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

Diagnosis: Back pain
Treatment: Pain management
The insurer denied Ablative Treatment for Spinal Pain.
The health plan's determination is upheld. 

The patient is a male with a history of chronic low back pain. The pain began more than 5 years ago. He has had multiple treatments, including spine surgery, lumbar injections, medications, physical therapy, as well as chiropractic care. The pain significantly impacts activities of daily living (ADL). Pain ranges from 6-10 out of 10. A magnetic resonance imaging (MRI) lumbar spine demonstrated Modic type II changes at L (lumbar)4, L5, S (sacral)1.

Ablative Treatment for Spinal Pain is not medically necessary for this patient.
Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care. Therefore, it is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intermittently painful wisdom teeth
Treatment: D9500 Operating Room Services
The insurer denied: D9500 Operating Room Services
The denial is overturned.

This patient is a teenage male who presented to an oral surgeon for evaluation of intermittently painful wisdom teeth. According to the clinical notation, the patient has mild to moderate mental retardation and attention-deficit/hyperactivity disorder (ADHD). 
His Mallampati score is four and American Society of Anesthesiologists (ASA) assessment is three. He was denied anesthesia services in the operating room, D9500, because "the information (we) received from your dentist did not indicate intravenous (IV) sedation was necessary for this dental service to be performed. You would need to have a mental or physical disability to have vital signs watched during this service." The case is being appealed because the provider believes the necessary criteria are met.

The requested health service is medically necessary.

The initial denial reason states that the dentist did not indicate intravenous sedation was necessary for this dental service to be performed. In addition, the patient would have to have a mental or physical disability to have vital signs watched during this service. According to the clinical records, the provider does state that the patient needs anesthesia services and also states that the patient has mild to moderate mental retardation (intellectual disability). Furthermore, patients with a Mallampati score of four and American Society of Anesthesiologists assessment of three are not appropriate patients for in office anesthesia. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II malocclusion
Treatment: D8080 Braces, D8670 Monthly Visit x (times) 12
The insurer denied: D8080 Braces, D8670 Monthly Visit x12
The denial is overturned.

This patient is a teenage female. The request is for orthodontic benefits with monthly visits. The patient has a skeletal Class II malocclusion with mild upper crowding and severe crowding on the lower arch. She has a deep bite and severe overjet. The prior denial was due to the handicapping index score of 17 points.

The requested health service is medically necessary.

The patient has very narrow upper and lower dental arches. She has a very high palate, which means her sinuses are small. She also has no room for her tongue to go since her lower teeth are very close together. This means that over time she will likely develop sleep apnea since her tongue will be forced back into her throat, and she will have a very small airway and sinus volume. Also, since her lower arch is retruded (class II), she will likely develop temporomandibular joint (TMJ) issues over time due to the increased pressure on her joints. Both of these are good reasons to correct the malocclusion with braces. The monthly visits are needed to make sure treatment is progressing properly. This case has medical necessity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: short stature
Treatment: growth hormone
The insurer denied Nutropin.
The health plan's determination is overtuned. 

The patient is a male diagnosed with idiopathic short stature (ISS). As per the documentation, he was diagnosed with Neuroblastoma. His treatment included multiple surgeries, chemotherapy and radiation therapy to the mediastinum and abdomen. He completed treatment. His pretreatment height velocity is reported to be 2.9 cm/yr (centimeters/year). 

Nutropin is medically necessary.
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height standard deviation score (SDS) less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient's height and growth velocity would not allow the patient to reach a normal adult height. The patient meets idiopathic short stature criteria. The request meets the standard of care and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee pain
Treatment: Custom-made knee brace with soft interfaces
The insurer denied the custom-made knee brace with soft interfaces.
The determination is upheld.

The patient is a male who walks on his toes and complains of left posterior knee pain. He saw an orthopedic surgeon who found achilles tendon tightness and hamstring tightness, greater on the left side. The examination showed a 10-degree left knee flexion contracture. The child was said to walk with a crouched gait, and there was concern about possible cerebral palsy. The orthopedic surgeon recommended a neurologic evaluation, physical therapy, and a dynamic night extension brace for the left knee. At issue is whether the left knee custom made brace is medically necessary.

The cause of the child's longstanding abnormal gait is unknown and requires investigation. An initial referral for physical therapy and neurologic evaluation is a reasonable approach. Using a dynamic brace to try to reduce a 10-degree knee flexion contracture, or to reduce knee pain, is not supported by published literature or accepted medical opinion and is not standard practice. There is no reason to think that this device would improve the child's crouch gait or reduce the pain that he reports; pain whose cause is unclear. The brace should not be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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


