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

Diagnosis: Maxillary and mandibular spacing, Class II canines and anterior crossbite with gingival attachment loss 
Treatment: Braces
The insurer denied coverage for braces.
The denial is overturned. 

This is a patient who consulted an orthodontist for orthodontic care. A diagnostic work up was performed that included lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images. The orthodontist recommended comprehensive orthodontics due to maxillary and mandibular spacing, Class II canines and anterior crossbite with gingival attachment loss (mandibular canines). The orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.

It is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific
conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. Based on the review of the medical record and literature, this automatically qualifying condition criterion is met for this patient, and does support the request for comprehensive orthodontic care. Braces are considered medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for braces is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower back pain and left leg pain with associated numbness and tingling.  
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This is a female patient admitted with lower back pain (of five years) and left leg pain with associated numbness and tingling.  

The patient was seen by ortho as outpatient and had a magnetic resonance image (MRI) of the lumbar spine.  She underwent lumbar left L5-S1 discectomy.  

Physical exam revealed no focal deficits in the emergency room (ER). The patient was taken to surgery for left L5-S1 discectomy. The patient denied pain in recovery and was transferred to a floor.

No, the inpatient stay is not medically necessary.  

The patient did not require admission the day prior to surgery and did not require a stay beyond the day of surgery.  The patient was stable without significant pain that required intravenous medications.  In addition, this operation should have been arranged as an outpatient procedure.  The patient had been treated as an outpatient previously and if surgery was warranted it should have been arranged as an in and out (outpatient) procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission.
The denial is upheld.

This is a male patient with a past medical history of hypertension, hyperlipidemia, and diabetes mellitus. The patient presented to the hospital for a scheduled cardiac catheterization due to an abnormal nuclear stress test. The patient's stress test revealed a large area of anterior wall ischemia. The patient reported exertional midsternal chest pain, dyspnea when walking in cold weather. The patient's symptoms had been present for the past 6 months. The patient underwent left heart catheterization with drug eluting stent placement. There were no complications. The patient was admitted to the Telemetry unit for further monitoring. The patient remained clinically and hemodynamically stable, and was tolerating oral intake and was ambulatory. After treatment, the patient was cleared for discharge to home with instructions to follow-up as outpatient.

Based on the review of the medical record and literature, inpatient admission status is not considered medically necessary for this patient. Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient one. The patient's clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization and attempted angioplasty. The patient could have been monitored at the Observational level of status after the procedure.

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

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

Diagnosis: Infertility
Treatment: Blood test
The insurer denied the blood test.
The denial is upheld. 

The patient is a female with a history of infertility. Hepatitis B surface antigen and Hepatitis C testing was performed.

No, the blood test was not medically necessary.

The medical literature was thoroughly reviewed. There are no medical records submitted. 

In this case, there are no medical records to support the indications for Hepatitis B and C testing. Therefore, the testing does not meet the standard of care and the testing is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a woman who presented to the emergency department after an episode of syncope. She reported having had intermittent episodes of tachycardia for 5-8 years. Several of these had been associated with syncope. On the day of presentation, she had sudden onset of heart racing followed by brief loss of consciousness. In the emergency department, her blood pressure was 109/77 mmHg with a heart rate of 118 beats/minute. Her room air oxygen saturation was 100%. Her physical exam was remarkable for tachycardia. The physician note indicates a rate of 209 beats/minute during the exam; this is likely a typographical error. An electrocardiogram showed sinus tachycardia at a rate of 111 beats/minute. The patient's serum troponin level was elevated, as was her D-dimer level. 

The inpatient stay is medically necessary.

There are myriad causes for syncope, ranging from the benign to the life-threatening. The prognosis for patients with syncope is considerably worse for patient with structural heart disease than for those with structurally normal hearts. During this woman's evaluation she was found to have pulmonary hypertension and associated tricuspid regurgitation. Per the 2017 American College of Cardiology (ACC) / American Heart Association (AHA) / Heart Rhythm Society (HRS) Guideline for the Evaluation and Management of Patients With Syncope, inpatient admission is recommended for patients presenting with syncope who have a serious medical condition potentially relevant to the cause of syncope identified during initial evaluation. This woman's pulmonary hypertension was potentially related to her syncope and thus, per this guideline, inpatient admission was appropriate. In addition, this patient's clinical history and her elevated troponin level were very suggestive of a poorly tolerated tachyarrhythmia. Given her pulmonary hypertension, an inpatient stay for arrhythmia recurrence was prudent.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Issue under review: Stelara

Determination:
The Stelara is medically necessary.

The patient is a teen-aged male. He has been diagnosed with moderate to severe Crohn's disease. He failed steroids, methotrexate and Remicade (infliximab). His physician requested Stelara.

