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

Diagnosis:  Chest pain.
Treatment:  Inpatient stay.

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

The patient is a male, who presented to the emergency department (ED) complaining of intermittent left-sided chest pain. His medical history was remarkable for coronary artery disease, percutaneous coronary interventions, hypertension, hyperlipidemia and a stroke six weeks prior. In the ED, his initial blood pressure was 181/112 and decreased to 146/86 without treatment. His heart rate was 110 beats/minute. His room air oxygen saturation was 94% (percent). An electrocardiogram showed sinus rhythm without acute changes. His high sensitivity troponin T level was 36, which was in the indeterminate range. A repeat level was 43. Chest X-ray showed no acute pathology. The patient was admitted to the hospital to rule out acute coronary syndrome.

Based on the documentation provided, an inpatient level of care was not medically necessary. This man, with known coronary artery disease, presented with symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable with no ischemic electrocardiographic changes. His serum troponin level was mildly elevated in the indeterminate range, with no significant delta troponin. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be both safe and effective and is in accordance with current guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Gastrointestinal bleed.
Treatment:  Inpatient stay.

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

The patient is a male, who initially presented to the emergency department with concerns for rectal bleeding and generalized abdominal pain. Pertinent history included gastritis, large external hemorrhoids, recurrent rectal bleeding, chronic anemia, hypertension and alcohol use disorder. Additional history included a similar presentation in which the patient left against medical advice. Initial vital signs revealed a temperature of 98.7F (Fahrenheit), heart rate (HR) 114, blood pressure (BP) 129/81, respiratory rate (RR) 20, and peripheral capillary oxygen saturation (SpO2) 98% (percent) on room air. Initial examination documented abdominal distension, blood on rectal exam, and tenderness without peritoneal signs. 

Based on the clinical documentation provided, evidence-based literature and standards of care, the inpatient hospital admission was not medically necessary. The patient had a history of recurrent rectal bleeding, large external hemorrhoids, and chronic anemia, and he presented with concerns for rectal bleeding. Initial examination documented the patient as afebrile, alert, oriented, tachycardia, and without hypoxia. Initial evaluation revealed a Hemoglobin (HGB) 10.1, PLT (platelets) 164, blood urea nitrogen (BUN) 15, Cr (creatinine) 1.2, and CT (computed tomography) findings suggestive of mild colitis and possible rectal foreign body. Treatment plan included supportive care, proton pump inhibitor, and consultations. Gastroenterology consulted, did not recommend urgent colonoscopy, but did recommend a colorectal surgery consultation. General surgery consulted and did not recommend surgical intervention. No urgent endoscopy was pursued. No blood products were transfused. Following observation care, there was no recurrent rectal bleeding, hemodynamics were stable, hemoglobin was stable, and oral intake was tolerated. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied Braces.
The determination is upheld.

The patient has a Class I occlusion with 4-millimeter (mm) overjet and 3 mm overbite. She has moderate maxillary and mandibular crowding. She is treatment planned for orthodontics to correct her malocclusion. At issue is the medical necessity of braces.

There is no medical reason to correct the patient's malocclusion with braces. While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) This patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. (2) The patient's overjet is slightly more than ideal but her overjet would not affect oral health related quality of life unless it was greater than 6 mm. (3) If her teeth were aligned, it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II malocclusion 
Treatment: Braces
The insurer denied the braces.
The health plan's determination is overturned. 

The patient in question is a male with a buccal (reverse) crossbite on tooth # (number) 4 and a deep bite. He has severe mandibular crowding. He presents with a skeletal Class II malocclusion with 5-millimeter (mm) overjet and 5 mm overbite. He is treatment planned for braces to correct his malocclusion. 

Braces are medically necessary for this patient.

Because tooth 4 is in buccal crossbite, it has no antagonist. As a result, it is extremely likely that this tooth will over erupt. Once this overeruption occurs, it is very difficult to treat. Buccal crossbite (also known as scissor-bite in the literature) can also negatively affect mandibular growth and should be treated as early as possible to eliminate the potential growth disturbance.