This is a female patient with a Class I occlusion with 5-millimeter (mm) overbite and 3 mm overjet. She has minor maxillary mandibular crowing. 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 her malocclusion with braces. While the patient has crowding, there is no evidence of 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) The records provided do not show the patient presenting with any 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. (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. Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is a patient with a past medical history (PMH) of hypertension (HTN), diabetes mellitus type 2 (DM2), and hyperlipidemia (HL) who was admitted with complaints of (c/o) chest pain associated with dizziness and emesis. The vital signs were unremarkable. The physical exam was unremarkable, HEART [history, electrocardiogram (EKG), age, risk factors, troponin] score was 5. Lab work was notable for negative troponin. Imaging studies included a computed tomography (CT) scan of the head which showed no acute pathology, magnetic resonance imaging (MRI) of the brain showed no acute disease. An EKG showed no acute ischemia. The patient was diagnosed with acute gastroenteritis, non-cardiac chest pain, and vertigo and treated with intravenous fluids (IVF), a proton pump inhibitor (PPI), and anti-emetics. Neurology evaluated the patient and recommended symptomatic management of vertigo/Meniere's disease. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) chest pain associated with dizziness and emesis. The patient did not have associated high-risk features, such as severe acute renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability, bowel obstruction, diabetic ketoacidosis, appendicitis, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. The patient had chest pain, but this was determined to be non-cardiac chest pain due to a lack of evidence of ischemia with negative EKGs, atypical features, and negative troponins. The patient did have dizziness, but neurology found central vertigo unlikely and both computed tomography (CT) and magnetic resonance imaging (MRI) of the brain showed no acute pathology, associated head trauma, fever, high clinical suspicion for central vertigo or cerebrovascular accident (CVA), cerebellar infarct or hemorrhage, vertebrobasilar insufficiency, acute suppurative labyrinthitis, intractable nausea/vomiting, or inability to ambulate, and neurology recommended symptomatic management of dizziness. The patient presented with gastroenteritis, was treated and responded to IVF, anti-emetics, and expert consultations, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Overdose
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is overturned in part.

This is a male patient with a past medical history (PMH) of alcohol abuse disorder who was admitted with complaints of (c/o) ingestion of about eight 150 milligram pills of trazodone and suicidal ideations. His vital signs were notable for systolic blood pressure (SBP) in the 80s, hypoxia with peripheral capillary oxygen saturation (SpO2) in the high 80s. Lab work was notable for an elevated anion gap, transaminitis. Imaging studies included a chest x-ray (CXR) which showed no focal infiltrates.  Poison control was called and advised to monitor for bradycardia, seizures, and electrocardiogram (EKG) changes, but noted that with the low amount of trazodone ingested that there was no significant concern for toxicity. The patient was diagnosed with suicidal ideations, intentional overdose, and alcohol withdrawal and treated with intravenous fluids (IVF), which improved his vital signs, 1:1 observation, Clinical Institute Withdrawal Assessment (CIWA) protocol, and expert consultations. The CIWA was noted to be 3 and the patient was recommended for inpatient psychiatry transfer, but no bed was available. At issue is the medical necessity of an inpatient level of care.

In part. This patient presented to the emergency department (ED) after an intentional overdose of trazodone and suicide attempt. Poison control was called and they recommended monitoring for bradycardia, seizures, and EKG changes, while the patient was found to have hypotension, hypoxia, and an elevated anion gap, increasing the patient's risk of clinical decompensation. In addition, the patient was a suicide risk and required 1:1 sitter observation to monitor the patient for further suicidal attempts, while the patient had concomitant alcohol withdrawal and was considered at high-risk of severe withdrawal symptoms, requiring CIWA protocol and close monitoring while on both trazodone and benzodiazepines (BZDs).
However, the patient was documented to have a low CIWA, there was minimal concern for continued trazodone toxicity, and the patient's vital signs normalized, at which point the patient could have been safely treated at a lower level of care, especially as it is documented that the patient's discharge was delayed due to the lack of an inpatient psychiatry bed rather than continued acute medical illness. Overall, this patient required close clinical monitoring after an intentional trazodone overdose, and initially, this could not have been safely provided at a lower level of care. However, care could have been provided at a lower level once the patient medically stabilized.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who was initially presented for concerns of persistent vomiting. Pertinent history included possible Achalasia, Crohn's disease, pancreatitis, diabetes mellitus, and multiple auto-antibodies. Initial examination documented the patient as alert with a non-tender abdomen. Initial laboratory testing revealed a white blood cell count (WBC) 2.8, Hemoglobin (HGB) 9.6, platelets (Plt) 82, Na (sodium)141, K (potassium)3.2, carbon dioxide (CO2) 23, blood urea nitrogen (BUN) 14, Cr (creatinine)1.6, Glucose 105. The patient was placed in the hospital thereafter with an impression of achalasia with persistent vomiting. Treatment plan included intravenous fluids and plans to proceed with an esophageal manometry. 

