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

Diagnosis: Gastroenteritis 
Treatment: Full hospital admission 

The insurer is denied coverage for full hospital admission. The denial is overturned. 

The patient is a female with a past medical history of diabetes mellitus, hypertension, hiatal hernia, irritable bowel syndrome, fibromyalgia, back pain, and migraines. The patient presented to the emergency department with subjective complaints of epigastric tenderness. The patient presented with abdominal pain and diarrhea for several weeks. The patient was seen in the emergency department and underwent a computed tomography (CT) scan showing colitis of the ascending and descending colon. The patient was discharged on a colitis diet. The patient had greater than 10 episodes of emesis and greater than 12 episodes of diarrhea. The patient had foul-smelling belching and diarrhea that was foul-smelling. The patient had seen her primary care physician who told the patient that she likely had a viral infection. The patient came to the emergency department due to the pain. The laboratory results revealed white blood cell count (WBC) 11.9. The patient had epigastric pain. The patient was unable to tolerate anything orally and was having diarrhea with vomiting. The patient was started on ciprofloxacin, Flagyl, famotidine, and normal saline intravenously. The patient was admitted for colitis. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The full admission is considered medically necessary for this patient. 

The patient had persistent symptoms suggestive of gastroenteritis. She was discharged from the ED several days prior to the presentation and was diagnosed to have colitis. Her symptoms persisted and have worsened leading to inability to keep anything down. Although she does not have severe clinical signs suggestive of sepsis or shock, persistent symptoms warrant further intensive monitoring. Discharging from ED is not an option since this was done once already. Given that she had persistent and worsening symptoms for several days, it is unlikely that her symptoms will get better in 24 hours of observation. Under these circumstances, the most appropriate decision is to admit and work up expeditiously. 

Based on the above, the medical necessity for the full hospital admission is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:Intertrigo
Treatment: Panniculectomy
The insurer denied a Panniculectomy.
The determination is overturned.


The patient is status post gastric sleeve surgery. This was performed for the treatment of morbid obesity. She was successful in losing 101 pounds (lbs) since bariatric surgery was performed. This amount of weight loss has resulted in redundant skin folds of the abdominal wall. As is documented in the progress notes and appeal letter from her provider, she is having problems with a rash, irritation and infection in the folds of the abdominal pannus. She also has difficulty carrying out basic activities and maintaining appropriate personal hygiene. She has required topical antimicrobial treatment for intertrigo without resolution of her condition. Photographs document a large anterior abdominal pannus that hangs below the pubis there is also associated dermatitis, cellulitis and skin breakdown in the intertriginous folds. Her post-surgical nadir following the sleeve gastrectomy procedure was 34.4 kilograms per square meter (kg/m2). At issue is the medical necessity of a panniculectomy.
A panniculectomy is medically necessary and appropriate for this patient. This patient has intertriginous skin rashes recalcitrant to local treatment and the size of the pannus precludes the member from carrying out basic activities of daily living/hygiene. This patient has lost 101 lbs following gastric surgery  and is now experiencing complications of a large abdominal pannus. She has required antibiotic therapy for intertrigo and also difficulty maintaining basic personal hygiene. Photos document the size and redundancy of the pannus. There is also photo documentation of associated dermatitis, cellulitis and skin breakdown in the intertriginous folds.
This patient meets the criteria established by the American Society of Plastic and Reconstructive Surgeons for third party payer coverage of abdominoplasty/panniculectomy. [1] She has a prominent overhanging apron of skin and fat in the lower abdomen that causes her symptoms related to chronic dermatitis/cellulitis. As can be expected in patients with a large anterior pannus, the patient also has difficulty with personal hygiene. The patient has required treatment for intertriginous skin rashes and has required medicinal treatment of this condition. Photographs document the size of the pannus and provide appropriate justification for insurance coverage of panniculectomy/abdominoplasty. The procedure proposed is reconstructive in nature and is performed to relieve the specific symptom of chronic intertrigo and to promote increased ability with regard to activities of daily living. This procedure is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ehlers-Danlos syndrome

Treatment: Right shoulder surgery

The insurer is denied coverage for right shoulder surgery. 

The denial is upheld. 

