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

Diagnosis: Chest pain/nausea
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female with medical history of hypertension. She had been evaluated for non radiating chest pain and nausea. Nausea improved with Zofran. Labs including troponin had been unremarkable, and an electrocardiogram showed sinus bradycardia. She had persistent epigastric pain despite proton pump inhibitor. Chest x-ray was unremarkable. She was treated with intravenous fluids. Proton pump inhibitor was increased to twice daily, and Maalox was added.

The inpatient admission was not medically necessary. The inpatient admission was not medically necessary. In this case, the patient presented with epigastric pain and nausea; cardiac workup was negative, and symptoms were concerning for gastroenteritis or inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease). Empiric proton pump inhibitor therapy and supportive care were appropriately initiated, and her symptoms improved within two days. However, there was no sustained tachycardia or hypotension, and her hemoglobin was initially normal and did not fall. No suspected or established complication such as gastrointestinal perforation, pancreatitis, intra-abdominal abscess, toxic megacolon, bowel obstruction, gastrointestinal bleeding, or peritonitis was found as a cause for symptoms. No Gastroenterology consultation or endoscopy was deemed necessary. All of the measures that were undertaken, including monitoring, labs, empiric proton pump inhibitor therapy, control of pain, and intravenous fluid administration, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: Braces (comprehensive orthodontic treatment) and adjustments for braces (periodic orthodontic treatment visit)

The insurer denied coverage for braces (comprehensive orthodontic treatment) and adjustments for braces (periodic orthodontic treatment visit). The denial is reversed. 

The patient was a female child. Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to maxillary and mandibular crowding, and anterior crossbite with gingival attachment loss (maxillary and mandibular canines). The orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. 

It is evident that the patient exhibited a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. And based on the review of the medical record, the patient met the automatically qualifying condition criterion and support for comprehensive orthodontic care.

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

The braces (comprehensive orthodontic treatment) and adjustments for braces (periodic orthodontic treatment visit) are considered medically necessary for this patient.

Based on the above, the medical necessity for braces (comprehensive orthodontic treatment) and adjustments for braces (periodic orthodontic treatment visit) is substantiated. The insurer's denial should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fatigue, gait ataxia, neuropathy, osteoarthritis.
Treatment: Personal Care Aide Level II - 20 hours/week.
The insurer denied the Personal Care Aide Level II - 20 hours/week.
The denial is upheld. 

The patient is a female with a history of fatigue, gait ataxia, low back pain, neuropathy and osteoarthritis. 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 an increase in Personal Assistance Services 20 hours/week to offer increased ADL support.

No, the proposed treatment of an increase in Personal Assistance Services to 20 hours/week is not deemed medically necessary. 

An in-home assessment of the patient's functionality and ability to perform ADLs was completed and revealed that the currently approved plan of 15 hours/week Personal Assistance Services is sufficient to meet the patient's current needs. There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed treatment of an increase in Personal Assistance Services to 20 hours/week is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Episode of supraventricular tachycardia (SVT).

Treatment: inpatient hospital admission.

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

This patient is a female who was brought to the hospital by ambulance because of an episode of palpitations. She stated that that she was awoken from sleep by terrible palpitations radiating to her neck that were associated with dyspnea and diaphoresis. She also reported a numbness and tingling sensation down her left arm and bilateral hands during the episode. She reported a similar episode in 2012 and stated that she was diagnosed with a transient ischemic attack (TIA) at that time. She stated that she experiences brief episodes of palpitations a few times a year which subside when she relaxes. She also reported that she can experience dizziness and near syncope at the time of the event. She has a past medical history of hypertension and chronic hypokalemia. She has a past surgical history of breast reduction, appendectomy, and tubal ligation.

This patient was brought to the hospital by ambulance because of an episode of supraventricular tachycardia (SVT). She has a history of a previous episode of SVT which resulted in a transient ischemic attack (TIA). She had an ablation procedure done. Following this, she became lethargic and diaphoretic. Her blood pressure was 63/49 and her heart rate was 45. Shortly afterwards, her blood pressure was 55/38 and her heart rate was in the 30's. The chart stated that the patient was unresponsive and needed to be put in the Trendelenburg position and given intravenous (IV) fluids to correct her condition. The literature states that patients may have an ablation procedure and then be discharged home several hours later if there are no complications. This patient has a history of hemodynamic consequences following her episodes of SVT. She certainly had significant hemodynamic complications following the procedure, which prompted her hospital admission. With these complications, the patient required hospital admission. 

Therefore, the denial of coverage for the inpatient hospital admission should be overturned.

The insurer did not act reasonably, or with sound medical judgement, or in the patient's best interest. 

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

Diagnosis:  Breast asymmetry.
Treatment:  19357 - Breast reconstruction with tissue expander, 19318 - Breast reduction, 19342 - Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction, 19371 - Periprosthetic capsulectomy, breast.

The insurer denied the 19357 - Breast reconstruction with tissue expander, 19318 - Breast reduction, 19342 - Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction, 19371 - Periprosthetic capsulectomy, breast.  The denial is overturned. 

