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

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

The patient is male with a past medical history significant for hypertension, asthma, gout, polysubstance abuse, diastolic CHF (congestive heart failure), non-obstructive CAD (coronary artery disease) by prior catheterization, who presented to the hospital with complaints of non-exertional sharp chest pain, epigastric pain and dyspnea.

The patient was hemodynamically stable. The patient's ECG (electrocardiogram) revealed no acute ischemic changes. The cardiac troponins were negative.

The patient was admitted to telemetry to rule out ACS (acute coronary syndrome). His urine toxicology was significant for cocaine presence, and possibility of cocaine induced chest pain was considered. The patient underwent a 2D echo (two dimensional echocardiogram), which revealed EF (ejection fraction) of 50%, Grade I diastolic dysfunction. No ischemic evaluation was planned. The patient was started on treatment for gout. He was discharged home with a plan for outpatient follow-up.

No, the Inpatient admission was not medically necessary.

This patient presented for evaluation of atypical chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. The patient had a prior catheterization, which revealed no evidence of obstructive coronary disease, and no further ischemic work-up was planned during this admission. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission. The care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and monthly visits for medical necessity. 
The denial was upheld. 

The patient is a female with Skeletal Class II malocclusion. The patient has mild maxillary spacing and mild mandibular crowding. She has a severe overjet and moderate overbite.

At issue is the medical necessity for braces and monthly visits.

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

No, the requested health service/treatment of Braces and Monthly Visits is not medically necessary for this patient.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 14 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 3.5 mm or greater. This patient has a Skeletal Class II malocclusion. She has mild maxillary spacing and mild mandibular crowding. The patient has a severe overjet and moderate overbite, but in evaluating the complete dentition, the patient's malocclusion is not severe enough to be determined medically necessary under generally accepted standards of care. The malocclusion does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary.

Thus, braces and monthly visits are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite and crowding
Treatment: Braces and Monthly Visits
The insurer denied the braces and monthly visits.
The denial is overturned. 

The patient is a male.  The request is for dental benefits for Orthodontic treatment (braces) and monthly visits.

Based on the dental clinical exam, summary, and orthodontic records, the patient presents with a skeletal class I molar relationship, a normal vertical growth pattern, Class II canines, and severe maxillary and mandibular crowding.  There is also an anterior crossbite with general attachment loss (mandibular right lateral incisor).  Findings and a treatment plan were discussed with the patient and parents.

Yes, the proposed treatment of orthodontic therapy (braces) and monthly visits is medically necessary.

As stated in the dental clinical summary, the patient has severe crowding in the maxilla and mandible.  The patient also has an anterior crossbite at the mandibular right lateral incisor.  These conditions are quite evident in the x-rays and photos.

This severe degree of crowding coupled with the crossbite can affect proper chewing, proper speech, the ability to maintain proper oral hygiene, and can lead to inflammation of the gums and gum disease.

If the patient's condition is left untreated, the complications of decreased proper function as it relates to chewing, speech, and compromised oral hygiene will only lead to more dental problems in the future.
Appeal type: Medical necessity
Decision: Upheld

Cardiac
Inpatient hospital

Diagnosis: Atrial Fibrillation
treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This woman presented to the emergency department after an episode of syncope. Her medical history was remarkable for recurrent falls, permanent atrial fibrillation, Grave's disease with hyperthyroidism, gastrointestinal bleeding and an intracerebral aneurysm. An echocardiogram showed normal left ventricular systolic function, mild mitral regurgitation and moderate tricuspid regurgitation. In the emergency department, her blood pressure was 128/70 mmHg (millimeters of mercury) with a heart rate of 98 beats/minute. Her room air oxygen saturation was 97%. An electrocardiogram showed atrial fibrillation with a ventricular rate of 103 beats/minute. Her physical exam was remarkable for a small forehead laceration, temporal swelling and an irregular heart rate. Her serum troponin level was normal. Her thyroid stimulating hormone (TSH) level was low. Head computed tomography (CT) scan showed no acute pathology and the previously diagnosed internal carotid artery aneurysm. The etiology of the patient's syncope was unclear. She was admitted to the hospital under observation status. 