Issue: Denial of coverage for right shoulder surgery 

This patient is a female with history of Ehlers-Danlos syndrome and right shoulder pain. She was evaluated and a corticosteroid injection was provided.  It was beneficial.  Physical Therapy (PT) made her condition worse.  MRI report was that of fluid in biceps tendon, probable SLAP tearing and no evidence of cuff tear.  Evaluation reported issues to both shoulders.  She underwent LEFT arthroscopic Bankart repair, rotator cuff repair. An office visit reported instability with impingement to the Right shoulder.  She received additional corticosteroid injections to the right shoulder.  She was seen with ongoing symptoms and + physical findings.  Her physician recommended arthroscopic surgery to her right shoulder.

Surgery is recommended to treat a pathological condition which has not improved with conservative management.  There should be consistency of subjective complaints, objective findings and diagnostic studies.  There should be a specific pathological condition which would more than likely improve with operative intervention. However, in this case, there is insufficient clinical documentation to support for surgical intervention. The patient's physician opined that the patient had right shoulder instability, acromioclavicular (AC) derangement, bicep tendon disease and rotator cuff pathology. However, the clinical documentation of this patient's history and physical examination does not substantiate these claims. The patient's physical examinations were not performed on several occasions, and conservative treatment was provided on an intermittent basis. A complete course of conservative treatment was not provided before considering surgical option. The patient had received solely a cortisone injection to her right shoulder, and the location of this injection was not defined. The patient had not received physical therapy (PT) in over a year. Literature review supports that patients with Ehlers Danlos should have a more extended period of conservative treatments. The patient has not met the national guidelines and criteria for arthroscopic surgery to the surgery at this time.  Thus, right shoulder surgery is not considered medically necessary for this patient.

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

The carrier's denial of coverage for right shoulder surgery is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left lower quadrant pain, PMH (past medical history) significant for hypertension, DM (diabetes mellitus), hyperlipidemia, hypothyroidism, h/o (history of) colitis on colonoscopy, and h/o left lower quadrant pain 
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with PMH (past medical history) significant for hypertension, DM (diabetes mellitus), hyperlipidemia, hypothyroidism, h/o (history of) colitis on colonoscopy. and h/o left lower quadrant pain three to four months prior, treated with oral antibiotics. He presented to the ED with left lower quadrant pain.

CT scan of the patient's abdomen and pelvis revealed cecitis/appendicitis. His CBC (complete blood count) revealed normal Hb/HCT (hemoglobin/hematocrit) and WBC (white blood count) of 15.7. The CMP (comprehensive metabolic panel) was normal. 

In the ED, the patient was hemodynamically stable, and afebrile. He was admitted to the surgical service with the diagnosis of colitis, and was treated with IV fluids, and combination of Cipro and Flagyl for two days. His CBC revealed normalization of WBC after two days. 

The patient was discharged home with oral Cipro and Flagyl for total course of 14 days, and advised to follow up with his GI (gastroenterologist) in two weeks, and undergo colonoscopy for the evaluation of colitis in six weeks. 

The patient was admitted with left lower quadrant pain, not associated with any nausea, vomiting, diarrhea, bloody stools, fever or chills. He underwent CT scan of the abdomen and pelvis, which revealed Cecitis/appendicitis/possible right-sided colitis. There was no evidence of bowel obstruction or perforation. His abdominal examination was benign, with no rebound tenderness to suggest peritonitis. His CBC revealed mild leukocytosis. He was admitted to the surgical service and treated with Cipro and Flagyl for two days, after which he was discharged home on total of two weeks course of Cipro and Flagyl, and advised to follow up with his GI doctor within two weeks for possible colonoscopy. 

The patient remained hemodynamically stable and afebrile throughput his hospital stay, and he did not require any surgical intervention or EGD (esophagogastroduodenoscopy)/Colonoscopy. Given this clinical scenario, the patient could have safely managed at the lower level of care for his condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Sided Chest Pain And Alcohol Intoxification 
Issue under review: Inpatient admission

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

The patient is a male with a past medical history significant for HTN (hypertension), dyslipidemia, diabetes, CAD (coronary artery disease), s/p (status post) PCI (percutaneous coronary intervention) x 3 in the past, bipolar disorder and alcohol abuse. He presented to the ER for chest pain and alcohol intoxication. The patient had fallen on the street and was evaluated for trauma as well, and was found to have rib fractures, which were treated medically. 

