Fahrenheit, heart rate (HR) was elevated to 119 and respiratory rate (RR) was in the mid 20's.

Oxygen (O2) saturations were 95% (percent) on room air (RA). The patient's peak expiratory flow (PEF) decreased from 300 to 150. She was noted to have some decreased breath sounds and rhonchi on left lung. Labs revealed white blood cell (WBC) count to be elevated to 12.1 thousand (K) with left shift. Lactate was elevated to 2.4. Procalcitonin (PCT) was 0.15. The patient's liver function tests (LFTs) were also elevated with aspartate aminotransferase (AST) of 107, and alanine transaminase (ALT) of 102. She had normal LFTs pre-op. The patient's chest x-ray (CXR) revealed left lower lobe (LLL) pneumonia (PNA). She also had a computed tomography angiogram (CTA) done as pulmonary embolism (PE) needed to be ruled out. CT (computed tomography) was negative for PE but revealed bilateral lower zone patchy opacities consistent with PNA. The patient was admitted to the hospital due to suspicion of healthcare-associated pneumonia (HCAP) in view of multi lobar infiltrates and recent discharge from the hospital.

The patient was treated with intravenous (IV) fluid boluses and broad-spectrum antibiotics to cover HCAP. She received Azithromycin and Ceftriaxone in the ED and subsequently switched to Zosyn for better coverage for HCAP. The next day the WBC increased to 14.3 K, still with left shift. A deep vein thrombosis (DVT) study was done which was negative. Right upper quadrant (RUQ) sonogram was done to rule out liver/gallbladder pathology.

The patient was treated with broad-spectrum antibiotics and then she improved. Her Lactate trended lower. By day 3 her WBC count normalized, and she was discharged home appropriately.

This patient's presentation was that of sepsis with fever, chills, cough, SOB, leukocytosis with left shift and elevated lactate and LFTs. This patient needed an inpatient level of care to make sure that she did not deteriorate further. She was not stable enough to be managed in observation setting given possibility of sepsis/HCAP. 

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

The insurer's denial of coverage for the full hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute focal neurological deficits

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

This was a female who presented to the ER (emergency room) for stuttered speech and questionable dysphagia. She had a prior medical history of atrial fibrillation, anemia and migraines as well as additional chronic medical problems. On exam, she had 3/5 power left upper extremity strength. A stroke code was activated. Head computed tomography (CT) showed a focus of hyperdensity in the left sylvian fissure along the course of the left middle cerebral artery concerning for thrombus. Computed tomography angiography (CTA) of the head/neck did not show a large vessel occlusion or significant stenosis. The neurological exam revealed mixed aphasia with fragmented speech and left-sided weakness.

Given that this patient had several vascular risk factors including atrial fibrillation and presenting with acute focal neurological deficits concerning for acute stroke with abnormal neurological exam in the ER, an inpatient admission was medically necessary.

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

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

Diagnosis: Worsening mental status. 
Treatment: Inpatient admission. 

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

The patient is a female with dementia who resides at a sub-acute rehab. She was sent to the emergency room for worsening mental status, likely due to urinary tract infection. The patient has prolonged hospitalization for the management of altered mental status. The prolonged hospitalization is denied, but the facility is appealing the denial. 

The proposed treatment is not  "medically necessary". 

At the time of admission, the patient was hemodynamically stable. The patient received conservative management. The co-morbid conditions were stable. The patient's condition and mental status were at baseline in 24 hours of admission. The prolonged hospitalization was not medically necessary. 

The patient was admitted to acute in hospital level of care with worsening mental status due to UTI (urinary tract infection) and pneumonia. The patient had elevated troponins, and acute coronary syndrome was ruled out. At the time of admission, the patient was hemodynamically stable. The patient received conservative management. The co-morbid conditions were stable. The patient's condition and mental status were at baseline in 24 hours of admission. The prolonged hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection.
Treatment inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

This is the case of an adult male with history of left ventricular assist device (LVAD) explant, diabetes, hypertension, chronic kidney disease, and coronavirus disease (COVID) pneumonia. The patient presented to the hospital with complaint of dysuria, fever, and chills. He had an elevated white blood cell (WBC) count. The patient was admitted and started on intravenous (IV) ceftriaxone. Infectious Disease (ID) was consulted regarding his care. They advised obtaining blood/urine cultures and continuing IV ceftriaxone. The patient was noted to improve as his WBC was noted to diminish. He was discharged on oral cefpodoxime 100 milligrams (mg) twice daily for an additional 2 days to complete 5-day course of antibiotics. 

The insurer has denied coverage for the inpatient hospital admission was not medical necessary. They noted that the patient had vital signs within acceptable limits on presentation (WBC count was elevated). The patient was treated with monitoring, antibiotics, observation, and testing. The patient could have safely been treated in an observational setting. 

The appeal on behalf of the hospital is noted and read in detail. Per Milliman Care Guidelines (MCG) Health Urinary Tract Infection (UTI) RRG, the patient fails to meet clinical indications for admission to inpatient care. These include:

1)	Hemodynamic Instability
2)	Alter mental status that is severe or persistent
3)	Persistence or worsening of clinical findings despite observation care treatment
4)	Parenteral antibiotics needed beyond observation care treatment
5)	Immunocompromised state
6)	Urinary system finding test requires invasive procedure, or places patient at increased risk for systemic illness or delayed recovery (Ureteral observation, renal or perinephric abscess, pronephroses, emphysema pyelonephritis, etc.
7)	Acute renal failure

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

The inpatient hospital admission is not considered medical necessary for this patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.