If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For these reasons, braces are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: possible myocardial infarction

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

Asked to review the case of a patient with a Past medical history significant for coronary artery disease, hypertension, lupus, and hyperthyroidism. On arrival to the hospital vital signs were stable (Blood Pressure (BP) of 145/81 and  pulse 81). Physical exam was significant for a pansystolic murmur and epigastric tenderness to palpation. 12 lead electrocardiogram (ECG) revealed a prolonged QTc interval without ST or T wave abnormalities.  Serum troponin was markedly elevated (324). Serum potassium and magnesium were abnormally low (2.9 and 1.12 respectively) The patient was admitted to the hospital for further workup. Both cardiology and gastroenterology consults were obtained. Recommendations for echocardiogram and serial troponin testing were made. Potassium and magnesium supplementation were provided.  The patient insisted on being discharged prior to receiving an echocardiogram. As troponin was trending downward she was discharged with outpatient follow up.

This patient presented with epigastric pain, nausea and vomiting.  She had a markedly elevated troponin level and a prolonged QTc interval on ECG. She required hospital admission for additional treatment and testing.  Her HEART score (a measure of cardiac risk) of six put her in a high risk category, consistent with a risk of future cardiac events. (Reference 1, 2). She was admitted and ultimately insisted on discharge after nausea and vomiting subsided.  Based on her high risk score using both the HEART and Thrombolysis in myocardial infarction (TIMI) risk stratification,  inpatient admission and work up was medically necessary.   Risk assessment of patients presenting with chest pain was performed by Sanchis et al. (Reference 3).  Using their risk stratification schema, this patient would have a high risk of future myocardial infarction or death within one year. In conclusion, acute care hospital admission was medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Adenovirus. 
Treatment: Inpatient stay. 

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

This is the case of a male, who presented to the emergency department (ED) with fever, headache, sore throat, and bilateral eye pain with redness. Symptoms began 3 days prior to arrival. 
ED vitals were T (temperature) 39.6 degrees C (Celsius), heart rate (HR) 104, respiratory rate (RR) 28, blood pressure (BP) 106/85, and O2 (oxygen) saturation 98% (percent) on room air. Exam noted ill appearance with congestion, rhinorrhea, bilateral conjunctival injection, posterior oropharyngeal erythema, and tachycardia. Labs showed white blood cell count (WBC)=16.0, C-reactive protein (CRP)=6.5, Flu/COVID (coronavirus)/Strep negative, and normal electrolytes. Given the concern for sepsis, intravenous (IV) ceftriaxone was given, and the patient was admitted to the hospital for further management. 

The inpatient hospital admission was medically necessary. 
Based on the medical records provided, this patient presented to the ED with altered vital signs (fever, tachycardia, tachypnea) and ill appearing. Initial evaluation showed mild to moderate elevations of both white blood cells (WBC) and C-reactive protein (CRP). There was concern for sepsis and the patient was started on intravenous fluids (IVF) and IV antibiotics. This required an inpatient hospital admission.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic idiopathic constipation. 
Treatment: Motegrity (prucalopride). 
The insurer denied Motegrity (prucalopride). 
The health plan's determination is overturned. 

The patient is a female with chronic idiopathic constipation. She failed Colace and fiber. She attempted Amitiza, but had dizziness, headache, and nausea. She had only a partial response to Linzess. Motegrity is being requested for the treatment of chronic idiopathic constipation. 

A formulary exception is indicated in this case. The formulary drugs have been ineffective. The patient has failed multiple laxatives in this case. The American Gastroenterological Association - American College of Gastroenterology guidelines for the management of chronic idiopathic constipation states that newer agents such as Motegrity should be used if non-pharmaceutical laxatives fail. Motegrity has shown efficacy for the treatment of multiple types of constipation, and associated symptoms including bloating and abdominal pain. The patient has already failed Amitiza (which is the branded version of generic lubiprostone) and Linzess. As the patient has chronic idiopathic constipation (for which Motegrity is Food and Drug Administration (FDA) -approved and guideline-recommended), and the patient has failed the formulary alternatives, the request for Motegrity is supported in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right arm laceration

Treatment: air ambulance transportation (procedure codes A0431 and A0436)

The insurer denied coverage for air ambulance transportation (procedure codes A0431 and A0436)

The denial is overturned

 
According to the records provided the patient was transported via air ambulance for a hospital to hospital transfer. As per the transfer record, the patient was an adult male with no reported medical history who presented to the local emergency department (ED) with a right arm laceration. He sustained the injury from punching a window. He arrived in a private vehicle with uncontrolled hemorrhage to the anterior arm near the antecubital fossa. A tourniquet was placed and blood transfusion was initiated. Due to concern for arterial laceration, transfer arrangements were made. Helicopter emergency medical services (HEMS) was utilized to decrease time to definitive care for this patient with a time sensitive injury. The records indicated the patient moved his extremities except for the right arm distal to the injury. He had no sensation distal to the injury with a tourniquet in place. 