The patient is a female.  She has breast asymmetry.  She suffers from emotional distress due to her asymmetry.  She has completed puberty.  She has a large right breast and a left tuberous breast deformity.  Breast reconstruction with tissue expander an implant and breast reduction for symmetry are planned procedures. 

Yes, the proposed treatment is medically necessary.

The patient has dramatic breast asymmetry with at least a two-cup size asymmetry.  Her tuberous breast is misshapen and notably different in appearance and shape compared to her right breast.  The American Medical Association defines cosmetic and reconstructive surgery as follows:  Cosmetic surgery is performed to reshape normal structure of the body in order to improve the patient's appearance and self-esteem.  Reconstructive surgery is performed on abnormal structures of the body caused by congenital deformity, trauma, infection, tumors or disease.  It is generally performed to improve function but may also be done to approximate a normal appearance.  Based on this definition, the condition is not cosmetic, because significant breast asymmetry is abnormal.  Therefore, the proposed breast surgery should be considered reconstructive and medically necessary to treat a very significant developmental anomaly.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral Infarction.
Treatment: Inpatient hospital admission.
The insurer is denied coverage for inpatient hospital admission.
The denial is overturned.

This is a female patient who presented to the Emergency Department (ED) with complaints of left-sided weakness, left facial numbness and left-sided body weakness.  The patient's blood pressure was 129/87. The initial evaluation revealed the patient was alert and oriented to person, place, and time with facial symmetry. Her pupil size was 3 mm bilaterally and the reaction to light was sluggish. She had unequal hand grasps and she was unable to ambulate. Her Glasgow coma scale revealed 15. The patient's National Institutes of Health stroke scale (NIHSS) revealed a total score of 5. A computed tomography (CT) scan of the head/neck and CT of the head were negative for acute process. The patient was admitted to Telemetry for a stroke work up. A magnetic resonance imaging (MRI) of the brain revealed no evidence of acute infarction or intracranial hemorrhage; there was a nonspecific right parietal subcortical white matter FLAIR hyperintensity, which may relate to migraines, prior infection/inflammation or microvascular angiopathy. The patient's transthoracic echocardiogram revealed a normal left ventricular systolic function, estimated ejection fraction 55-60%. Neurology was consulted. They noted that the patient had decreased sensation to light touch, pinprick and pinprick in the left upper extremity and left lower extremity. The patient had 4/5 strength in plantar/dorsiflexion in the left leg. The patient had 4/5 strength in the left arm deltoids, triceps, and left leg iliopsoas and quadriceps. The patient had 5/5 strength in the left arm biceps and handgrip. The patient was medically stable and discharged.

Based on the review of the medical record and literature, inpatient admission was medically necessary. The patient had severe, unilateral weakness on the day of admission which slowly improved. Although the patient's stroke workup did not reveal a definitive cause for this patient's symptoms, inpatient admission was medically necessary for this patient's diagnostic workup and close monitoring. Due to the neurological deficits, which included decreased strength on the left side of this patient's body, the patient could not have been treated in the Emergency Department (ED) or in Observational level of care.

The health plan did not act 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 is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough, congestion, fever, sore throat.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

No, the Inpatient admission is not medically necessary. 

The patient is a female teen that presented to the ED with several-day history of fever to 102.9, cough, headache, and congestion. She also reported several-month history of low back pain and one-month history of right shin pain. Vital signs included temperature 100.7, heart rate 117, respiratory rate 17, and blood pressure 104/64. Examination was significant for mild distress, good hydration, rhinorrhea, clear lungs, benign abdomen, and non-focal neurologic exam. Laboratory testing included rapid influenza testing, negative for both influenza A and influenza B. Chest x-ray was unremarkable. X-rays of her right lower leg and low back were also unremarkable. She had two episodes of vomiting in the ED so was admitted for further management. She was treated with one dose of ceftriaxone for yellowish phlegm. She reported chest palpitations, prompting an electrocardiogram that was unremarkable. 

She reported no sore throat. She denied palpitations and chest pain. She had no fevers. She was able to tolerate her diet. She was diagnosed with sinusitis, acute upper respiratory infection, and pharyngitis prior to discharge home.

This young woman presented to the ED with signs and symptoms of acute viral respiratory infection, including fevers, runny nose, cough, and headache. Influenza testing was negative. She had two episodes of vomiting while in the ED and so was admitted for further management. Laboratory screening including testing for STIs (sexually transmitted diseases) was overall unremarkable. She was treated with IV fluids, anti-pyretic, and antibiotics for sinusitis. Because she was not tolerating fluids by mouth in the ED, it was not unreasonable to monitor her in the hospital. However, she was overall hemodynamically stable, with no evidence of sepsis or significant dehydration. She did not require acute inpatient admission and could have been safely and appropriately managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lower leg blood clot.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. 
The denial is overturned. 

Yes, the Inpatient admission was medically necessary.

