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

Diagnosis: Substance abuse and attempted suicide
Treatment: Continued inpatient stay 
The Continued inpatient stay was not medically necessary for this patient.

The continued treatment of the patient's psychiatric disturbance did not require the continued structure of an acute inpatient level of care or 24-hour monitoring. Moreover, the patient did not display evidence of suicidal plan or intent and had denied suicidal thoughts, as noted in the clinical summary; other symptoms such as severe cognitive impairment (dementia or delirium), thought disorder, mania or psychosis were not present in this case, nor was there psychiatric co-morbidity or substance-related disorders that would warrant acute inpatient level care. The patient was cooperative with treatment; and medication adherent, and the psychosocial stressors in this case were not so severe to require continued acute inpatient care or 24-hour monitoring. Additionally, the patient had committed to participate in treatment for the substance use disorders and was being referred for rehabilitation treatment with lower level care in a less restrictive treatment setting. Thus, medical necessity is not met for the Continued inpatient stay in this case scenario. 

The patient's treatment for her psychiatric disturbance and substance-related disorder could have been safely and effectively provided at a lower level of care. Specifically, the patient did not present with persistent general medical complications or severe withdrawal symptoms from alcohol or complications of co-occurring substance use disorders, as he had previously received detoxification and measures to address the overdose. The patient's mood disturbance and associated symptoms of anxiety and functional impairments did not require continued inpatient level structure or monitoring during the time interval under review. There was no imminent risk for suicidal behaviors or documented symptoms that would have necessitated the inpatient admission or continued assessment, safety monitoring and treatment in an acute inpatient setting, as proposed. The psychosocial stressors in this case were not so severe to warrant inpatient level care, monitoring or structure for the DOS under review.

These answers are consistent with the scientific literature, ASAM Criteria, and New York State instruction regarding medical necessity reviews, as well as NY State OASAS LOCADTR 3.0 Guidelines.
Appeal type: Medical necessity
Decision: Overturned

Malpositioned teeth
Dental/Orthodontic procedure 

The patient has a Class 1 malocclusion with protrusive maxillary incisors. Teeth 8 and 9 are severely proclined. Teeth 4 and 13 are in a crossbite. The patient is treatment planned for 24-30 months of orthodontics with extraction of teeth 4, 13, 20 and 29 to correct the crowding and protrusion.
The health plan's determination of medical necessity is overturned  in whole. 
Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. Extraction of four premolars can help correct incisor protrusion and given the position of the maxillary second premolars extraction of four second premolars is a logical choice.
There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. Extraction of four premolars combined with orthodontics will make his teeth less protrusive. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the morbidity of repairing these teeth. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Dental disease
Treatment: Dental services

The patient is a female with congenital medical condition causing loss of teeth. The request is for 3-unit implant supported bridge, teeth 3-5, as well as crowns on teeth 6 and 7.

The Dental services are medically necessary, in part.

Specifically, the implants for 3 and 5, as well as bridge that attaches to them are medically necessary. The need for these specific services is due to the loss of these teeth due to the patient's genetic disorder. Therefore, they are medically necessary. The request for crowns on teeth 6 and 7 are not medically necessary and are not due to the patient's medical condition. Teeth 6 and 7 are existing, sound teeth that need crowns, but not because of the genetic condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Assault trauma
Treatment: Inpatient admission
The Inpatient admission was medically necessary.
The patient is a male. He presented to the emergency room after having been assaulted.  The patient had multiple traumas and required immediate ORIF (open reduction internal fixation) to prevent soft tissue damage.  The patient required management of elevated blood pressure, and afterwards, he underwent physical therapy and IV pain control.

The patient suffered from polytrauma as a result of an assault.  This required operative intervention to stabilize his fractures.  His condition was complicated by several factors.  One was the elevated blood pressure, which required IV medication for medical optimization prior to surgery.  Once medically cleared, he did undergo surgery, which was extensive and complex given the nature of his injuries.  Even when the surgery is scheduled in a delayed situation, the patient is typically admitted.  Postoperatively, the extensive nature of his surgical reduction required IV pain medication.  Given all of these factors, the extensive nature of his trauma, the necessity for IV antihypertensive medication, and IV pain medication postoperatively, hospital admission was medically necessary.

