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

Diagnosis: Finger injury
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a female who had sustained an injury to her left ring finger. She had undergone surgery. She reinjured the digit and was advised by her physician, "one of the screws had come out of place." Her doctor recommended she go to the ED (emergency department) to be met and have the condition treated. She was admitted to hospital for preoperative testing and evaluation.

An x-ray showed redisplacement of the patient's fracture (proximal phalanx). A revision ORIF (open reduction internal fixation) to the proximal phalanx was performed. This was completed.

The patient's post-surgical course was complicated by pain requiring Pain Management Consult. She also was found to have hypertension. She was discharged.

No, the inpatient hospital admission was not medically necessary.

The records showed a semi-emergent condition not requiring the acute admission. The patient's admission was to obtain preoperative testing and evaluation. These services could have been provided as outpatient. Her surgery was not complex nor extensive. The duration of anesthesia was limited. Her post-surgical pain was addressed with timely consultation. Her hypertension was transient and treated with change in medication.

The patient did not require treatment for underlying medical conditions. There were no problems with her wound. She was able to tolerate oral pain medications at a later time.

These findings support that treatment could have been provided at a lower level of care (Observation).

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip replacement. 
Treatment: Inpatient stay. 

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

The patient is a male patient who has a history of left hip pain and known osteoarthritis of the hip. He failed conservative treatment and opted to undergo an elective left total hip replacement surgery. The surgery was successful with no documented complications. The patient progressed well with therapy after the operation and despite one episode of hypotension, the patient was able to mobilize and ambulate long distances after surgery without difficulty. The patient was subsequently discharged home. 

The requested inpatient hospital admission was not medically necessary for this patient. This patient underwent elective left total hip replacement with no documented complications. The patient's lab values were within normal limits after the operation and his recovery progressed well. The patient experienced one episode of hypotension. His troponin level was found to be normal and he was able to ambulate 100 feet twice with supervised physical therapy that same afternoon. The patient was then discharged home the next day. Based upon the documentation in the medical records, the inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I Occlusion. 
Treatment: D8670 Monthly Visit.  
The insurer denied D8670 monthly visit.  The denial is upheld. 

The patient is a female with a Class I occlusion with 4-millimeter (mm) overbite and 4 mm overjet. She has minor maxillary spacing and moderate mandibular crowding. She has treatment planned for 24 months of orthodontics to correct her malocclusion.
At issue is the medical necessity of D8670 monthly visit.

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

The requested health service/treatment of D8670 monthly visit is not medically necessary for this patient.
The patient is scored on the handicapping labio-lingual deviation (HLD) at a 17 (4 overjet, 4 overbite, 5 mandibular anterior crowding, and 4 labio-lingual spread), and there is an absence of an auto qualifying condition. However, even discounting the HLD score, there is no medical reason to correct her malocclusion with braces. While the patient has crowding, 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. This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient's overjet would not affect her oral health related to quality of life unless it was greater than 6 mm. If her teeth were aligned, it would provide an aesthetic improvement, but it would not create a medically significant improvement to the patient's health. 

The patient has mandibular crowding. Her overbite is deep but there is no indication of damage to the incisors. Her cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication that there is severe soft tissue damage (or any soft tissue damage) on this patient.
Therefore, the requested health service/treatment of D8670 monthly visit is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Saxenda
The insurer denied Saxenda. 
The health plan's determination is overturned.

The patient is a female with history of obesity.
Per office note, the patient has history of gestational diabetes, hypothyroidism, migraines, PCOS (polycystic ovarian syndrome). Body mass index (BMI) is 43.38. Hemoglobin A1c is 5.1. She has a long history of obesity despite efforts with diet and exercise. In the postpartum period, she has found it more difficult to lose weight. The patient was counseled on diet and exercise. The provider recommends Saxenda. Per prior authorization form, the patient is participating in weight watchers.

