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

Diagnosis: Symptomatic Bradycardia.

Treatment: Inpatient stay.

The insurer denied coverage for inpatient stay.

The denial is upheld.

This patient presented to the hospital complaining of chest pain and palpitations over a four-month period. Past medical history was significant for hypothyroidism. Vital signs were stable on presentation (blood pressure (BP) 149/78, Pulse 50). Physical examination was significant for left lower extremity tenderness in the popliteal area and a goiter.  Serum blood testing revealed normal thyroid function studies, mild anemia with a hemoglobin of 10.7g/dl (grams per deciliter), and no elevation in troponin (<0.01). A 12- lead electrocardiogram revealed sinus bradycardia at a rate of 45bpm (beats per minute) and prolongation of the PR (interval EKG [electrocardiogram]) (233 Millisecond).  Venous duplex study of the lower extremities revealed no evidence of deep vein thrombosis (DVT).  The patient was admitted to the hospital for evaluation and treatment of symptomatic bradycardia.  Telemetry monitoring demonstrated heart rates in the 40 range with an increase to 90bpm with ambulation. The patient was found to have no evidence of chronotropic incompetence and was discharged home.

The health care plan acted reasonably, with sound medical judgment and in the best interest of the patient. There were no significant abnormal findings on physical examination to warrant acute inpatient hospital admission.  Most patients with palpitations can be evaluated in the outpatient setting (Reference 1-2). Electrocardiogram demonstrated sinus bradycardia and there was no evidence of chronotropic incompetence, the patient's heart rate increased to 90 bpm on ambulation. In one study, over 300 patients presenting with heart rates less than 50bpm had no increase in cardiovascular morbidity or mortality over a ten-year period. In conclusion, acute inpatient hospital admission was not medically necessary in this case. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient stay is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Drive Line Kit. 

The insurer denied a Drive Line Kit. 
The denial was overturned in whole. 

The patient is a male with ischemic dilated cardiomyopathy (INTERMACS 1) who underwent left ventricular assist device (LVAD) exchange from CentriMag LVAD to HeartMate3 LVAD device. The patient requires drive line site care to prevent drive line infection (DLI). 

Overturn in whole. The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment, or in the best interest of the patient. The patient is status post HeartMate3 LVAD placement in a redo setting after exchange of the previous CentriMag LVAD. These cases are likely higher risks for DLI if proper care of the drive line site is not completed with diligence. The relative risk reduction with standardized dressing and care kits are well documented in not only this situation but also in peripherally inserted central catheter (PICC) lines, central lines and central line insertions (now a JCAHO [Joint Commission on Accreditation of Healthcare Organizations] requirement for bundled dressing and central line insertion) with reduction of infectious rates of 60-75% (percent) similar to those observed with use of a drive line standardized care kit. (1-4) 

While the components of the durable medical equipment (DME) required could be acquired individually from a pharmacy, this burdens the patient's heath care custodian (i.e. [that is] significant other or family member) with what is already a somewhat technical task for anyone with non medical background. These kits are used routinely for LVAD patients to ensure the best infectious free care of the drive lines. The patient has foreign body (HM3) that is helping support his cardiovascular system that exits to the exterior of the skin. This situation is precarious for a subsequent infection of the drive line and device that requires constant monitoring and meticulous care. For this reason, a standardized drive line care bundle is medically necessary for the patient's well-being.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Perirectal abscess.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient is without past medical history who presented with rectal pain for 7 days, and purulent drainage. She was found to have a perirectal abscess and was admitted for incision and drainage. Initial pulse was 103 per the Emergency Physician note, and an electrocardiogram (EKG) showed pulse of 105. She was afebrile, with temperature of 37.2 and 100% (per cent) oxygen saturation. White blood count was initially 16 with 71% neutrophils. A computed tomography (CT) scan showed a 4.9 centimeter (cm) left sided perianal abscess. She was treated with Piperacillin/Tazobactam and underwent surgical exam under anesthesia the following day. The incision and drainage procedure was performed for an anterior ischiorectal abscess. The patient was discharged home.