The inpatient hospital admission is not medically necessary.
This patient presented with syncope. Her cardiac rhythm was atrial fibrillation, which was a chronic condition. She was hemodynamically stable. She had a normal left ventricular ejection fraction. Her head CT scan showed no acute pathology. She was initially admitted under observation status, which was appropriate for a stable patient without high risk features such as advanced age, family history of sudden cardiac death or significant valvular disease, such as aortic stenosis, that can be associated with syncope. Based on the records provided, the reasons for the patient's continued hospitalization was for physical therapy evaluation and treatment. This did not justify an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Inguinal Hernia. 
Treatment: Surgical Services. 

The health plan denied coverage for the requested inguinal hernia repair. 
The health plan's determination is overturned. 

This is a man with no past medical history who presented for evaluation due to a protruding left inguinal hernia of 2-weeks duration. The pre-surgical history and physical (H&P) states that he had no pain related to this hernia. However, the appeal letter states that the patient was having pain and physical limitation due to the enlarging left inguinal hernia. He underwent a left inguinal hernia repair. 

At issue is the medical necessity of the requested service of a hernia repair. 

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

Yes, the inguinal hernia repair as performed in this case was medically necessary and consistent with the standard of care. This patient had symptoms of left groin pain and was found by the attending surgeon to have a left inguinal hernia. Left inguinal hernia repair is/was medically necessary in this case because the patient had symptoms of pain and had an enlarging hernia on exam. It is standard surgical practice to repair inguinal hernias once diagnosed, especially if there are associated symptoms, as in this case. An untreated inguinal hernia will typically enlarge over time and become associated with greater symptomatology (pain) as noted in this case. 

To not repair this patient's inguinal hernia would subject him to ongoing pain, physical limitation and risk for hernia incarceration/strangulation and the serious health complications associated with this.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Diarrhea
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a history of obesity, kidney stones, and GERD (gastroesophageal reflux disease) who underwent an acute hospitalization. The patient had presented to the emergency department of the facility filing the appeal with the report of abdominal pain, nausea, emesis and diarrhea for the three days preceding the presentation. The patient had first presented to an urgent care center and was contacted by them after his discharge with the report of a white count of 20 and a troponin of 0.7. He was directed to the ED (emergency department). His white count was elevated, but his troponin was normal. He received treatment in the ED (emergency department) and was then discharged home.  The patient then re-presented with the complaints of abdominal pain.

The patient had normal vital signs. The patient had abdominal pain which was an 8 out of 10. The white count was 16. A CT (computed tomography) scan suggested ulcerative colitis. The patient was admitted and he received supportive care including IV (intravenous) fluids, IV (intravenous) antibiotics, and anti-nausea medication.  The patient had no blood in his stool. A Gastroenterologist consultant felt the presentation was more consistent with an infectious etiology. Once deemed clinically stable, the patient was discharged home.

No, the Inpatient admission was not medically necessary.

Despite the patient's presentation the care as provided could have been rendered in its entirety at a lower level of care. The patient had colitis, yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for prolonged NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, need for blood products, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care could have been rendered in its entirety at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck and Back Pain
Treatment: Chiropractic Services
The health plan denied the requested chiropractic services. 
The health plan's determination is upheld.

The patient is a female who allegedly fell off a horse and began chiropractic treatment  for neck and back pain. The neck and back diagnoses were unchanged at which time the chief complaints were neck and mid-back pain, with an unchanged diagnosis. Neck and back disability scoring was worse than it had been at the beginning of care, although the patient's pain was reportedly more occasional in nature at that time. It is noted that the schedule of treatment was more sporadic, sometimes going a full month without treatment. There was no report of a new injury or episode of pain causing the patient to return to care.
At issue is the medical necessity of the requested chiropractic visits.