The patient was assaulted and showed a severe, often easily missed, fracture.  When these are not immediately recognized or there is excessive edema, the patient surgery can be delayed for three weeks. However, when the injury is immediately recognized, before swelling can set, this should be stabilized immediately and can lead to better outcomes with lower healing time.  The nature of the injuries and the severity of the injuries required inpatient management for observation, pain control, and avoidance of infection.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic dermatitis.
Treatment: Dupixent (dupilumab).
The insurer denied the Dupixent (dupilumab).
The denial is upheld. 

No, the Dupixent (dupilumab) is not medically necessary. 

The patient is a male with atopic dermatitis, treated with topical steroids, topical calcineurin inhibitors and Excimer laser therapy per notes.  Provider is requesting Dupixent.

Dupixent is Food and Drug Administration (FDA) approved for the treatment of moderate to severe atopic dermatitis in patients over the age of 12. The standard treatment options for patients with atopic dermatitis include a regimen of topical steroids as well as topical calcineurin inhibitors. After topical agents fail, standard practice is to pursue systemic therapy such as phototherapy.

Therefore, because the documentation does not support that the patient has tried and failed a systemic immunosuppressant and does not have a contraindication to these, the requested Dupixent does not meet health plan criteria and is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hypertension and multiple other medical conditions.
Treatment:  Personal Care Assistance 56 hours/week.

The insurer denied the Personal Care Assistance 56 hours/week.  The denial is overturned. 

Yes, the Personal Care Assistance 56 hours/week is medically necessary.

The patient is a female with past medical history of hypertension, hypothyroid, emphysema, osteoarthritis, CVA (cerebrovascular accident), cervical radiculopathy, disc herniation, lumbar spinal stenosis, urinary incontinence requiring diapers, unsteady gait requiring walker usage, and frequent falls.  The patient was determined by her treating physician to be totally dependent for adult daily living tasks.  The patient lives alone.  

The patient has history of hypertension, hypothyroid, emphysema, osteoarthritis, CVA, cervical radiculopathy, disc herniation, lumbar spinal stenosis, urinary incontinence requiring diapers, unsteady gait requiring walker usage, and frequent falls.  The patient was determined by treating her physician to be totally dependent for adult daily living tasks.  The patient lives alone.  The health plan's currently approved plan of 32 hours per week is not sufficient to meet this patient's needs.  Therefore, the requested Personal Care Assistance 56 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psychiatric Stabilization.

Treatment: Inpatient Mental Health Treatment.

The insurer denied the inpatient mental health treatment.

The denial was upheld.

This is a male patient who was admitted to inpatient mental health treatment due to worsened psychotic symptoms that included paranoia and grandiose delusional thinking, disorganized thoughts, bizarre thinking, thought blocking, noncompliance with medication and outpatient mental health treatment. The patient had reports of homicidal ideation. The patient reportedly had a past recent psychiatric hospitalization. The patient took Olanzapine and reported improvements. He was medically stable and was discharged. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior are candidates for inpatient treatment. There were no reports of further serious psychotic symptoms such as delusions, hallucinations, or disorganized behavior, suicidal or homicidal ideation, intent, or plan, manic symptoms, aggressive, threatening, self-injurious, or agitated behavior, withdrawal symptoms or acute medical instability. Notes reported that the patient denied hallucinations, had no delusional thinking or statements, denied suicidal or homicidal ideation, and had good mood and sleep. Notes a few days into his admission reported that the patient denied suicidal or homicidal ideation, hallucinations, and he was compliant to taking his medication. It also reported that the patient denied delusions, hallucinations, suicidal or homicidal ideation. The day before discharge notes reported that the patient denied hallucinations, suicidal or homicidal ideation, or magical thinking, and had no delusions or paranoia, and had better mood; the patient was then discharged. Several days after admission there were no reports of acute or severe mental health or behavioral symptoms that required 24-hour acute hospital treatment, and there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital treatment setting as of then or that could not be achieved in a less restrictive level of care as of then. The health plan did act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the continued inpatient mental health treatment is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder
Treatment: Inpatient Hospital
The insurer denied the inpatient stay.
The denial is upheld.

