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

Diagnosis: Genitourinary/Kidney Disorder- UTI
Treatment: Inpatient hospital stay
The health plan denied the inpatient admission as not medically necessary. 
The reviewer has upheld the health plan determination.

The patient has a history of hypertension who presented to the hospital . The patient had been homeless and coming to work with defecation on the  body. The patient refused help in the housing program and was brought in for psychiatric and social work evaluation. Vital signs showed blood pressure 187/84 temperature 98.2 Fahrenheit heart rate 84 respiratory rate 20 oxygen saturation 100% on room air. On physical examination, the patient was in no acute distress, heart was regular, breath sounds were normal, and no cranial nerve deficit was reported. Analysis of urine was positive for infection. Head computed tomography  scan was negative for acute stroke. The patient was admitted for urinary tract infection and psychiatric evaluation. The plan of care included intravenous ceftriaxone, urine culture, urine toxicology testing, psychiatry consult, social work consult, physical therapy, and heparin deep vein thrombosis (DVT) prophylaxis. The psychiatry team saw the patient and their assessment was that the behavior may have been attributable to dementia or paranoia/delusional disorder. They had no concerns about suicidal ideation. They recommended a dementia work up and agreed with placement. The patient was discharged  with oral antibiotics to stay at a daughter's house with suspicion that the symptoms may have been exacerbated by the urinary tract infection.

The inpatient hospital admission was not medically necessary. The patient presented with urinary tract infection and concern for dementia versus psychiatric illness in the setting of being unable to care for self. Other than the evidence of urinary tract infection, there were no other acute abnormalities that would normally trigger inpatient care. For example, psychiatry had low concern for suicidal ideation for mania. Regarding the urinary tract infection, there was no evidence of sepsis.

The patient presented with dementia and urinary tract infection, and concerns about a psychiatric diagnosis were lessened due to the improvement of  symptoms with treatment of the urinary tract infection. In addition, the patient was not suicidal, homicidal, acutely manic, or with signs of sepsis or pyelonephritis. Overall this patient could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left femoral neck fracture

Treatment: Non-emergency air and ground ambulance service

The insurer denied coverage for the non-emergency air and ground ambulance service.

The denial is overturned. 

This is a female patient with atrial fibrillation, diabetes mellitus, hypertension and macular degeneration who fell and sustained a left femoral neck fracture. She was air transported to another location and surgery was performed. The insurer denied coverage for the non-emergency air and ground ambulance service. The insurer asserts the required care could have been provided at facilities closer to the location of where the patient was injured. However, there is no evidence, nor does the insurer indicate they provided the patient (or representative) with any appropriate alternative and closer facilities.  

From a physical medicine and rehabilitation/pain management perspective as well as within a reasonable degree of medical certainty, the non-emergency air and ground ambulance service was medically necessary. The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  

Based on the above, the medical necessity for the non-emergency air and ground ambulance service is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection
Treatment: Full hospital admission
The insurer denied coverage for the full hospital admission.
The denial is upheld.

This is a female patient who presented to the emergency department (ED) with complaints of dysuria, fever, and chills for 5-7 days. Emergency room triage revealed blood pressure 85/45, temperature 101.4 F.  Laboratory findings were significant for a white blood cell count of 19,100, lactate 3.2, and a urinalysis positive for leukocyte esterase. The patient met criteria for sepsis from complicated cystitis/ pyelonephritis and was admitted. The patient gradually improved on antibiotic therapy and her white blood cell number trended downward. Urine/ blood cultures were negative; the patient was discharged on day 3 of admission with outpatient follow up. 

The insurer has denied coverage for the full hospital admission. They noted the patient's presentation with a urinary tract infection, but lack of high fever, very low blood pressure that did not improve, or worsened kidney treatment. 

Per Milliman Care Guidelines (MCG) Health Urinary Tract Infection the patient fails to meet clinical indications for admission to inpatient care. These include: hemodynamic instability, altered mental status, severe or persistent vomiting, bacteremia new onset coagulopathy, urinary system finding or obstruction requiring drainage procedure, etc.

The healthcare plan acted reasonably and with sound medical judgement and in the best interests of the patient.

The full hospital admission was not medically necessary.

The carrier's denial of a full hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries. 
Treatment: Inpatient Hospital. 
The insurer denied the inpatient stay. 
The denial is upheld in whole.