A recent multi-center cohort study evaluated the response to Ustekinumab in children with moderate to severe Crohn's disease (Chavannes et al 2019). At 12 months, 38.6% of the 44 patients achieved clinical remission and 47.8% achieved clinical response. They concluded that "Subcutaneous Ustekinumab should be considered a viable therapeutic option for paediatric patients who are refractory to other biologic agents." 
Recently, Dayan et al (2019) published their real-world experience with ustekinumab at a tertiary care pediatric inflammatory bowel disease (IBD) center. Fifty-two children and young adults initiating ustekinumab were analyzed. Most patients (81%) failed >1 anti-TNF (tumor necrosis factor), and 37% failed anti-TNF and vedolizumab; 10 patients were biologic-naive. At week 52, 75% were still on ustekinumab, and 50% (bio-exposed) and 90% (bio-naive) were in steroid-free remission. Their results suggested that ustekinumab is efficacious and safe in pediatric patients with IBD.

In summary, current medical evidence shows that ustekinumab is reasonably safe and effective in children with severe Crohn's disease. 

This teen-aged patient has been diagnosed with moderate to severe Crohn's disease. He failed one biological agent, Remicade.  The requested Stelara would be indicated and is supported by current medical literature. The proposed treatment is medically necessary, according to generally accepted standards of medical practice, based on credible scientific evidence published in peer-reviewed medical literature.
Appeal type: Medical necessity
Decision: Upheld

This is patient with a Class II, spaced maxillary occlusion, crowded mandibular occlusion, and a deep bite. He is missing teeth 7 and 10. He is treatment planned for orthodontics to correct his malocclusion. At issue is the medical necessity of braces, monthly visit.
The health plan's determination is upheld. The patient has a Class II malocclusion. His bite is deep but there is no indication of damage to the incisors or the palate either in the photographs or documented clinically. A deep bite without damage is not a cause for orthodontic treatment. The patient has no complaints of pain or discomfort. Further, research indicates that patients with missing teeth actually benefit from being treated closer to skeletal maturity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe Eclampsia.
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. The denial was upheld. 

This is a female patient who presented to the Emergency Department (ED) with complaints of a headache and shortness of breath on exertion. The patient had a normal vaginal delivery several days earlier and was recently admitted to the hospital for preeclampsia. The patient's presenting symptoms were similar to her previous admissions symptoms. The patient's blood pressure was 174/96 despite treatments. The patient's presenting vital signs were: blood pressure 157/88, heart rate 58 beats per minute, respiratory rate 16 breaths per minute, temperature was 98.5 F, and pulse oximetry reading was 100% on room air. The patient was treated with intravenous (IV) labetalol and IV hydralazine. The patient's headache improved and blood pressure stabilized after treatments. The patient was admitted to the hospital with severe preeclampsia. The patient was given 975 milligrams of oral acetaminophen and 600 milligrams of oral for pain, 200 milligrams of oral labetalol every 8 hours, and 30 milligrams of oral Procardia a day. Neurology was consulted. They noted that the patient had persistent pressure dependent postpartum headaches with recommendations for continued blood pressure medications and the monitoring of the patient's headaches for improvement. The patient was discharged after a period of medical stability. 

Based on the review of the medical record and literature, inpatient admission was not medically necessary. The patient presented with elevated blood pressure and headache dependent on her pressures consistent with her diagnosis of preeclampsia. The patient had completed a course of magnesium sulfate for her preeclampsia. The patient's treatment and management was controlling her blood pressure. The patient had no focal neurological symptoms that required neurological workup. The patient could have been safely treated and monitored at the observational level of care. Once this patient's blood pressure was controlled, the patient could have been discharged home on home blood pressure monitoring and close outpatient follow-up. Thus, inpatient admission was not medically necessary. 

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

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

Diagnosis: Pneumonia

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.

This is a male patient who presented to the hospital with complaints of cough with some blood streaked sputum, pleuritic chest pain and shortness of breath. It was reported that he had been recently been admitted to the hospital with similar complaints.  The patient's presenting vital signs were: temperature of 98.9, heart rate of 78, respiratory rate of 18, blood pressure of 126/83 mm Hg, and an oxygen saturation of 98% on room air. The patient's sputum culture and sensitivity at that time revealed H. Influenzae. Laboratory work up revealed white blood cell (WBC) count was 4.1K, hemoglobin 12.1 with electrolytes were within normal limits with the exception of his potassium 3.2.  Blood urea nitrogen (BUN)/ Creatinine levels were 10/0.8 and a urine toxicology screening was positive for PCP and cannabinoids.   Venous blood gases (VBGs) revealed a pH of 7.39, a partial pressure of carbon dioxide (pCO2) level of 41, a partial pressure of oxygen (pO2) level of 51, a bicarbonate (HCO3) level of 24, and a blood oxygen saturation level of 85%. The patient's computed tomography of the chest revealed questionable aspiration pneumonia. .  The patient was treated with Clindamycin and Azithromycin.  The patient was subsequently switched to Unasyn and Azithromycin.  The patient improved significantly with treatment.  The patient was seen by Pulmonary and Infectious Diseases (ID) who concurred with the treatment. The patient signed out against medical advice during that stay.

This patient did not need acute inpatient hospitalization.  He was afebrile and hemodynamically stable.  The patient's pneumonia was mild and his CURB 65 score was Zero.  He could have been placed in Observation status while diagnostic testing and treatment were continued.  The patient had a normal white blood cell count, he was not hypoxic, and he was tolerating oral intake.  The patient could have been initially treated with intravenous (IV) antibiotics while in observation status and once stable, he could have been switched to oral antibiotics and discharged home with close follow-up in an outpatient setting.  The prior denial is upheld.