Saxenda is medically necessary for this patient.
Regardless, lifestyle changes remain the first line therapy according to the obesity guidelines, which for obese and overweight individuals, recommend a comprehensive lifestyle program including lower calorie diet and in increased physical activity (strong recommendation with strong level of evidence, and which benefits significantly outweigh risks). The 2015 Endocrine Society obesity guidelines and the American Association of Clinical Endocrinologists (AACE) obesity guidelines recommend consideration of weight loss medication in patients with BMI > (greater than) 27 with comorbidity or BMI over 30, but only as adjuncts to reduction of food intake and increased physical activity. Saxenda is an effective weight loss agent - in clinical trials after 1 year, it was able to produce about 8 kg (kilograms) and about 5% body weight of weight loss.
In this patient with morbid obesity with BMI >40 and has failed lifestyle modifications, she meets medical necessity criteria for Saxenda based on peer reviewed literature.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is a female who had abdominal pain that was off and on for one month duration. The patient presented to the hospital. The patient denied any history of smoking or alcohol use. The patient reported that she had taken Plan B after intercourse  and missed her menses and then started with off and on bleeding. She was also noted for a prior chest pain evaluation. She had changed one pad on the date of presentation. She denied any chest pain, shortness of breath, weakness, lightheadedness and dizziness. She was noted to have no fever. She had normal vital signs with blood pressure (BP) 109/61 with a pulse of 87. The patient had a normal temperature. The exam was normal. She had tenderness in the suprapubic area. She had no costovertebral angle (CVA) tenderness. There were normal bowel signs. She had negative rebound or guarding. The patient had a normal pelvic exam without tenderness. There was no bleeding noted on exam. The patient had a positive HCG (human chorionic gonadotropin) of 273. Her hemoglobin was 9.9 with a Hematocrit (HCT) of 31.1%. She had an ultrasound that noted no intrauterine gestation. She had a thickened endometrium. There was a possible arteriovenous malformations (AVM) noted in the endometrium. There was a 1.9 centimeter (cm) thick walled cystic structure in the right adnexa that was separate from the right ovary. There was mild pelvic fluid noted. She was given a diagnosis of miscarriage and abdominal pain for a plan of D&C (Dilation and curettage). The patient underwent a suction D&C under general anesthesia. A 6 millimeter (mm) suction curette was used for completion of the D&C. 

The inpatient hospital admission was not medically necessary. In this case, the patient was noted to have vaginal bleeding associated with an incomplete abortion. She was taken to the operating room and underwent an uncomplicated dilation and curettage (D&C). She had blood loss from the procedure of 100 mL but her hemoglobin and hematocrit were stable post-op and there was no active bleeding. She was treated for possible risk for bleeding given possible the AVM with methergine and cytotec and a balloon catheter was placed. She tolerated this well. Vital signs were stable throughout the hospitalization. The procedure of D&C is performed as an outpatient procedure. based upon the recommendations of American College of Obstetricians and Gynecologists (ACOG), surgical D&C does not require the acute inpatient level of care. However, given bleeding and infection considerations in this case, observation would have been appropriate. This could have been performed at a lower level of care.  There would have been no indication for admission to acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastrointestinal/Digestive System. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is overturned. 

The patient was a male with unremarkable past medical history who presented to the hospital with a 2-day history of abdominal pain. He reported sudden onset of severe periumbilical pain that almost caused him to faint. The patient described bloating as well as several episodes of diarrhea. He noticed moderate volume bright red bowel movements while in the emergency department. The patient also complained of nausea and fever. He denied vomiting. The patient was unable to eat or drink anything for two days. The patient was admitted to the hospital with abdominal pain and acute onset of diarrhea. The patient received a dose of ceftriaxone to cover possible infection of salmonella due to the fact that the patient ate chicken before his symptoms started. The patient also received treatment with Flagyl due to possible colitis and possible diverticulitis. Stool culture and lactoferrin were sent. The patient received treatment with intravenous fluids. During the hospital stay, the patient's diarrhea resolved, and he was discharged home with a prescription for oral antibiotics the next day after the day of admission. 

The health plan's determination is overturned. 

The presence of severe abdominal pain and diarrhea pointed to a severe infection that was possibly related to salmonellosis, the infection that the patient developed after he ate chicken several hours before his symptoms started. He had radiographic evidence of involvement of the colon and ileum. 
Based on the nationally accepted standards of care, admission at the acute inpatient level of care is generally indicated when patients present with symptoms of gastroenteritis and have a suspected severe infection. One of the manifestations of severe infection is bloody diarrhea, which was reported in this clinical case. In addition, the patient had severe abdominal pain. 
Therefore, based on the severity of the patient's symptoms, the admission at the acute inpatient level of care was justified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nausea; vomiting.
Treatment: Inpatient admission.