The patient was evaluated for his chest pain to rule out ACS (acute coronary syndrome). The patient was hemodynamically stable. The ECG (electrocardiogram) revealed sinus rhythm with PACs (premature atrial complexes), with no ST segment deviations. The cardiac troponin was elevated at 0.35 ng/dL, consistent with myocardial injury. The patient was noted to have decreased magnesium level, which was supplemented. He was monitored and serial troponins and ECGs were done. He was treated for alcohol withdrawal. His troponin level trended down and he was discharged home. 

Yes, the inpatient admission was medically necessary. 

The patient presented with new onset chest pain, in the setting of acute alcohol intoxication. He was suspected of having ACS with evidence of troponin elevation. The patient had multiple risk factors for CAD (coronary artery disease), including diabetes, as well as a known history of coronary artery disease, requiring prior percutaneous revascularization in the past. His ECG was unrevealing. However, the cardiac troponins were abnormal, suggestive of acute myocardial ischemia. His course was also complicated by trauma due to fall, rib fractures, thrombocytopenia, hypomagnesemia, and risk of alcohol withdrawal. Given this presentation, suspicion for an acute coronary syndrome, as well as risk factors, co-morbid conditions and known CAD, it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post cardiac catherization monitoring

Treatment: Inpatient hospital admission 

The insurer is denied coverage for inpatient hospital admission.

The denial is upheld.

The patient was a male with a history of end stage renal disease (ESRD) on hemodialysis, coronary artery disease status post 3 vessel coronary artery bypass graft (CABG), status post multiple stents and brachytherapy, atrial fibrillation/flutter, status post ablation, diabetes mellitus, hyperlipidemia and cerebra vascular accident.  The patient presented needs a cardiac catheterization. The patient had been experiencing exertional dyspnea and angina for the past month. The patient's recent stress test showed reversible ischemia. The patient underwent coronary angiography with radiation oncology assisted brachytherapy to the ramus intermedius coronary artery. There were no procedural complications. The patient was admitted for post-procedure monitoring and was cleared for discharge home.

Inpatient admission status is not medically necessary for this patient. Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient procedure. This patient's clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary. There were no extenuating circumstances in this case that warranted inpatient admission status post-procedural of the elective cardiac catheterization and attempted angioplasty. 

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 at the acute level of care is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Severe headache
Treatment: Inpatient stay
The insurer denied Inpatient stay.
The denial is Partially overturned

The patient is a male who presented to the hospital due to a severe headache along with fatigue and fever for ten days. Motrin had not been helpful for his headache. The patient reported a recent trip to Mexico during which he was bitten by a mosquito. Following the trip, the patient and his wife had gastroenteritis, which improved with antibiotics, but the patient then began having headaches.  The patient had been seen previously in the emergency department the week prior, at which time he refused to undergo a computed tomography (CT) scan or lumbar puncture but his fever improved with intravenous (IV) medication. Due to the duration of his headache, the patient's primary care physician recommended the patient return to emergency department to undergo a CT scan. 

The patient had symptoms of intracranial infection including nuchal rigidity, altered sensorium, fever and un-resolving headaches. Structural lesions and increased intracranial pressure were ruled out but the patient was diagnosed with viral encephalitis. Considering this diagnosis, the patient was treated with antiviral medications and antibacterial medications until the cultures came back clear and PCR for the most severe and most treatable type of viral encephalitis, namely herpes, came back negative. Additionally, the patient had severe symptoms. Therefore, admission for the first three days were justified and medically necessary for appropriate diagnostic workup, intravenous therapies, imaging, spinal tap, and intravenous medications.

However, the last two admission days were not medically necessary. The patient's cerebrospinal fluid tests were normal, symptoms of encephalitis have resolved, and the patient had post spinal tap headaches, a condition which can be typically managed with maintaining horizontal body position for 24 to 48 hours, as well as oral analgesics and oral caffeine. These interventions are commonly done on an outpatient basis. There was no need in the hospital admission for the management of post-spinal tap headaches and therefore the last two admission days were not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and costochondritis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male who was admitted to the hospital with a diagnosis of chest pain and costochondritis.  There are also reports of dizziness.  There are no abnormalities noted on the vital signs, and the physical exam is mostly normal.  

No, the inpatient admission was not medically necessary.