The patient is a male who presented to the emergency department with head trauma and amnesia. Reportedly, the patient was assaulted outside a bar 2 days prior. According to the history and physical (H&P) note, after the assault the patient was functioning well, however he experienced a headache. He worked the day before without issues. Reportedly, the patient underwent a computed tomography (CT) scan of the head that demonstrated right epidural hematoma.
When the patient was seen by the admitting physician, he was hemodynamically stable. He was awake, alert, and oriented times 3. The patient was speaking clearly and had normal bilateral breath sounds. His blood pressure was 130/90, heart rate 70 beats per minute. The Glasgow Coma Scale was 15. The patient had ecchymosis around the left eye as well as small healing abrasion in the right occipital area. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed sodium 140, potassium 4.5, chloride 104, bicarbonate 24, blood urea nitrogen (BUN) 21, creatinine 0.97, glucose 88. White blood cell count was 5.4, hemoglobin was 14.8, hematocrit was 41.8, and platelets were 280.
The patient was admitted to the hospital with a right epidural hematoma and right frontal skull fracture.
The patient was evaluated by a neurosurgeon who indicated in the consultation note that no acute neurosurgical intervention was required. The patient was recommended to have a CT scan of the head to monitor the expansion of hematoma. The patient also required monitoring for acute changes in his mental status.
The patient was admitted to the hospital and subsequently transferred to the intensive care unit with questionable worsening of an epidural hematoma on the repeat CT scan of the head.
In the intensive care unit, the patient was monitored closely, including frequent neuro checks.
While in the intensive care unit, the patient remained in stable clinical condition and had no issues overnight. On the next day after the day of admission, the patient had a minimal headache. The patient tolerated his diet and ambulated without difficulties.
Therefore, he was discharged from the hospital the next day after the day of admission.

The health plan's determination is upheld.

The hospital admission was not medically necessary for this patient at the acute inpatient level of care. Even though the patient was admitted to the intensive care unit, he remained in stable clinical condition with significant improvement in his symptoms within a short period of time. Furthermore, the patient did not require any diagnostic studies, procedures, or surgical interventions necessitating admission at the acute inpatient level of care. The review of medical records demonstrated that the severity of the patient's condition and the complexity of the services provided were most appropriate for a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: Braces
The insurer denied the braces. 
The denial is overturned. 

The patient is a male. The request is for orthodontic benefits.

Yes, the proposed braces and monthly visits are medically necessary. 

The patient has a deep impinging overbite with severe soft tissue damage to his palate. This is an automatic qualifier according to the handicapping index scale.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's dementia, hypertension and depression. 
Treatment: Increase Home Care/Personal Care home health care - Level II
Personal Care Service, per 15 minutes to 70 hours/week. 

The insurer denied the Increase Home Care/Personal Care home health care -
Level II Personal Care Service, per 15 minutes to 70 hours/week. 
The denial is upheld. 

The patient is a female with a history of Alzheimer's dementia, hypertension and
depression. Due to impairments related to these conditions, she requires
assistance for completion of the majority of her activities of daily living (ADLs). An
appeal review was requested for potential approval of 70 hours/week personal
assistance services to offer increased activities of daily living (ADLs) support. 

No, the increase home care/personal care home health care - level II personal care
service, per 15 minutes to 70 hours/week is not medically necessary. 

The patient is a female with a history of Alzheimer's dementia, hypertension and
depression. Due to impairments related to these conditions, she requires
assistance for completion of the majority of her activities of daily living (ADLs).
However, an in-home assessment of the patient's functionality and ability to perform
activities of daily living (ADLs) was completed and revealed that the currently
approved plan of 42 hours/week Personal Assistance Services is sufficient to meet
the patient's current needs. Although there is a hand-written appeal note that reads,
"During COVID-19 pandemic, [the patient's] service hours decreased from 10 hours
per day to 6 hours per day. [The patient] developed suicidal thoughts/tendencies,"
there is no additional objective medical documentation that demonstrates that the
patient has sustained further functional and psychological/mental loss since the
date of this last assessment. For these reasons, the proposed treatment 70
hours/week Personal Assistance Services is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional-FTT (Failure to thrive). 
Treatment: Enteral Formulas. 
The health plan denied the Enteral Formula as not medically necessary. 
The reviewer has upheld the health plan's determination in whole. 

This is the case of a pediatric patient with hydrocephalus and cow's milk allergy. The patient has an inability to chew solid food, is only able to take liquids or pureed foods by mouth. Requested is PediaSmart soy powder, 1200 kcal/day, 22 cans per month. Per medical history, this patient has severe developmental delays, cannot walk or talk, and has hydrocephalus with occipital encephalocele. The only home medication is albuterol. The patient's surgical history includes ventriculoperitoneal (VP) shunt placement x 2. A physical exam showed weight to be 58 lbs, which is 75-90 percentile for a child almost the age of this patient. 