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

The patient is a female. The patient presented with the complaint of nausea and vomiting.  Findings were consistent with hypokalemia hypochloremia hyperbilirubinemia and elevated liver function tests.

The patient was admitted for management of hyperemesis gravidarum. She underwent a D&C (dilatation and curettage) for an elective termination of pregnancy.  She left against medical advice.

Yes, the Inpatient admission was medically necessary.

As per ACOG (American College of Obstetricians and Gynecologists), there are no controlled trials comparing hospitalization with outpatient management of hyperemesis gravidarum. When a woman cannot tolerate liquids without vomiting and has not responded to outpatient management, hospitalization for evaluation and treatment is recommended. After the patient has been hospitalized on one occasion and a workup for other causes of severe vomiting has been undertaken, intravenous hydration, nutritional support, and modification of antiemetic therapy often can be accomplished at home. Nevertheless, the option of hospitalization for observation and further assessment should be preserved for patients who experience a change in vital signs or a change in affect or who continue to lose weight.

According to UpToDate: Women who are unable to maintain adequate hydration, normal electrolyte levels, and acid-base balance should be admitted to the hospital for intravenous fluids and medications. Women who have severe vomiting, weight loss, ketonuria, dry mucous membranes, poor skin turgor, dehydration, hypotension, alkalosis from hydrochloric acid loss, hypokalemia, or nutritional deficiencies are admitted to the hospital.

This patient was dehydrated with elevated liver function test, hypokalemia, hypochloremia, and hyperbilirubinemia.  Admission to the hospital was medically necessary to manage her hyperemesis.

In addition, once in the hospital, the patient decided to proceed with an elective termination of pregnancy, which was performed during this admission.  While such a procedure does not require hospital admission, the patient was already admitted to manage her hyperemesis and as such continued admission was medically necessary.

In summary, the inpatient hospital admission was medically necessary and indicated for managing this patient's medical condition.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The patient has severe hyperemesis gravidarum necessitating hospital admission for electrolyte management.  In addition the patient needed a termination of pregnancy. While this procedure is usually an outpatient procedure, the fact that the patient had hyperemesis gravidarum made the hospital admission medically necessary to manage her hyperemesis and to proceed with the D&C (dilatation and curettage).
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with no significant past medical history who presented with acute onset of left arm numbness and weakness. Review of system was positive for numbness and tingling of his left 4th and 5th digits. The patient was afebrile and was described as well nourished. His blood pressure was 176/28, pulse rate of 105, respiratory rate of 20, and oxygen saturation of 96% on room air. Physical examination was remarkable for positive Tinel sign and decrease in sensation of digits 4/5. The patient was admitted for workup of transient ischemic attack (TIA). 

The inpatient hospital admission was not medically necessary.
The patient was admitted for Transient Ischemic Stroke (TIA). The patient was admitted for subjective symptoms that were concerning for a stroke versus TIA. The patient had no objective focal neurologic deficits that represented a central nervous system (CNS) etiology (National Institute of Health (NIH) stroke score was zero), and imaging studies were unremarkable for acute neurologic finding. The patient's symptoms were thought to be related to ulnar nerve neuropathy from repeated typing. In this case, a lower level of care would have been appropriate to monitor patient and rule out of a stroke.
The documentation does not support inpatient level of care given the lack of positive findings on imaging and presence of hemodynamic stability. The patient did not require intravenous treatment, procedural interventions, or Tissue Plasminogen Activator (TPA).
Patients with neurologic symptoms consistent with Transient Ischemic Attack (TIA) or minor stroke are at increased risk for recurrent stroke, and therefore require urgent evaluation to assess the need for immediate intervention. The American Heart Association and American Stroke Association recommends admission to the hospital for patients with TIA who meets certain criteria based on risk stratification and evidence-based guidelines. There is a risk stratification score called the ABCD2 score which can help identify patients at high risk for short-term stroke. In this case, patient's ABCD2 score is calculated at 1 point, which estimates a 1.0% 2-day risk of stroke after a suspected TIA. Given the low-risk stratification, patient could have been safely monitored for 24-48 hours at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Tremfya 100 milligrams per milliliter
The insurer denied the Tremfya 100 milligrams per milliliter.
The determination is upheld.