Chest pain in children is benign and does not require an admission to the hospital unless there are other factors involved such as an arrhythmia or abnormal testing.  This adolescent had a normal electrocardiogram (EKG) and a normal echocardiogram.  The patient could have been safely sent home with observation.  (1-2)
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abscesses.
Treatment: Inpatient hospital admission.
The insurer is denied coverage for inpatient hospital admission. 
The denial is upheld. 
This is a patient who presented to the emergency department (ED) with complaints of a right and left gluteal abscesses and a rash for 3-4 days. It was reported that he had fever; 101.4, with episodes of vomiting. His presenting vital signs were: Temperature C: 37.2, Heart Rate: 136, SpO2 (Pulse Ox): 99%. On physical exam she was well appearing, non-toxic, interacting appropriately on exam, was not dehydrated, no rashes. An incision and drain was performed on each abscess with 2-3 milliliters of pus was drained from both.
The patient was treated with intravenous antibiotics. The patient was medically stabilized and discharged.
 
The Attending Assessment & Plan states that she was failing outpatient antibiotic therapy, but that she does not appear septic, but likely will need I&D [incision and drainage] for drainage. This was performed in the emergency department (ED) on both abscesses with 2-3 mL of pus drained from each. The areas were soft after drainage, and no packing or drain was needed. There is no mention of extensive erythema that would indicate extensive cellulitis. The ED physician's medical decision making note does not adequately justify reasons for deciding to use IV antibiotics and a need for treatment as an inpatient. Although febrile at home, the patient was afebrile in the ED and her vital signs were stable, and criteria were not fulfilled for sepsis syndrome.

Also, there were no abnormal laboratory criteria other than leukocytosis (23,800/cu.mm), which reflects a reaction to the bacterial soft tissue infection. The likelihood of bacteremia was extremely small. This scenario is specifically addressed in Reference # 1. The abscesses were small, less than 5 cm, were successfully incised and drained, a drain was not placed, and the clindamycin could have been administered orally following an initial intravenous (IV) dose. Her lack of improvement was not a failure of outpatient antibiotic therapy, rather it was because drainage was needed to expedite improvement (and ultimately the culture yielded MRSA which was resistant to cephalexin).

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

The inpatient hospital admission was not considered medically necessary for this patient. After initial care given in the ED, the patient could have received outpatient follow-up care.

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

Dental/ Orthodontic Procedure.
Diagnosis: Tooth decay.

Treatment: D2751 - White glass with metal crown, tooth #7 and #9 and 
D3310 - Nerve treatment on front tooth, tooth #9.
The insurer denied the D2751 - White glass with metal crown, tooth #7 and #9 and 
D3310 - Nerve treatment on front tooth, tooth #9.
The denial is overturned.

The patient is a male requesting dental benefits for crowns on teeth #7 and #9, and a root canal procedure on tooth #9.

Yes, the proposed treatment with D2751 and D3310 is medically necessary. 

There is severe decay in both teeth #7 and #9 requiring them to be restored with crowns. Tooth #9 also will need to have the nerve removed (root canal treatment) due to the severity of the decay, which is into the nerve. The crowns and the root canal procedure are all medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Respiratory.
Inpatient Hospital.

Diagnosis: Viral Infection.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a woman with a history of supraventricular tachycardia (SVT) status post ablation who presented to the hospital with a cough that has been ongoing for three days. She also reported chest pain and stated the pain was achy and occurred while she coughed. She denied substance use. Past history also included bronchitis and anxiety. Review of systems was negative for fevers and chills. Vital signs showed blood pressure 159/91, Heart rate 137, temperature 38.8 Celsius, and respiratory rate 22. On physical examination, heart was rapid, breath sounds were normal, abdomen was soft. Labs showed D dimer negative, and lactate 1.2. Chest computed tomography (CT) angiography was negative for pulmonary embolus, but demonstrated bilateral opacities in the upper lobes.

The inpatient stay is medically necessary. The patient presented with hemodynamic instability in the setting of fever, suspected infection, and abnormal CT imaging findings. Because of the risk of an atypical infection in the setting of sepsis, she required a more intensive level of care, and a lower level of care would not have been clinically appropriate. Pulmonology was consulted and it was ultimately determined that her infection was likely viral in origin. While the patient did improve rapidly, she required telemetry and close management at the time of presentation due to the risk of acute decline, and it would not have been appropriate to manage her at a lower level of care.