The requested service/treatment of Inpatient Stay is not medically necessary for this patient. There is no entry within the medical record describing high risk for this patient such as concern for sepsis, spreading cellulitis, immunocompromise, uncontrolled diabetes, or other factors that would warrant Inpatient Stay. The abscess was described in routine fashion, treated with routine incision and drainage, and the patient remained afebrile before and after the procedure. Patients such as this one without past medical history and without immunocompromise are safely managed at a lower level of care. The incision and drainage is the critical and necessary treatment, whereas the need for intravenous (IV) antibiotics is "controversial and only weakly supported by current guidelines due to low-quality evidences" (Mocanu). Ischiorectal abscess is a common condition that is best treated with incision and drainage, with lower level of care management, except in cases of sepsis or immunocompromise. This patient was young and healthy without a past medical history. Such cases are commonly managed with lower level incision and drainage as is described by Divizia in his 2021 publication (Divizia).
There is not a rationale in this case to support Inpatient stay for antibiotics or any other reason.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiectasis
Treatment: Cayston
The insurer denied the Cayston.
The denial is overturned.

The patient is a female with sarcoidosis, pulmonary hypertension, and bronchiectasis with pseudomonas pulmonary infection. She was prescribed Cayston inhalation therapy. The patient has tried and failed tobramycin nebulizers. The patient has been receiving systemic antibiotics ciprofloxacin and levofloxacin.

The Cayston was denied coverage by the health plan, since the patient does not have cystic fibrosis. This denial is being appealed.

Yes, the requested Cayston is medically necessary.

The patient has pseudomonas pulmonary infection due to non-cystic fibrosis bronchiectasis. The patient has tried and failed systemic antibiotics as well as inhaled tobramycin to clear pseudomonas infection.

Inhaled aztreonam has been shown to improve cough, sputum production and sputum color in patients with pseudomonas infection in the setting of non-cystic fibrosis bronchiectasis. The patient has tried and failed all available treatment. The patient has had positive outcomes with the use of inhaled Cayston. The current standard of clinical practice is to continue with the treatment. Not continuing it is likely to lead to destabilization of pulmonary infection, worsening quality of life, and more doctor's visits.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Cholecystitis.

Treatment: inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This patient has a history of hypertension, diabetes mellitus and prostate cancer s/p (status post) prostatectomy. He presented to the emergency department via ambulance, with epigastric abdominal pain and emesis for one day. A computed tomography of the abdomen and pelvis showed acute cholecystitis. The patient was admitted as an inpatient and scheduled for surgery. Once he was medically stable, he was discharged.

Acute cholecystitis and biliary complaints are a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests (elevated alkaline phosphatase and total bilirubin), ambulatory laparoscopic cholecystectomy is safe and feasible. [5, 8] A 50% (percent) increase in the liver function tests can be labelled as mild elevation and is considered negligible by many. [9] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes. [6]

Per clinical documentation, this patient presented to the emergency department with abdominal pain, nausea, and vomiting. Vital signs in the ED (emergency department) were consistent with hypertension and bradycardia. The patient was afebrile. A CT (computed tomography) scan demonstrated acute cholecystitis. Liver function tests were normal. White blood cell count was 10.3. The patient underwent a laparoscopic cholecystectomy. A Jackson-Pratt (JP) drain was placed. There were no reported complications. There are no postoperative notes that indicates any further need for admission. The patient was discharged. Per Milliman Care Guidelines (MCG) criteria, laparoscopic cholecystectomy is considered an ambulatory procedure. Admission is indicated when there is conversion to an open procedure, severe infection postoperatively, care of active comorbidities, complications of the procedure, or a gallstone ileus. [7] Although a drain was placed, there are no post-operative notes to indicate management of the drain or reason for inpatient admission. Peer-reviewed literature and MCG criteria indicate that inpatient admission is not necessary in this circumstance. Per provided clinical documentation, inpatient admission was not medically necessary. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute kidney injury
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld. 

The patient is a female with a past medical history remarkable for rheumatoid arthritis, hypertension, asthma, and chronic leg ulcerations, who was admitted for lethargy and decrease in appetite. Review of system was negative for additional symptoms.

The patient was afebrile (Temperature of 97.9). She was described as well-appearing and resting comfortably. Her blood pressure was 125-152/53-74, pulse rate of 72-77, respiratory rate of 15, and oxygen saturation of 98-100% (percent) on room air. Physical examination was remarkable for right lower extremity ulceration, induration and possible fluctuance near the ulcer border. The patient was evaluated by the nephrologist and the acute on chronic kidney injury was thought to be related to dehydration and Bactrim use.

The patient was admitted for anorexia and decreased oral intake in the setting of ongoing infection, and cellulitis. The patient was treated with ciprofloxacin and Flagyl. The patient was also noted to have acute kidney injury. 