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

No. The treatment in this case did not meet the requirements of medical necessity, insofar as there was no ongoing clinical improvement objectively demonstrated. There was no documented and clear non-supervised home rehabilitation program in place. The treatment included large gaps in care and was often on a maintenance schedule of care. The diagnoses went unchanged for months at a time. The neck and back disability scoring was actually worse over time, rather than better.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, depressive disorder, anxiety/panic attacks and insomnia
Treatment: Increase Home Care/Personal Care HHC - Level II Personal Care Services, 15 Mins (minutes), Increase to 84 Hour (s) per Week
The insurer denied the Increase Home Care/Personal Care HHC - Level II Personal Care Services, 15 Mins, Increase to 84 Hour (s) per Week.
The denial is overturned. 

The patient is a female with a history of Alzheimer's dementia, depressive disorder, anxiety/panic attacks and insomnia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 84 hours per week Personal Assistance Services to offer increased activities of daily living support.

Yes, the proposed treatment of 84 hours per week Personal Assistance Services is deemed medically necessary.

This is a female with a history of Alzheimer's dementia, depressive disorder, anxiety/panic attacks and insomnia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent correspondence from the patient's medical provider indicates that due to worsening cognitive impairment related to the patient's dementia, gait ataxia from her chronic low back pain and increased fall risk, the currently approved plan of 40 hours per week Personal Assistance Services is not sufficient to meet the patient's current needs. For these reasons, the proposed treatment 84 hours per week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End stage renal disease (ESRD).
Treatment: Skilled nursing facility (SNF) services.
The insurer denied coverage for the Skilled nursing facility (SNF) services
The denial is overturned.

This female patient has multiple chronic medical problems including end stage renal disease (ESRD) on hemodialysis, hypertension, and anemia.  The patient was admitted to a skilled nursing facility (SNF) after having a heart attack and diagnosed with Covid 19.  Under review is the medical necessity for SNF services provided.   

The patient was at a level of impairment/medical acuity and had potential for functional improvement to support the medical necessity of rehabilitation services at the SNF during to the time period under review.1, 2  The patient was previously functionally independent.  The physical and occupational therapy notes document the patient's continued functional progress over the course of her certified stay at the SNF.  Also of significant clinical importance was the patient's underlying medical status. The patient required 2-4 liters of nasal oxygen and oral/intravenous (IV) antibiotics for underlying pneumonia. Given this patient's recent myocardial infarction and respiratory failure requiring mechanical ventilation, it was important that this patient continue under medical observation in a SNF setting.  In addition, the post-febrile reaction after the Covid vaccine injections also supported continued medical observation at this SNF setting.

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the SNF services provided were medically necessary.

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. 

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

The carrier's denial of coverage for the Skilled Nursing Facility services provided should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe crowding in upper and lower jaws
Treatment: Braces and Adjustments for Braces, Pre-service
The insurer denied the Braces and Adjustments for Braces, Pre-service.
The denial is overturned. 

The patient is a female with severe crowding in her upper and lower jaws. The request is for Braces and Adjustments for Braces.

Yes, the proposed Braces and Adjustments for Braces are medically necessary.

All four of the patient's canines are out of their proper positions. They are out in front of their normal position. This does not allow for the patient's teeth to mesh properly during the chewing cycle.  Instead of riding up and over each other in a coordinated fashion (called canine guidance) the teeth will grind together out of sync. This will lead to fractured and prematurely worn down teeth as well as probable temporomandibular joint (TMJ) issues in the future. This case has medical necessity for orthodontic treatment.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Inpatient hospital

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

This case involves a man with type 2 diabetes, hypertension, coronary disease, and chronic kidney disease stage III, who presented to the hospital with a chief complaint of weakness and falls. Symptoms have been ongoing for several months, increasing lower extremity weakness in the bilateral lower extremities and 3-4 falls. The patient has been experiencing memory loss with decreased ability to focus as well. He followed outpatient with a neurologist and was evaluated with a brain magnetic resonance imaging (MRI), showing degenerative parenchymal changes. Outpatient electroencephalogram (EEG) was also negative. There are no associated fevers, chills, or shortness of breath. There are no palpitations, nausea, vomiting, diarrhea, or melena.

