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

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

The patient is a previously healthy woman who presented with abdominal pain and nausea. At the time of presentation, the patient was without fever and vital signs were normal. Exam identified mild diffuse abdominal tenderness. The white blood cell (WBC) count was 13.4. The complete metabolic panel identified normal liver enzymes and bilirubin. Imaging with a computed tomography (CT) scan and ultrasound showed gallstones.

The inpatient hospital admission was not medically necessary. This patient presented to the hospital with abdominal pain and was diagnosed with cholelithiasis/cholecystitis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. At the time of presentation, vital signs were normal, lab data identified elevation of white blood cell count and normal transaminases.
Surgery was performed and the patient had an uncomplicated initial recovery period. She was stable for discharge from the hospital on the first post-surgical day. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care.

A lower level of care would have provided for initial assessment, perioperative care and monitoring, provision of IV antibiotics and fluid, surgical treatment, and overnight care. There were no peri-operative complications or other clinical issues that mandated an inpatient designation in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Postpartum Preeclampsia, chest pain, headache.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is overturned.

The patient is an adult female who presented to the emergency room (ER) with complaints of shortness of breath (SOB), chest pain, and headache. Headache was severe (10) not relieved by analgesics. The patient had an uncomplicated vaginal delivery. On evaluation, the patient's blood pressure was elevated to 164/92 and 178/95. Both aspartate transaminase [AST]/ alanine transaminase [ALT] 76/157 were elevated. 
The patient was given 5 milligrams (mg) of Hydralazine, Procardia, and Keppra. She was admitted with the diagnosis of postpartum preeclampsia. Procardia and Keppra were continued. Liver function tests (LFT) downtrended and the patient continued to have headaches. Imaging of the head was negative. Pain medication was given. The patient was stable, blood pressure was well controlled and liver function tests were back to normal. The plan was to discharge her that day. However, because of continuous headache despite a negative workup, she was kept in hospital. Her headache improved on Fiorocet and she was discharged to be followed by neurology.

This patient presented 6 days after delivery with elevated blood pressure. Delayed postpartum preeclampsia can be defined as signs and symptoms of the disease leading to readmission more than two days but less than six weeks after delivery.  The diagnosis of preeclampsia is based on the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman:  Systolic blood pressure >(greater than)=(equal)140 mmHg (millimeters of mercury) or diastolic blood pressure >=90 mmHg, and Proteinuria >=0.3 grams in a 24-hour urine specimen or protein: creatinine ratio >=0.3, or signs of end-organ dysfunction (platelet count <(less than) 100,000/microliter, serum creatinine >1/1 mg/dL (milligrams per deciliter) or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration).

This patient had elevated blood pressure, severe headache, possible pleural effusions, protein in the urine and elevated LFTs. This patient did have a diagnosis of preeclampsia, admission was medically necessary. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Acute infarct
Treatment:  Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is overturned. 

This is a case of a  male admitted for a diagnosis of stroke. The patient presented with a chief complaint of confusion and forgetfulness. He originally presented because of subjective disorientation and forgetfulness. He was transferred after a computed tomography (CT) scan showed basal ganglia infarct. At the time of admission, it was noted that the symptoms had resolved, and there was no weakness, vision changes, headaches, numbness, tingling or dizziness. Vital signs demonstrated blood pressure 165/105, temperature 98.2F (degrees Fahrenheit), pulse 77, respiratory rate 18 and O2 (oxygen) saturation 99% (percent). Physical exam showed no acute distress with negative neurologic exam. White blood cell count was 7.0 with hemoglobin 13.8. Complete metabolic panel was normal. Coagulation times were normal. A magnetic resonance angiography (MRA) of the head and neck was unremarkable. Echocardiogram did not show patent foramen ovale (PFO) and ejection fraction was preserved at 55%. A magnetic resonance imaging (MRI) of the brain showed acute infarct and neurology consult was requested. 

The inpatient hospital admission was medically necessary. The patient in this case was positive for stroke on both CT and MRI imaging. It is well-established that the presence of a minor acute infarction on MRI places the patient at a high risk category for a major stroke recurrence. He required neurology consultation, cardiac imaging and medical optimization with antiplatelet therapy and antihypertensive therapy. The level of monitoring required to ensure the patient safety during the highest risk time-frame (at least 48 hours) could not be reasonably done at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted teeth
Treatment: D8070 Braces, D8670 Monthly Visit
The insurer denied: D8070 Braces, D8670 Monthly Visit
The denial is overturned.