The inpatient hospital admission was not medically necessary. The patient presented with concerns for persistent vomiting and dehydration. Initial examination documented the patient as alert, oriented, hemodynamically stable, and without significant abdominal findings. Initial evaluation revealed baseline laboratory abnormalities without significant electrolyte abnormalities. Treatment plan included nothing by mouth (NPO) status in preparation of an endoscopy and esophageal manometry. These procedures were performed which ruled out achalasia, but did note motility dysfunction. Following the procedure, diet was advanced and tolerated. No other issues or complications were documented.
Moreover, clinical indications for admission to inpatient care were not met. The patient did not have a complete or partial gastrointestinal obstruction, vomiting due to significant metabolic derangement (eg, severe hypercalcemia, diabetic ketoacidosis), other cause of vomiting requiring hospitalization (eg, poisoning, increased intracranial pressure), acute kidney injury stage 2, acute renal failure stage 3, severe dysphagia with inability to manage secretions, hemodynamic instability, vomiting that is severe or persistent, severe electrolyte abnormalities requiring inpatient care, severe pain requiring acute inpatient management, bacteremia, appropriate outpatient antimicrobial treatment unavailable or not feasible, or inability to maintain oral hydration that persists after emergency department and observation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: neck/back/shoulder pain
Treatment: Pain Management Injection 
The insurer denied Pain Management Injection 
The health plan's determination is overturned. 

The patient is a female with a past medical history (PMH) of a motor vehicle accident (MVA) in which she was the restrained driver. She had level of care (LOC) at the time of the accident and her car was totaled. She is having ongoing R (right) sided shoulder and hip pain as well as headaches. Pain is between 8 to 10 (8-10) on the Visual Analog Scale (VAS) in her neck and upper extremity (UE). Her physical examination is notable for cervical paraspinal tenderness, positive facet loading, positive Spurling's bilaterally, and loss of cervical range of motion (ROM). She had a cervical magnetic resonance imaging (MRI) which demonstrated L (left) lateral recess stenosis at C (cervical) 5-6 and a 5 millimeter (mm) disc herniation. She is taking Norco, Gabapentin, Ibuprofen, Lidoderm Patches and Lexapro.

The pain management injection is medically necessary for this patient. It is medically reasonable for her to have a cervical epidural given her ongoing cervical radicular symptoms including bilateral positive Spurling's on examination and demonstration of a cervical disc herniation at C (cervical) 5-6. She has been compliant with multimodal therapy. She has pursued conservative therapies including multimodal medication management and physical therapy with ongoing symptoms. This injection may help reduce her medication burden. Therefore, the requested pain injection is indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II Subdivision Left Malocclusion and Crowding
Treatment: Braces

The insurer denied braces. 
The health plan's determination is overturned.

The patient in question is a male with an impacted tooth # (number) 6. This tooth is impacted in a mesioangular inclination, and it is in close proximity to the root of tooth #7. He presents with a skeletal Class II subdivision left malocclusion and crowding. The recommended treatment is braces to address the malocclusion and the impacted tooth.

The braces are medically necessary for this patient. If the impacted tooth is left untreated, the damage likely to the patient's teeth will be more time-consuming and difficult to correct than the patient's existing orthodontic problem. Studies show that impacted canines with a mesioangular inclination have a less than 15% (percent) chance of spontaneous eruption. Complications of impacted canines include potential root resorption and devitalization of the adjacent lateral incisors. Tooth #7 is at risk of being damaged due to its proximity to tooth #6, if the situation is not addressed soon. For this reason, braces are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Cystitis 
Treatment: Inpatient Hospital Services 
The insurer denied Inpatient Hospital Services.
The determination is upheld.

The patient is a female without significant past medical history who presented with severe right sided lower back pain radiating to her right flank and lower abdomen for one day, associated with nausea, emesis, and headache. Her review of systems was also positive for appetite change, chills, fatigue, fevers, and difficulty urinating. She was afebrile with a pulse up to 122, a blood pressure of 104 over 63 (104/63), a respiratory rate of 18 and she was not hypoxic. On exam, she was initially curled up in pain, she had right costovertebral angle tenderness and right flank/lower abdomen quadrant tenderness.
Her labs showed a creatinine of 0.87, a white blood cell (WBC) of 13.2, a hemoglobin of 13.1, and a urinalysis showed 51-100 WBCs and few bacteria. A computed tomography (CT) scan of the abdomen and pelvis showed a 4-millimeter (mm) calculus in the proximal right ureter with mild hydronephrosis. She was admitted for sepsis due to acute cystitis with right obstruction ureteral stone. She was started on intravenous (IV) ceftriaxone, IV fluids, IV analgesics and IV anti-emetics. Her WBC count increased to 23.5 and then improved the following day down to 15. She clinically improved over the next few days and was considered stable for discharge home.
At issue is the medical necessity of Inpatient Hospital Services.

The requested health service/treatment of Inpatient Hospital Services was not medically necessary for this patient.
The inpatient admission was not medically necessary based on the documentation provided. The patient presented with an acute onset of right flank pain. She was found to have a 4mm right obstruction ureteral stone and a suspicion of a urinary tract infection. She was hemodynamically stable. There was no documentation of a worsening of her clinical condition. She did not have a documented complicated urinary tract infection. She did not have an acute kidney injury. She did not have bilateral ureteral obstruction. She did not have severe or persistent pain, nausea or vomiting that required inpatient management. She did not require an inpatient surgical procedure or have a complication from a procedure that required inpatient monitoring. She did not have any significant co-morbid conditions that would place her at a higher risk of complications.