The inpatient hospital admission is not medically necessary for this patient. This presentation includes a patient with generalized weakness, without focal neurologic deficits, who has undergone extensive outpatient evaluation for chronic symptoms. He was found to have mild AKI (acute kidney injury), which resolved within 24 hours of hospitalization. There were no severe electrolyte derangements, warranting inpatient hospitalization. The patient did not require renal replacement therapy or aggressive interventions from nephrology to correct the renal dysfunction. 24-hour video EEG was negative for seizure activity. There was a delay in obtaining a brain MRA, which, when completed, was normal. There were no cardiovascular issues, warranting inpatient hospitalization, as the patient had a negative troponin, normal EKG (electrocardiogram), and remote history of coronary disease. From a diabetes management standpoint, this is an outpatient issue, with gradual adjustment in both the oral anti glycemic agents and the insulin, to reach a target A1c level. The patient was not in diabetic ketoacidosis, with no evidence of nonketotic hyperosmolar coma to warrant inpatient hospitalization.
From an orthostatic hypotension standpoint, this type of presentation is typically treated under observation level of care, with gentle fluid hydration, until the symptoms resolve. There is no indication for this to warrant inpatient hospitalization.
In conclusion, none of the patient's conditions were severe enough to warrant an inpatient hospitalization. The entire hospital stay can be managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Zygomatic fracture.

Treatment: Inpatient stay.

The insurer denied coverage for the inpatient stay.

The denial is upheld. 

This is a male patient who presented to the Emergency Room (ER) with complaints of a left zygomatic fracture after being assaulted on a train.  He reported losing consciousness and having a mild left sided headache. 

It was noted that the patient had normal ocular movements and no vision deficits.  He had been cleared by Ophthalmology.  The patient did have a zygomaticomaxillary complex (ZMC) fracture, but this type of fracture is amenable to outpatient or observation level of care.  Admission to a hospital is not required for care of ZMC fractures with a normal Ophthalmologic exam.  Up to Date discusses the associated injuries which require emergent care. 

This patient did not have any of these conditions.  He had a facial fracture that required repair but this repair could have been performed at a lower level of care.  He did not have an ocular injury and his pain was well managed.  He could have received steroids and antibiotics as an outpatient while waiting for surgery.  

The health plan acted in the best interests of the patient.  

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

Diagnosis: Amyotrophic lateral sclerosis.

Treatment: Sodium phenylbutyrate 500 mg [milligrams], 360 tablets in 30 days for one year for amyotrophic lateral sclerosis.

The insurer denied coverage for sodium phenylbutyrate 500 mg [milligrams], 360 tablets in 30 days for one year for amyotrophic lateral sclerosis.

The denial is overturned. 

This is a male patient with a diagnosis of early onset amyotrophic lateral sclerosis (ALS).  The patient's medications included Nuedexta, tauroursodeoxycholic acid (a supplement), Theracurmin, Methylcobalamin, Radicava, Riluzole and Lexapro.  The patient's ALS-specialist neurologist prescribed sodium phenylbutyrate.  This was denied by the insurer as not medically necessary.  

Although this requested medication is not approved by the Food and Drug Administration (FDA), the combination of the requested sodium phenylbutyrate and the taurursodiol supplement that the patient is already taking has been shown to be effective in the treatment of amyotrophic lateral sclerosis (ALS) disease.  As per Paganoni, et al (2020) and Paganoni, et al (2021), studies show that sodium phenylbutyrate and taurursodiol significantly slowed functional decline and prolonged survival in an important recent trial.  

As per review of the medical record and literature, sodium phenylbutyrate is considered medically necessary for this patient with amyotrophic lateral sclerosis (ALS) who is also taking taurursodiol. 

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

The medical necessity for the prescription sodium phenylbutyrate 500 mg [milligrams], 360 tablets in 30 days for one year for amyotrophic lateral sclerosis is substantiated.  The insurer's denial should be overturned.