The patient is a preteen female. The request is for orthodontic treatment (braces) and monthly visits. Per the Provider's dental clinical summary, the patient presents with impacted bilateral upper canines.

The health plan denied coverage for the request, because the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) Index report. The denial was appealed because of the diagnosis of impacted canines.

The requested orthodontic treatment (braces) and monthly visits are medically necessary.

As supported by the x-rays, the patient presents with bilateral impacted maxillary canines. Typically, most maxillary canines erupt in the mouth by age 11-12. The x-rays show that the canines are impacted and there is insufficient space to allow the natural eruption process to be completed.

Under these circumstances, surgical exposure of this tooth coupled with orthodontic treatment is indicated as the corrective measure. Therefore, the requested orthodontic treatment and monthly visits are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Bilateral Varicosities.
Treatment:  Vein procedure (37765 x 1, 37766 x 1).
The insurer denied coverage for vein procedure (37765 x 1, 37766 x 1).  
The denial is overturned.

The office note indicates the patient continues to have varicosities significantly bilaterally. Her symptoms include pain and heaviness, and the left leg becomes swollen. According to the documentation submitted, the patient has a history of deep vein thrombosis (DVT) in pregnancy, pulmonary embolism (PE), varicose veins, and venous insufficiency in the lower extremities. The patient underwent a left greater saphenous vein radiofrequency ablation and right anterior saphenous vein radiofrequency ablation.

The requested procedure codes are 37765 (stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions) and 37766 (stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions). The patient has varicosities significantly bilaterally. Her symptoms include pain and heaviness, and the left leg becomes swollen. 

This is a request for supplemental procedures following endovenous ablation of the great saphenous veins. Evidence-based peer-reviewed medical literature indicates that in most patients the treatment of the great saphenous vein in this setting will successfully relieve symptoms. However, in a subset of patients the symptoms will persist, and in this subset of patients it is appropriate and medically necessary to proceed with treatment of the residual tributary veins. 

"The advancement of endovascular technology for the treatment of venous disease has been accompanied by staggering rates of utilization and warrants clinical standards as the field evolves. These appropriate use criteria (AUC) for venous care provides the first appropriate use document for venous procedures and may serve to fill in the gap where high-quality scientific evidence is lacking to aid clinicians in making the day-to-day decisions for patient care. As a product of a collaborative effort with multiple professional societies, it serves as an expansion of existing guidelines based on an appropriate use process while identifying areas in which research is needed to provide further support for evidence-based decisions." (Masuda et al., 2020) 

In this particular case presence of persistent symptoms is well-documented. Therefore, the request qualifies as medically necessary.                                                         

Based on the above, the insurer's denial must be overturned. 

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 vein procedures (37765 x 1, 37766 x 1) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Reverse Crossbite
Treatment: Braces
The insurer denied: Braces
The denial is: Overturned

The patient in question is a female with buccal (reverse) crossbite on tooth 4. She presents with a skeletal Class I malocclusion with severe maxillary and mandibular crowding. Tooth 14 is missing. She is treatment planned for orthodontics with the extraction of three premolars to correct her malocclusion. The subject under review is the medical necessity for the requested treatment with braces.

The health plan's determination is overturned.

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 overerupt. Once this overeruption occurs, it is very difficult to treat.1 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.2
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and complicated to correct than the patient's existing orthodontic problem. For these reasons treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left sided weakness
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The determination is upheld.

This is a patient with a medical history of hypertension, hyperlipidemia, diabetes mellitus, and a prior stroke who was admitted to the hospital after he presented to the emergency room with left-sided weakness in the arm and leg. Of note, the patient had recent use of crack cocaine and alcohol prior to his presentation. The patient had a similar presentation to another hospital where he was evaluated for signs and symptoms of stroke. At that time, the patient underwent computed tomography angiography (CTA) of the head and neck and an MRI (magnetic resonance imaging) that was "negative" for an acute stroke. On this admission, the patient was admitted to the hospital but left against medical advice. The patient was discharged on aspirin and a statin. A computed tomography (CT) scan of the head performed on admission showed a chronic basal ganglia stroke and a CTA of the head and neck showed no large vessel occlusion. At issue is the medical necessity of an inpatient stay.