Situations in which air ambulance transportation is medically appropriate included but are not limited to :a) extensive burns requiring specialized treatment; b) pediatric patients where airway control is unobtainable: c) transplant candidates with end stage organ disease; d) significant mechanism of injury with catastrophic life threatening illness or trauma with signs and/or symptoms suggesting: 1. Multiple orthopedic injuries, including multiple pelvic fracture; 2. Vascular compromise; 3. Neurologic presentation suggestive of spinal cord injury; 4. Laryngotracheal trauma or injuries of the face or neck, which may result in an airway compromise; 5. Penetrating head injury; 6. Open injury with CSF fluid leak; 7. Major chest wall damage ; 8. Pneumothorax/ hemothorax; 9. Partial or total amputation of a limb; 10. Airway or obstruction or compromise; 11. Penetrating abdominal injury; 12. Bunt injury with shock; or 13. Scalping or degloving injury. Hospital air transport is considered medically appropriate if: the transferring hospital does not have adequate facilities to provide medical services needed for the patient; and 2. Ground ambulance could endanger the patient's health; and 3. The medical criteria, as stated in policy statement 2 above, are met. The patient suffered a limb threatening injury that had uncontrolled life threatening hemorrhaging prior to tourniquet application. Due to the need for emergent vascular surgical repair, rotor air transport was medically necessary and reasonable.

Certificate of medical necessity was completed for life threatening trauma.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for air ambulance transportation (procedure codes A0431 and A0436) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting.
Treatment: Inpatient Hospital Stay.

The insurer denied Inpatient Hospital Stay.  The determination is upheld.

The patient has a history of type 2 diabetes, gastritis, and cannabis hyperemesis. He had a previous upper endoscopy that showed esophageal ulcers and gastritis. His medications were insulin, metformin, Lipitor, and sucralfate. His last admission was for cannabis hyperemesis. He presented to the emergency department with a one-day history of non-bilious, non-bloody vomiting five times associated with nausea and epigastric pain. He said he smoked marijuana the evening before. He said he had taken his long-acting insulin the morning prior to presentation. His vital signs were normal. His physical exam was normal except for obesity and epigastric tenderness. His point of care glucose was 245. He was admitted to the hospital for dehydration and diabetic ketoacidosis. A progress notes stated emergency department (ED) lab results showed the patient was not in diabetic ketoacidosis (DKA). He was able to take fluids orally. He was discharged. At issue is the medical necessity of inpatient admission.
Inpatient hospital admission was not medically necessary. This is a patient with type 2 diabetes requiring metformin and insulin. He had a history of esophagitis and gastritis and prior admissions for suspected cannabis hyperemesis. He presented with vomiting and vomited once in the ED but was able to take fluids orally. He was not clinically dehydrated based upon his vital signs, physical exam, and laboratory values. He did not have a fever and did not appear ill. As was noted by the admitting physician, he was not in diabetic ketoacidosis. He had ketones in the urine, from vomiting, but he was not acidotic-his pH was normal at 7.41. He did not have any evidence of another condition that required hospitalization, such as acute pancreatitis or acute esophageal or gastrointestinal bleeding. To whatever extent he was relatively "dry" (but short of clinical dehydration), he was fluid repleted in the emergency department. His anti-nausea and gastrointestinal (GI) medications were available to him orally, and his insulin was administered subcutaneously, all of which could have been administered at home with outpatient follow up as needed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental surgery.
Treatment: Inpatient stay.

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

The patient is a female who underwent orthognathic surgery. There were no postoperative complications. The patient was discharged the following day. Under review is the inpatient hospital admission.

The inpatient hospital stay was not medically necessary.