Per the medical records indicating good weight gain >50th percentile that has been sustained for over 3 years, this patient no longer qualifies as failure to thrive or calorie malnourished. The patient is able to accept liquid and pureed foods by mouth to meet  nutritional needs and maintain proper weight. 

Per the medical documentation provided, this patient has a history of failure to thrive at a younger age. However, the patient has received proper nutritional supplementation and has maintained documented weights above the 50th percentile for age for the past 3 years. The patient is able to take liquid and pureed foods by mouth to meet daily nutritional needs. Therefore, supplemental soy beverage is no longer considered medically necessary as there is no current documented malnutrition or metabolic abnormality that requires a prescription beverage.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted teeth. 
Treatment: Braces. 
The insurer denied the Braces. 
The denial is overturned. 

The patient is a male. The request is for orthodontic benefits. 

Yes, the Braces are medically necessary. The patient has impacted maxillary canines. Based on the handicapping index, this is an "automatic qualifier" in that the impacted anterior teeth (maxillary canines) are not to be extracted. Given this, the Braces are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Maxillary/mandibular crowding, moderately excessive overjet
Treatment: Braces (D8080) and 12 monthly visits (D8670)
The insurer denied the Braces (D8080) and 12 monthly visits (D8670). 
The denial is overturned. 

The patient is a female requesting dental benefit coverage for comprehensive orthodontic treatment. An orthodontic treatment plan indicates a clinical exam was performed showing findings of Class I skeletal classification, moderate maxillary crowding, severe mandibular crowding with a deep bite and a moderately excessive overjet. 

Yes, the proposed braces (D8080) and 12 monthly visits (D8670) are medically necessary.

Considering the combination and the degree of misalignment of the first and second premolars in the mandible and the degree of overbite (amount of overlap of the upper front teeth over the bottom front teeth) and the overjet (the amount of space bucco-lingually of the upper and lower incisors) as noted on the handicapping labio-lingual deviation (HLD) index, the only effective corrective course of action would be comprehensive orthodontics. Of particular concern is the degree to which the lower left premolar is backed out of the arch, meaning that when the patient closes or attempts to chew, this tooth does not articulate with the opposing tooth. This speaks directly to a loss of function and possibly could act as an irritant to the tongue and other soft tissue adjacent to this tooth. Additionally, the proposed monthly visits are medically necessary. Braces are a process that takes time; the monthly visits are a standard and necessary part of the process that allows for the orthodontist to monitor and make adjustments as treatment progresses.
Appeal type: Medical necessity
Decision: Upheld

Cardiac
Inpatient hospital

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

This man was referred to the emergency department by his physician for tachycardia. The patient had received chemotherapy for colon cancer five days prior. He presented to his physician's office for routine blood work and was noted to have a heart rate of 150 beats/minute. He reported nausea, anorexia and diarrhea. An electrocardiogram was performed. Per the cardiologist who subsequently saw the patient in the hospital, this showed sinus tachycardia without acute ischemic changes. In the emergency department, the patient's blood pressure was 112/80 mmHg with a heart rate of 140 beats/minute. His heart rate slowed to 90 beats/minute with intravenous hydration. His serum troponin level was 0.1 ng/ml then rose to a peak of 0.17 ng/ml. His lactate level was minimally elevated. He was treated with aspirin and admitted to the hospital. 

The inpatient hospital stay was not medically necessary.

This patient was hospitalized with sinus tachycardia that was thought to be due to volume depletion. He reported nausea, anorexia and diarrhea after having received chemotherapy five days prior. He was normotensive and his heart rate slowed to normal with intravenous hydration. While his serum troponin level was mildly elevated, he denied chest pain and had no ischemic electrocardiographic changes. Other than aspirin, no treatment for acute coronary syndrome was provided.