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

The patient presented with a migraine, difficulty urinating and flank pain. The patient was seen by urology a few days earlier due to urinary frequency and was placed on Flomax. The patient denied fevers, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting or diarrhea. Vital signs showed that the patient was afebrile with a pulse of 67 beats per minute (bpm), a blood pressure of 140/78 millimeters of mercury (mmHg), a respiratory rate of 16/minute and a room air pulse oximetry of 97%. On exam the patient was uncomfortable due to a migraine and had mild costovertebral angle tenderness. Labs showed a creatinine of 2.0, a potassium of 4.1, a white blood cell count (WBC) of 10.7, and a hemoglobin of 16. A urinalysis (UA) showed large hemoglobin, negative nitrites, small leukocyte esterase, negative bacteria, >50 red blood cells (RBCs)/hpf and a 25-50/hpf white blood cell count (WBC). A computed tomography (CT) scan of the abdomen showed mild bilateral hydronephrosis with bilateral perinephric stranding without obstructing calculi. A Foley catheter was placed in the emergency room and the patient was started on intravenous (IV) Ceftriaxone and Gentamicin. The patient was admitted for acute renal failure with a urinary tract infection and obstructive uropathy. Urology was consulted and recommended continuing the Foley catheter, starting Flomax and continuing antibiotics. Infectious disease was consulted and recommended continuing Ceftriaxone and stopping Gentamicin. A nephrology consult was obtained and advised continued hydration. A renal ultrasound (US) showed the urinary bladder collapsed around the Foley without evidence of hydronephrosis. The creatinine improved to 1.4 and 0.9. The patient was deemed to be stable for discharge with follow up with urology. At issue is the medical necessity of the inpatient stay.

No, the inpatient stay in this case was not medically necessary based on the documentation provided. The patient presented with obstructive uropathy. The patient was hemodynamically stable and did not have a documented complicated urinary tract infection with obstruction. The patient did not have bacteremia. The patient did not have severe or persistent pain, or severe or persistent nausea or vomiting. The patient did not require intravenous (IV) fluids beyond what could have been provided at a lower level of care. The patient did not require an inpatient surgical or radiologic procedure. A Foley catheter was placed with resolution of the obstruction and improvement in the creatinine. The patient's care could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Blood disorder /other 
Treatment: Inpatient hospital 
The insurer denied the inpatient hospital stay 
The denial is overturned in whole 

The patient with a past medical history significant for sickle cell disease, splenectomy, cholecystectomy, and right hip replacement due to avascular necrosis who presented to the emergency department with pain in the  back and legs consistent with previous painful crises. It began on the day of admission. Reportedly, the patient took Tylenol #3 and Percocet for pain control, but this, unfortunately, did not resolve the pain.
Yes, the inpatient stay was medically necessary for this patient. The admission at the acute inpatient level of care was justified to provide adequate treatment for the sickle cell crisis, which required frequent administration of intravenous pain medications.
Painful episodes are the most frequent complication in sickle cell disease. Patients who have had recurrent episodes may be treated at home with oral analgesics (acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), or opiates). If the episode is more severe, they may require higher-dose therapy in a hospital-based setting. Severe pain requiring repeated doses of intravenous (IV) analgesia is best treated as an in-patient.
The gold standard for the assessment of pain is the patient's report. There is no combination of physical findings or laboratory tests that can be used to determine (or confirm) whether an individual with sickle cell disease (SCD) is in pain. The absence of hemolysis or the stability of the hemoglobin level cannot be used to justify withholding or underdosing of pain medication.
Taking into consideration all these facts, it was clear that the pain medications administered prior to admission were not controlling the pain adequately, therefore the patient was admitted to the hospital and received treatment with intravenous opioids, which were administered frequently. This care required admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Exacerbation 
Treatment: Hospital admission
The insurer is denied coverage for hospital admission.
The denial is upheld. 
This is a female patient with history of asthma (multiple intubations in the past) who presented to the presented to the emergency department (ED) with complaint of shortness of breath, wheezing, chest pain and some coughing. The patient had been seen in ED the previous night and was discharged on steroids. The patient developed wheezing again and took her inhalers and prednisone but as she did not get relief came back to emergency room (ER). In ED vital signs: Temperature 37.1 F Heart Rate 105, Respiratory Rate 20, Blood Pressure 113/79 mm Hg,, oxygen , saturations 96% on room air. The patient was in no acute distress. Lung exam revealed faint wheezing. The patient was alert and oriented x3. White blood cell count (WBC) was 19.8K (questionable steroid induced leukocytosis) Hb was 13.6 electrolytes within normal limits. Chest x-ray revealed no acute infiltrate. Clinical impression was mild exacerbation of asthma. The patient was treated with prednisone, and bronchodilators via nebulizer therapy.  The patient had a temperature 36.3, heart rate 91, respiratory rate 18, blood pressure 113/72, and oxygen saturation saturations werre93%. The patient was medically stable and discharged home. 
 