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

The patient was evaluated in the hospital for left-sided numbness and weakness. The symptoms improved sufficiently for the patient to discharge home against medical advice. The hospitalization lasted less than 24 hours. The patient did not require rehabilitation services. The patient did not require inpatient management of electrolyte abnormalities or unstable vital signs. The patient did not require complex nursing care. There were no services provided that could not have been performed at a lower level of care due to the short stay and incomplete nature of the evaluation/diagnostic studies. Care for transient ischemic attack and minor stroke is routinely performed at a lower level of care as neurologic symptoms rapidly improve and the treatment involves oral medications with a large portion of the "work-up" that is performed in the emergency room.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder-Left Arm numbness.
Treatment: Inpatient Admission.
The health plan denied the requested inpatient admission. 
The health plan's determination is upheld.

The patient is a woman with hypertension who presented to the emergency room with complaints of left arm numbness and weakness which began the day prior to admission. On exam her blood pressure was 117/74 millimeters of mercury (mmHg), a pulse of 72 beats per minute (bpm), and she was in sinus rhythm. In the emergency room (ER), her National Institute of Health (NIH) stroke score was 1 (+ drift). She was given Aspirin 325 milligram (mg). A neurology consultation was obtained. A head computed tomography (CT) without contrast showed no acute intracranial abnormality. A computed tomography angiography (CTA) of the head and neck showed no significant intracranial stenosis, aneurysms, or arterial venous malformation.
The patient was admitted and was reported to have mild arm weakness, 4.5/5. A magnetic resonance imaging (MRI) of the brain showed no acute pathology. A transesophageal echocardiogram showed an ejection fraction (EF) of 60% (percent) and no significant valvular disease. Per the discharge summary, the patient had right upper extremity (UE) pain with active and passive motion, and a history of arthritis. Her weakness was more likely due to arthritis rather than a transient ischemic attack (TIA). The patient was discharged home with outpatient followup.
At issue is the medical necessity for the inpatient stay.

It is recommended that the health plan's determination of medical necessity be upheld, in whole.

The inpatient admission was not medically necessary.
The patient, with history of hypertension, presented with arm weakness and numbness over one day. While there was concern initially for cerebrovascular accident (CVA) or TIA, the initial work up done within the first 24 hours of hospitalization, including a head CT, The CT angiogram of the head and neck, head MRI, and neurology consultation, did not indicate that the patient had any acute neurologic process. Per Milliman guidelines, hospitalization is indicated for patients with TIA who have in addition - hemodynamic instability, recurrent focal neurologic signs, abnormal brain imaging, altered mental status, acute cardiac arrhythmias, significant cardiac or vascular disorder, severe hypertension, suspected vasculitis or need for parenteral anticoagulation. The patient did not meet any of these conditions.
Inpatient admission was not indicated. The hospitalization could have been handled at an alternate status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure. 
Treatment: Inpatient Hospital Admission. 
The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adolescent male. He presented after a new onset seizure. He was watching television when he stood up and his head and neck moved to the right, followed by shaking of his whole body. The seizure lasted 15 minutes. He required 2 mg (milligrams) of Versed from the emergency medical services responders. 

In the emergency room, the patient was awake with agitation and sinus tachycardia. Evaluation in the ER (emergency room) included a head CT (computed tomography) and labs, which were unremarkable for significant metabolic derangements. He was admitted for further evaluation, soon after midnight. He was back to normal mental status later that morning upon re-evaluation. MRI (magnetic resonance imaging) brain was normal. An EEG (electroencephalogram) showed mild diffuse dysfunction. Neurology consultation was obtained. The recommendation was to discharge the patient home on no anticonvulsants and with outpatient follow up. He was discharged home. 

The admission was denied coverage by the health plan because of the assertion that MCG (Milliman Care Guidelines) criteria for admission were not met. The plan stated in their letter that an observation level of care was approved. The treating facility appealed this decision stating the patient required admission level care due to the intensity of the care he received, including telemetry monitoring and nursing checks every 2 hours as well as EEG (electroencephalogram) and MRI (magnetic resonance imaging) tests. This review is in regard to the admission. 

The Inpatient Hospital Admission was not medically necessary. 