The causes of troponin elevation are myriad. An abnormal troponin level does not necessarily indicate the presence of coronary artery disease or acute myocardial infarction. While troponin elevation in the setting of increased myocardial oxygen demand is sometimes a manifestation of a "type 2 myocardial infarction", which is a non-ST segment elevation resulting from a supply/demand imbalance, the criteria for diagnosis of a type 2 myocardial infarction (MI) were not met in this instance. Per the Fourth Universal Definition of Myocardial Infarction, the criteria for type 2 myocardial infarction (MI) include detection of a rise and/or fall of cardiac troponin level with at least one value above the 99th percentile and evidence of an imbalance between myocardial oxygen supply and demand unrelated to coronary thrombosis, requiring at least one of the following: symptoms of acute myocardial ischemia: new ischemic electrocardiographic changes, development of pathological Q waves, imaging evidence of new loss of viable myocardium, or new regional wall motion abnormality in a pattern consistent with an ischemic etiology. This patient did have a troponin elevation but did not meet any of the other criteria. Given his hemodynamic stability, his favorable response to intravenous hydration in the emergency department, and lack of diagnostic criteria for myocardial infarction, a lower level of care would have been appropriate. An inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient with a past medical history of hypertension, cerebrovascular accident with residual weakness, gastritis, myocardial infarction, right ovarian cystectomy, fibroid uterus, frequent marijuana use, and alcohol use, who presented to the emergency department with left lower quadrant pain, nausea, and vomiting. She had been seen the day prior in the emergency department and had an ultrasound performed which showed fibroids and non-ruptured ovarian cysts.
On presentation, she was afebrile with a blood pressure of 157/90, heart rate 80, respiratory rate 18, and an oxygen saturation of 100% on room air. The exam otherwise noted exquisite tenderness on the abdominal exam in all quadrants with right and left costovertebral tenderness. Lab results were notable for a complete blood count, comprehensive metabolic panel and lactic acid all within normal limits aside from a total bilirubin of 1.49. The patient was brought into the hospital with plans for pain control, further imaging, and gynecology consultation.
The patient subsequently underwent a computed tomography (CT) scan of the abdomen and pelvis which revealed bilateral adnexal cysts. Chlamydia and gonorrhea testing was sent. The gynecology assessment was that she required no acute gynecologic interventions if her pain were controlled and could follow up in the outpatient setting.
The next day, the patient's pain was controlled, she was tolerating oral intake and she was subsequently discharged with the diagnosis of mid-cycle pelvic pain and with plans to follow up in the outpatient setting.
The issue for review is whether care at the inpatient level of care was medically necessary.
The requested health service of inpatient hospital admission was not medically necessary.
This is a patient who presented with abdominal pain with normal lab results aside from a total bilirubin of 1.49 and imaging that did not show any acute process with need for urgent surgical intervention, with primary plan of care being pain control. Given the degree of her pain, she was appropriate to bring into the hospital for pain control. It is unclear, however, why prolonged hospitalization would have been anticipated given the primary plan for symptomatic management with need for nothing by mouth status, and indeed, her pain was able to be controlled in less than 24 hours. Care could have been provided at a lower level than inpatient. As previously noted, in the absence of abdominal imaging requiring acute surgical intervention, pain requiring nothing by mouth status or precluding the patient's ability to take food or oral medications, and with all normal labs aside from total bilirubin of 1.49, it is unclear why this patient presenting with abdominal pain whose pain improved quickly could not have been safely cared for at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea

Treatment: Outpatient surgical implantation of an upper airway stimulation (UAS) device for the hypoglossal nerve

The insurer denied coverage for outpatient surgical implantation of an upper airway stimulation (UAS) device for the hypoglossal nerve.

The denial is overturned.

This is a female patient who is diagnosed with severe obstructive sleep apnea (OSA), based on sleep study, with an apnea-hypopnea index (AHI) of 29.8, and no evidence of central sleep apnea. She has a normal body mass index (BMI) of 24.9. The patient has tried multiple masks both full face and nasal in order to use her continuous positive airway pressure (CPAP) machine, but is not tolerant to it and cannot wear it for more than 2 hours at night. A sleep endoscopy was performed showing no concentric collapse. All of these factors make her a good candidate for the upper airway stimulator.

Scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. "Long-term 3-year improvements in objective respiratory and subjective quality-of-life outcome measures are maintained. Adverse events are uncommon. UAS [upper airway stimulation] is a successful and appropriate long-term treatment for individuals with moderate to severe OSA" (Woodson et al 2016).      

The upper airway stimulator is Food and Drug Administration (FDA) approved and due to its success the inclusion criteria were expanded to include patients with an AHI up to 65. The patient is a good candidate for outpatient surgical implantation of an upper airway stimulation device for the hypoglossal nerve. The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation via the hypoglossal nerve for the treatment of adult OSA syndrome to be an effective second-line treatment of moderate to severe OSA in patients who are intolerant or unable to achieve benefit with positive pressure therapy. Not all adult patients are candidates for upper airway stimulation therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper patient selection. CPAP is the gold standard first line but for patients who cannot tolerate CPAP and fit the inclusion criteria, the upper airway stimulator is the second line treatment. 

This patient has severe OSA, a normal BMI and has failed multiple attempts at CPAP therapy.  She therefore, meets the criteria for upper airway stimulation device implantation, and this is most likely to be more beneficial than any other standard treatments/procedures for this patient.                                                    

Based on the above, the medical necessity for outpatient surgical implantation of an upper airway stimulation device for the hypoglossal nerve is substantiated. The insurer's denial is overturned.