The patient has psoriasis. Her hands and feet are affected. She has tried and failed triamcinolone and Otezla. She has also failed Enbrel, methotrexate, soriatane, and acitretin. The medication under review is Tremfya 100 milligrams per milliliter (mg/ml) subcutaneous (SC) solution prefilled syringe (SOSY).

The requested health treatment of Tremfya 100 mg/ml SC SOSY is not medically necessary for this patient. The formulary medications Siliq, Renflexis, Avsola, Infectra have been shown to be effective for psoriasis, and should be tried and failed prior to the requested nonformulary medication Tremfya 100 mg/ml SC SOSY. According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, the preferred medicines are effective treatments for the management of psoriasis (1, 2). Within the peer-reviewed literature, Garnock-Jones writes "Subcutaneous secukinumab [Cosentyx] is an effective and generally well tolerated first-line treatment for moderate to severe plaque psoriasis" (3).
The evidence-based literature is consistent and in line with the patient's medical policy. The preferred agents are appropriate agents for the treatment of the patient's psoriasis. The formulary medications should be tried and failed prior to initiating Tremfya. It is noted that the patient has tried and failed topical therapies, Enbrel and Otezla. However, after review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Tremfya prior to the formulary alternatives such as Cosentyx.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ear/Nose/Throat/Allergy/Throat tightness.
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a woman with a history of antiphospholipid syndrome, pulmonary embolus, anxiety, hypothyroidism, and iron deficiency anemia. She presented to the emergency room with swelling of her face, both hands, redness, itching, throat tightness, shortness of breath, and "total body pain" that did not respond to a dose of Benadryl. Vital signs were notable for a pulse of 107 beats per minute. She was noted to be alert and in no acute distress. There was no stridor, uvula swelling or tongue swelling. Skin exam revealed an erythematous rash on both hands with some swelling. Labs were non-contributory. She was treated with intravenous fluids, as well as parenteral diphenhydramine, famotidine, and corticosteroids. The rash improved but she still complained of pain throughout her body. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with the continuation of the regimen started in the emergency room. The patient was evaluated by the pulmonary consultant who agreed that she was suffering from an allergic reaction. There are no progress notes or a discharge summary in the information provided. Case notes report that the patient left the hospital against medical advice.
At issue is the medical necessity for the inpatient stay.

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

No, the requested health service/treatment of an inpatient stay was not medically necessary for this patient. 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 or labs of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no stridor, hypoxia, hypotension, significant edema, muscle or joint tenderness, or mental status changes. She responded well to treatment in the emergency room and was apparently admitted because of persistence of "total body pain." Pain symptoms without worrisome objective findings does not substantiate the need for inpatient admission. In addition, there were no significant objective findings to support a diagnosis of anaphylaxis, as the rash on her hands would not be sufficient to make that diagnosis. Therefore, based on the standard of care, and the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary, and the patient could have been managed at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep impinging overbite with soft tissue damage.
Treatment:  D8080 Braces and D8670 Monthly Visit.
The insurer denied the  D8080 Braces and D8670 Monthly Visit.
The denial is upheld.

The patient is a female. The request is for dental benefits for orthodontic treatment and monthly visits. Per the provider's dental clinical diagnosis--the patient presents with a deep impinging overbite with soft tissue damage.

The health plan denied the claim because the patient did not score a 26--the score necessary for orthodontic therapy approval on the Handicapping Labio-Lingual Deviation ( HLD) Index Report.  The provider appealed based on the patient's diagnosis.

No, the proposed treatment of orthodontic therapy and monthly visits are not medically necessary.
One of the automatic qualifiers for orthodontic therapy according to the Handicapping Labio-Lingual Deviation (HLD) Index Report is a "deep impinging overbite with soft tissue damage".  In other words, the areas on the anterior soft palate should show possible redness, ulcerations, and/or swelling.

However, per the photos provided there is no evidence of that tissue damage occurring on the anterior palate of the patient. Orthodontic treatment was not warranted because the photos did not support the kind of tissue damage consistent with a deep impinging overbite.

Yes, the health plan acted reasonably, with sound medical judgement and in the best interest of the patient.
Orthodontic treatment was not warranted because the photos did not support the kind of tissue damage consistent with a deep impinging overbite.