The patient in this case is a man with a history of left lower extremity DVT (deep venous thrombosis) treated in the past with a course of warfarin. He was not taking warfarin at the time of the admission in question. He was brought to the ED on after a fall with head trauma and no loss of consciousness.  His daughter noted that one week before this visit, he was involved in an accident as a pedestrian struck by a vehicle and that he had sustained a "microscopic brain bleed" and also had sustained L1-L4 vertebral body fractures.  He was in the hospital for six days and discharged with a one-week course of Keppra. His daughter witnessed him falling out of bed. 

At the time of initial evaluation, the patient complained of headache and also complained of left lower extremity pain and swelling.  Doppler ultrasound of the left leg revealed deep venous thrombosis of the left popliteal vein and also thrombosis of the left greater saphenous vein extending up to the junction, likely chronic.  He was diagnosed with acute DVT along with chronic DVT.  Evaluation also revealed a 10cm laceration along the right buttock with surrounding erythema and ecchymosis.  A right kidney hematoma was also identified, along with right 8th rib fracture, L1-L4 fractures, left hip contusion and mild anemia. Injuries were from his prior accident one week before this presentation.  

The patient was admitted and treated with full dose anticoagulation and also monitoring.  He had stable hemoglobin while in the hospital without any concerning symptoms.  He was seen by physical therapy. He was discharged to sub-acute rehab. It was noted that he was admitted because he was unable to ambulate on his own and he had significant pain due to his multiple injuries requiring intravenous pain medications.

The patient in this case was diagnosed with acute deep venous thrombosis.  He required full dose anticoagulation.  Records also indicate that he had multiple injuries from his trauma one week before this admission.  These included a hematoma on his kidney.  He had inability to walk, and he also required intravenous pain medications.  With initiation of full-dose anticoagulation he was at risk of bleeding due to his recent injuries.  He required monitoring for that reason, and he also required treatment for pain and assessment due to his inability to walk (which was due to his multiple traumatic injuries).  He also had a large wound on his buttock that required cleaning and appropriate care, which it had not been getting. Once it was clear that he was tolerating anticoagulation without bleeding and pain was under reasonable control, he was discharged.

It is standard in most cases to treat DVT with outpatient management.  However, this patient was at increased risk for bleeding, and this largely justified acute care inpatient admission while full-dose anticoagulation was started.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Chest Pain.
Treatment: Inpatient hospital stay.
The insurer denied inpatient stay.
The health plan's determination of medically necessity is upheld. 

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. 

The patient has a history of hypokalemia and tobacco, alcohol, and cannabis use. The patient presented to the emergency room with a 2-3 week history of a productive cough and a 2 day history of chest pain. The vital signs and oxygen saturation were normal. The patient was in no acute distress, and the physical exam was normal. Labs were notable for a potassium of 2.7 and elevated liver transaminases. The chest x-ray was normal and the electrocardiogram (EKG) was negative for acute ischemia or arrhythmias but did show a prolonged QT interval. The patient was admitted for further treatment and evaluation.

Upon admission, the patient was treated with intravenous and oral potassium supplements. The patient was witnessed by another patient to be drinking alcohol in the hospital brought in by a visitor. The patient left the hospital against medical advice (AMA).

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that could not have been treated in the emergency room (ER) or an observation stay. There was no evidence of hemodynamic instability, hypoxia, seizures, arrhythmias, acute renal failure, vomiting, or dehydration. There was no credible evidence for pneumonia or an acute coronary syndrome. Therefore, based on the standard of care and peer reviewed literature, the acute inpatient level of care was not medically necessary and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Endocrine/Metabolic/Nutritional
Inpatient Hospital

This case involves a female with a history of alcohol dependence and anxiety disorder who presented to the hospital with a chief complaint of shaking and palpitations. Symptoms started the morning of the presentation. She did consume two shots of whiskey in the morning, but the shaking persisted. She denied nausea, vomiting, or dizziness. She also reported no chest pain or shortness of breath. The patient was admitted to the hospital with a principal diagnosis of alcohol withdrawal. Alcohol withdrawal scale on admission was three, and the blood alcohol level was 243. The patient was started on intravenous (IV) thiamine folic acid and intramuscular injections of Ativan, both scheduled and as needed. In addition, the laboratory studies revealed the presence of elevated liver function tests

The health plan's determination is overturned. The inpatient stay was medically necessary. This patient presents with clear signs of alcohol withdrawal, as evidenced by tachycardia, tremors, and palpitations. The patient has a clearly established history of alcoholism, with a slightly positive blood alcohol level. It is clinically evident that the patient is undergoing alcohol withdrawal, and requires prompt and aggressive treatment to prevent delirium tremens. The patient was appropriately admitted under inpatient status and started on the scheduled treatment of benzodiazepines, which is the standard of care for alcohol withdrawal. The patient rapidly improved because of the appropriate treatment that was started. These types of presentations require close monitoring of vital signs, and frequent assessment of CIWA scores to determine the dosing of benzodiazepine medications. This is not something that can be evaluated and treated under an observation level of care or outpatient status. An inpatient level of care was medically necessary.