The inpatient hospital admission was not medically necessary.

The patient was admitted for Acute Kidney Injury (AKI) in the setting of dehydration, decrease in oral intake and prior elevated serum creatinine levels. The patient was hemodynamically stable and did not have any electrolyte derangements such as hyperkalemia or metabolic acidosis. Additionally, the patient responded to intravenous (IV) fluids with improvement in her creatinine.

The patient was admitted for acute kidney injury due to poor oral intake. The patient's creatinine improved with IV fluids. Additionally, the patient did not have a clear history of underlying Chronic Kidney Disease (CKD) or other comorbid conditions that increases the risk for chronic kidney disease and progression of renal dysfunction. Patients with underlying CKD are at risk for worsened renal outcomes. Factors that affect renal relief are presence of underling CKD and presence of infection. Hydronephrosis is also a patient-specific factor also likely to increase the risk of CKD. The patient presented with AKI in the setting of poor oral intake and responded to IV fluids.

Regarding the infection, the patient did not have systemic signs such as fever, tachycardia, or leukocytosis. Additionally, the infection was reported as chronic with polymicrobial pathology that required oral antibiotic therapy. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender Dysphoria. 
Treatment: Triptodur. 

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

The patient is a transgender male and uses he or him pronouns. As per history, the patient always felt different but came to the conclusion that he wants to be a male by age 9 years. The patient has come out as transgender male and dressed like a male. The patient has not been evaluated by a psychiatrist or psychologist for gender dysphoria. The patient wants to start testosterone treatment and eventually would like to have surgery to remove the breasts, uterus and ovaries. The health care provider is requesting treatment with gonadotropin-releasing hormone (GnRH) analogue (Triptodur) to suppress puberty. 

Triptodur is medically necessary for this patient. 

Gender dysphoria is listed in the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-V) and is assigned by a mental health professional. The proposed criteria for Gender Dysphoria (in adolescents) in DSM-V include a marked incongruence between one's experienced/expressed gender and secondary sex characteristics than assigned gender, a strong desire to get rid of one's primary and/or secondary sex characteristics and get secondary sex characteristics of the other gender which is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

Most clinical practice guidelines (The World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7, An Endocrine Society Clinical Practice Guideline 2017) for the treatment of transsexual patients recommend treating transsexual adolescents (Tanner stage 2) by suppressing puberty with GnRH analogues until age 16 years old after which cross-sex hormones may be given. 

This patient meets some of the criteria for the diagnosis of gender dysphoria. The patient expresses identification with the male gender and expresses discomfort with female sex. Although the patient will need formal diagnosis of gender dysphoria from psychologist or psychiatrist prior to testosterone treatment, the patient can be started on Tripodur analogue to suppress puberty which is the current standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right upper extremity transradial amputation.
Treatment: Upper arm prosthesis.
The insurer denied Right Artificial Arm: L7499 - Upper Extremity Prosthesis, Not Otherwise Specified, L6615 - Upper Extremity Addition, Disconnect Locking Wrist Unit, L6616 - Upper Extremity Addition, Additional Disconnect Insert for Locking Wrist Unit (each). The health plan's determination is upheld. 

The requested prosthesis is not medically necessary. There are many standard treatments for the diagnosis of right upper extremity prosthesis, including standard right upper extremity prostheses with one standard wrist unit, rather than multiple wrist units and standard prosthetic covering. The requested items are not considered standard of care and there are no well-designed well conducted studies published in peer-reviewed journals to support this device, to demonstrate that this device affects health outcomes, or show that this device is equally or more effective than conventional therapies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma exacerbation secondary to bronchitis

Treatment: inpatient stay rendered

The insurer denied coverage for inpatient stay rendered

The denial is upheld.

This is the case of a male with history of asthma, as well as marijuana and alcohol (ETOH) use. He presented to the emergency department (ED) with complaints of wheezing, shortness of breath (SOB) and chest tightness of 2 days duration.  Vital signs at presentation were temperature 98.2 Fahrenheit, respiratory rate (RR) 20, blood pressure (BP) 134/70, heart rate (HR) 101, and oxygen (O2) saturations 98% (percent). The patient was alert and oriented. Audible wheezing was heard. The patient was in some respiratory distress. He was treated with intravenous (IV) steroids, DuoNebs, and magnesium. Labs at presentation included white blood cell (WBC) count 9.7, hemoglobin 15.5, and electrolytes were within normal limits (WNL). Chest x-ray (CXR) revealed no acute infiltrate. The patient was admitted to the hospital for treatment of asthma exacerbation secondary to bronchitis.