Most patients with this surgery (orthognathic) are treated, observed, and discharged the same day or the following day as long as they meet discharge criteria. The surgery is performed in an operating room (OR) setting; ambulatory surgery is medically necessary and is the minimum required to accomplish the surgery. An inpatient setting would not be necessary unless the patient did not meet the criteria for discharge. In the United States, it has been reported that between 46 percent (%) and 84% of patients go home the same day of surgery after an orthognathic procedure. It is rare for an orthognathic surgery patient stay to extend beyond the first postoperative day following a 3.5-hour bimaxillary surgery. In this patient's case, no extenuating circumstances required an inpatient level of care. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned



Diagnosis: Class I malocclusion
Treatment: braces/monthly visit
The insurer denied braces/monthly visit
The health plan's determination is overturned.

The patient in question is a female with a Class I malocclusion with maxillary spacing and mandibular crowding. She has 7 millimeter (mm) overjet and a 2 mm anterior open bite. She is congenitally missing teeth 20 and 29. She is treatment planned for braces to correct her malocclusion. 

Braces and Monthly Visit are medically necessary for this patient.
Teeth number (#) 8-9 are protruding forward within the dental arch. This makes them more prone to trauma. There is strong medical evidence that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+mm overjet, which this patient has. For these reasons, the requested orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peritonsillar abscess
Treatment: Inpatient Hospital

The insurer denied Inpatient Hospital Stay.  The determination is overturned.

The patient is a female with a history of several days of a sore throat and otalgia, who presented initially to urgent care after a recent diagnosis of acute streptococcus pharyngitis. She was prescribed dual antibiotic therapy with Azithromycin and Clindamycin. Due to a progression of symptoms, she subsequently presented to the hospital's emergency department with concern for a right peritonsillar abscess. A computed tomography (CT) scan of the neck was performed which showed a large 3.5 centimeter (cm) right peritonsillar abscess. She was admitted to the hospital for intravenous antibiotic therapy, and subsequently underwent incision and drainage by the otolaryngology physician. She was discharged in stable condition with close outpatient follow up and oral antibiotics.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient admission was medically necessary for this patient. The patient had a large right peritonsillar abscess requiring incision and drainage and intravenous antibiotics after initially failing to improve on oral antibiotic therapy as an outpatient. Peritonsillar abscess is a potentially life-threatening condition that requires prompt recognition and treatment. The patient required intravenous antibiotics in this situation until the infection was sufficiently improved, so that the patient could be safely discharged on a course of oral antibiotics. Airway compromise can happen rapidly in these situations; thus, the patient was promptly started on intravenous corticosteroids. The patient was discharged after an appropriate course of intravenous antibiotics/intravenous corticosteroids, until the patient was deemed medically stable for discharge and thus could be managed on an outpatient regimen. The patient was evaluated daily to determine continued need for hospital admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diarrhea.
Treatment: Inpatient Stay.

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

The patient is a female with a medical history of irritable bowel syndrome, anxiety, depression, joint pain, urinary incontinence, and herpes simplex virus. She presented to the emergency department with diarrhea, weakness, lethargy, and nausea. She had been seen prior and discharged on metronidazole. Vital signs were unremarkable. Physical examination was notable for a soft abdomen with left lower quadrant tenderness. Labs showed an elevated white blood cell count of 12.8 with 81.8 percent (%) neutrophils, unremarkable comprehensive metabolic panel, and elevated fecal calprotectin of 288; testing for Clostridioides difficile was positive. 

The inpatient hospital admission was not medically necessary. The patient had a finding of Clostridioides difficile infection with colitis; however, there was no sustained hypotension, persistent severe volume depletion or sepsis, toxic megacolon, or other reasons for the inpatient level of care, such as perforation or abscess. Although uncomplicated Clostridioides difficile infection was present, the patient did not have persistent gastrointestinal bleeding, peritonitis, or other complications warranting an inpatient level of care. She was appropriately started on treatment for Clostridioides difficile infection with oral vancomycin. The patient did have hypokalemia, and repletion was successful; she did not have any complications of hypokalemia. The measures undertaken, such as observation, labs, antibiotic administration, and Gastroenterology consultation, could have been performed at a lower level of care.