The patient presented with a single new onset seizure and transient alteration of mental status. The patient required prompt evaluation with neuroimaging and neurophysiology tests. The patient remained stable through the hospital stay. The patient did not require starting an anticonvulsant medication. The patient did not have meningitis or encephalitis, status epilepsy, prolonged alteration of mental status, unexplained focal neurological deficits, need for multiple doses of medication to abort seizures, continued intravenous treatment with anticonvulsant medications or intravenous treatment to correct major metabolic derangements. It would have been reasonable to expect that the patient's care could be completed within two midnights. The patient was not at high risk of morbidity and mortality from seizure recurrence or other complications due to having a single seizure without other accompanying features as discussed above. The patient's care was reasonably expected to be completed at a lower level of care (such as observation care) as argued by the plan. Thus, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower Back Pain
Treatment: pain injections (64483 x 1 and 64484 x 1)
The insurer denied coverage for pain injections (64483 x 1 and 64484 x 1)
The denial is upheld.

This is an adult male with hypertension, hypercholesterolemia, anxiety and chronic back pain. He presented in a follow-up visit with a complaint of constant and severe lower back pain (LBP) with radiation to bilateral lower extremities (R>[greater]L). His pain interferes with daily activities and has lasted for more than 12 months. He reports more than 6 weeks of physical therapy (PT)/home exercise program, medication such as nonsteroidal anti-inflammatory drug (NSAIDS) and 6 weeks of activity modification with no relief. Documents show that he is taking Percocet with good relief and without side effects. Previous lumbar transforaminal epidural steroid injections (TFESI) were performed. The last injection was a few years ago. Visit note only states: status post (s/p) TFESI with good relief - now regressed. The doctor recommended repeat steroid injection. However, there is lack of sufficient documentation of the degree or duration of pain relief with these prior injections. 

According to Center for Medicaid and Medicare Services (CMS) guidelines [Epidural Steroid Injections (ESI) for Pain Management] it is generally not considered medically reasonable and necessary for treatment with ESI to extend beyond 12 months. However, use beyond 12 months may be medically reasonable and necessary if the following criteria are met: Pain is severe enough to cause a significant degree of functional disability or vocational disability; The ESI provides at least 50% (percent) sustained improvement of pain and/or 50% objective improvement in function (using same scale as baseline); Rationale for the continuation of ESIs including, but not limited to, patient is high-risk surgical candidate, the patient does not desire surgery, recurrence of pain in the same location relieved with ESIs for at least three months; The primary care provider must be notified regarding continuation of procedures and prolonged repeat steroid use.

Based on the documentation provided, this patient does not meet the CMS recommended criteria for additional ESI beyond 12 months. There is lack of sufficient documentation in the medical record of the duration of pain relief or degree of functional improvement. Based on this information, outpatient procedure (64483 x 1 and 64484 x 1) is not considered medically necessary for this patient and should not be allowed by the medical plan.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for pain injections (64483 x1 and 64484 x1) services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Retractions and tachypnea
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a former 29-week twin male. He presented to the emergency department (ED) with shortness of breath and cough. Associated symptoms included decreased oral intake and nasal congestion. The review of symptoms (ROS) was negative for fever, rash, wheezing, cyanosis, or gastrointestinal (GI) illness.
The ED vital signs were a temperature of 97.5 Fahrenheit (oF), a heart rate (HR) of 109 beats per minute (bpm), a respiratory rate (RR) of 40/minute, and a peripheral capillary oxygen saturation (SpO2) of 96%(percent) on room air. The exam was notable for retractions and tachypnea. He was given albuterol and intravenous fluids (IVF) with a documented good response. The complete blood count (CBC) and comprehensive metabolic panel (CMP) were normal; COVID-19, flu, and respiratory syncytial virus (RSV) testing was negative. A chest x-ray showed slight right upper lobe (RUL) opacity. The patient received a total of 3 albuterol nebulizers in the ED but persisted with retractions and tachypnea. The decision was made to admit him to the hospital for further management. The patient's condition improved rapidly, and he was able to be discharged home.
At issue is the medical necessity of the inpatient hospital stay.
The health plan's determination of medical necessity is upheld in whole.
The requested inpatient stay was not medically necessary for this patient. His case could have been managed at a lower level of care. This male patient presented with bronchiolitis and mild respiratory distress. He was successfully treated with IVF and albuterol in the ED. There were no laboratory abnormalities, no indication of sepsis, and no need for supplemental oxygen. Thus, his case could have been managed at a lower level of care, and the inpatient stay was not medically necessary.