As per the History & Physical (H&P), the patient was alert and oriented, in no apparent distress (NAD), and no use of accessory muscles. Lungs revealed bilateral wheeze, right greater than left. Normal heart sound and neuro exam was unremarkable. Peak expiratory flow (PEF) was 170 (baseline was 265). After the initial dose of IV Steroids, the patient was placed on prednisone 40 mg (milligrams) daily and bronchodilators. 

The patient remained stable after admission. Vital signs were stable. The patient was in NAD, and he decided to sign out against medical advice (AMA). This patient did not need acute inpatient hospitalization. He could have been placed in Observation status while diagnostic testing and treatment were initiated. He did not have pneumonia (PNA) or pneumothorax (PTX) or pleural effusions. He was alert and oriented. Was saturating well. There was minimal wheeze on lung exam. WBC and other labs were WNL.

This patient could have been kept in observation (which could be for up to 48 hours). Following a period under observation he could have been discharged home on oral meds and bronchodilators with close follow up in outpatient setting.

The health care plan acted reasonably with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for the inpatient stay rendered is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied Dental Treatment Plan- Tooth #18, tooth #20. 
The denial is overturned. 

The patient is a female who presented to the office of her dental provider for evaluation and treatment of teeth #18 and 20. Provided for review are previous letters of appeal and denial, full mouth panoramic radiographic images from an unknown date, two pages of American Dental Association (ADA) claim forms, and a periapical image from an unknown date. She has been recommended for treatment of porcelain fused to base metal crown (2751) for teeth #18 and 20. Previous denials have been based on health plan argument for the presence of furcation involvement for tooth #18 as well as subcrestal decay on #20.
At issue is the medical necessity of Dental Treatment Plan- Tooth #18, tooth #20.

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

The requested health service/treatment of Dental Treatment Plan- Tooth #18, tooth #20 is medically necessary for this patient.
The patient is missing crowns on teeth #18 and 20. Previous crowns on those teeth did not have the correct contours and had overhangs included in the design. Currently as the teeth do not have any coverage, coverage is indicated. There is not any direct restoration capable of restoring these teeth and the appropriate restoration is that of a full coverage crown for each tooth. Despite the health plan's argument that the presence of furcation involvement for tooth #18 is rationale for not placing a crown as well as subcrestal decay on #20, these attestations are not supported. Based on the provided documentation there is not decay on #20 and the furcation involvement of tooth #18 is class I at worst, which is not a counter indication to crown placement. The entire treatment of porcelain fused to base metal crown (2751) for teeth #18 and 20 is medically necessary for the patient.
Therefore, the requested health service/treatment of Dental Treatment Plan- Tooth #18, tooth #20 is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstipation.
Treatment: Inpatient stay.

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

The patient is a girl with a history of chronic constipation who presented with constipation, abdominal pain, and decreased appetite. She was in her usual state of health until 4 days prior to admission when she developed constipation. Along with this, she developed decreased oral intake and moderate abdominal pain that was alleviated by curling her legs up to her stomach. She had been chronically having symptoms of constipation on and off for several months and also had intermittent blood in her stools. She had tried prune juice and MiraLAX at home with little result. She had no vomiting or urinary symptoms. Her diet consisted mainly of milk, without much vegetables or cereals. She was brought to the emergency department due to persistence of her symptoms. She was subsequently admitted due to fecal impaction and the need for bowel cleaning.

The Inpatient Hospital Admission was medically necessary for this patient. For children with obstipation, if attempts at disimpaction fail to yield abundant stool, hospitalization is necessary to provide more intensive treatments including nasogastric administration of an electrolyte solution such as GoLYTELY. In this case, consultation with a pediatric gastroenterologist was also indicated along with close monitoring for potential deterioration of clinical status and for resolution of symptoms.
This is a young girl who presented with obstipation. She had chronic constipation with more recent lack of stools for several days. She was having abdominal pain and decreased appetite. She was treated as an outpatient without success. In the emergency department, the appropriate interventions were attempted, but they were not successful. She required inpatient admission for more intense treatments with nasogastric administration of GoLYTELY along with intravenous fluids, specialist consultation, and monitoring.