The patient complained of shortness of breath, and wheezing. Pulmonary function tests (PEF) was 150- patient's baseline 250. The patient was in no acute distress. The patient had a mild wheeze noted. She was subsequently admitted for asthma exacerbation. As per the history and physical (H&P) the patient appeared comfortable. There was no accessory muscle use. She was speaking complete sentences; WBC was 17.5 K Electrolytes were within normal limits. The patient was tolerating oral intake. The patient remained stable after admission; she was afebrile and hemodynamically stable. She had no evidence of hypoxia, no pneumonia or pneumothorax. The patient had one drop in PEF to 150 which was 60 % of her best and subsequently improved to 260 LPM.

The patient did not need acute hospitalization. She could have been placed in observation status while diagnostic testing and treatment were initiated. The patient remained stable after admission. Was afebrile and hemodynamically stable, tolerating oral intake. The patient could have remained in Observation status and could have been discharged once improved on PO Steroids and BD with close (F/U) in outpatient setting.

In sum, the patient's asthma was mild and she had no evidence of pneumonia and was not hypoxic. The patient's leukocytosis was likely secondary to her steroids with no obvious focus of infection noted.

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

Based on the above, the medical necessity for the hospital admission is not substantiated. The insurer's denial is upheld
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Sensitivity.
Treatment:  Crowns on teeth #8 and #9.

The insurer is denied coverage for crowns on teeth #8 and #9.  The denial is upheld.

This is a patient who consulted a dentist for an evaluation for sensitivity on teeth #8 and #9.  Diagnostic images were performed that included periapical radiographs.  The doctor recommended full coverage crowns for these teeth due to the sensitivity issue and erosion on the lingual aspects of the teeth. 

The objective documentation provided for review is periapical radiographs.  It appears that there is no evidence of fracture or other pathology specifically affecting either #8 or #9.  There does not appear to be any radiographic evidence of caries.  The radiographs do not substantiate the requested dental services as enumerated above; therefore, the requested crowns are deemed not medically necessary.

Uphold the denial of coverage for crowns on teeth #8 and #9 as not medically necessary, as the documentation is insufficient to justify or substantiate the treatment.

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

The carrier's denial of coverage for Crowns on teeth #8 and #9 is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic Esophageal Cancer

Treatment: Inpatient admission
	
The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with a history of breast cancer, bone metastases, and thyroid cancer, Hodgkin's lymphoma treated with ABVD, metastatic gastroesophageal (GE) junction esophageal cancer to the mediastinum, anemia, morbid obesity, esophageal reflux, asthma, hypertension, type 2 diabetes mellitus, depression, Attention Deficit Hyperactivity Disorder (ADHD), diverticular disease, arthritis, status-post surgery, chemotherapy and radiation, gastro-bronchial fistula, mucoepidermoid carcinoma of the right maxillary gingiva status post excision, basal cell carcinoma, and follicular carcinoma of the thyroid who now presented with dysphagia.  She was hemodynamically stable.  A CAT scan suggested a malignant stricture.  An endoscopy was performed.  The stricture was dilated.  Food was removed from the esophagus.  She was treated with intravenous (IV) fluids, IV lorazepam, IV acetaminophen, and IV pantoprazole. Her diet was advanced. After a period of medical stability stable she was discharged home.

MCG for Gastroenterology GRG (MG-GAS) list clinical indications for admission for severe dysphagia.  These include esophageal perforation, caustic ingestion, severe dehydration, inability to manage secretions, hemodynamic instability, severe electrolyte abnormalities, and acute renal failure.  The patient did not have these conditions.

This patient had a stricture resulting in dysphagia.  She required an esophageal dilatation.  She was stable to have had the endoscopy and dilation performed on an outpatient basis.  She tolerated the procedure and no complications were reported.  Afterwards, the diet was able to be advanced.  She did not meet MCG criteria for admission for Gastroenterology - severe dysphagia.  She was stable for treatment with observation status.  The healthcare plan acted reasonably and with sound medical judgment and in the patient's best interest.  An inpatient admission was not medically necessary.  The denial is upheld.

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.