The insurer acted reasonably, with sound medical judgement, and in the patient's best interest.

The carrier's denial of coverage for the full hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission. 
The denial is upheld.

This is a male patient with a medical history of hypertension. The patient presented to the Emergency Department (ED) with syncope. The patient was on a subway train when he felt lightheaded so he got off the train and past out. The patient reported no chest pain, shortness of breath, palpitations, nausea, vomiting, tongue biting, bowel/bladder incontinence. The patient had 3 similar episodes in the past, always on a train, always with prodromal symptom. The patient reported that sometimes, he went days without eating because he was either not hungry or was too busy. The patient reported eating the night prior to this incident, but did not eat breakfast that morning. The patient was on amlodipine and had no recent increase in dose. The patient's blood pressure was 160/84 and his pulse was 78. On exam, the patient's head showed no clinical sign of contusion or laceration. An electrocardiogram (EKG) was done that revealed sinus rhythm with borderline T wave abnormalities. It was noted that the patient had syncope likely vasovagal versus orthostatic secondary to dehydration rule out cardiogenic. A  transthoracic echocardiogram was done revealed left ventricular ejection fraction of 65%, and normal left ventricular, and right ventricular function with dilated right atrium. The patient underwent a chest x-ray, which was unremarkable. The patient was treated with fluids and serial troponin levels; troponin levels were negative. Orthostatic blood pressures were monitored. The patient was admitted to Telemetry as the observation unit was full. The patient was discharged.

Based on the review of the medical record and clinical guidelines, inpatient admission was not medically necessary. The patient's clinical presentation would have been appropriate for the observational level of care. It was noted that the patient presented to the observation unit and it was full, so the patient was admitted to telemetry. The record did not establish that the patient had a cardiac condition indicating the necessity for immediate intervention such as telemetry monitoring. The patient's electrocardiogram (EKG) revealed sinus rhythm with borderline T wave abnormalities, and his serial troponin levels were negative. The patient had this syncopal episode occur previously while riding the train with prodromal symptoms, which did not suggest cardiac etiology. All of the testing to rule out a cardiac abnormality could have been performed at an observation level of care and did not require an inpatient admission. Thus, inpatient admission was not medically necessary for this patient.

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

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

Diagnosis: Hematemesis.
Treatment: Inpatient admission. 

The insurer is denied coverage for the inpatient admission. The denial is upheld. 

This is a female patient with a history of schizoaffective schizophrenia, aggressive behavior, asthma, bipolar, gastric ulcer and self-harm with suicide. She presented to the Emergency Department (ED) with complaints of vomiting blood and epigastric pain. The patient reported that the epigastric pain starts after she eats. The patient had previously been scheduled for an esophagogastroduodenoscopy (EGD) but had not completed. The patient was refusing a physical examination. It was recommended that the patient undergo laboratory studies and receive Pepcid as well as Maalox. The patient's bloodwork showed: white blood cell (WBC) count 11.7, hemoglobin 11.2, and venous pH 7.462. The patient's hemoglobin level was noted to be stable, and the patient was hemodynamically stable. Due to patient's episode of bloody vomit with a positive Hemoccult in the ED, the patient was admitted for continued treatment and monitoring. The patient was discharged the following day with instructions to follow-up as outpatient. 

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient had a history of multiple presentations to the hospital and a history suggestive of malingering. There was no evidence of active bleeding or hemodynamic compromise. There was an episode of hematemesis in the Emergency Department, but the patient had no drop in hemoglobin or hemodynamic instability. The patient could have been discharged after a period of monitoring at the Observational level of care. 

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

The carrier's denial of coverage for the inpatient hospital admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis (facelift surgery).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

No, the Inpatient admission was not medically necessary.

The patient is a female. She was admitted as inpatient due to presenting to the Emergency Department-(ED) complaining of swelling and redness to anterior neck x three days. The patient was status post facelift five weeks prior to admission. She stated she was well until three days prior to admission, when she felt some "fullness" in her neck where she had recent surgery. The next day she noticed some "bumps" that were red and painful. She went to see her plastic surgeon who drained "pus" from the neck. She was given clindamycin, of which she took only a couple doses. On the day of admission, she had some more drainage and was sent into the hospital for IV antibiotics. 

On admission, the patient was afebrile and her vital signs (VS) were stable. Her white blood cell count (WBC) was 4.22.  In the emergency room the patient was treated with intravenous (IV) antibiotics including Vancomycin for cellulitis neck and IV Azactam for cellulitis. The patient was admitted to surgical unit under Plastic Surgery service secondary to cellulitis with need for continuous monitoring and intravenous antibiotics. ID (infectious disease) evaluated for antibiotic management. The gram stain showed Gram positive rods. Recommended to continue vancomycin 1 gram IV every 12 hours for gram positive coverage, Aztreonam 1 gram IV every eight hours for gram negative coverage, follow up cultures and Penicillin skin testing. The patient was optimized with improvement in symptomatology and deemed stable for discharge home.

She had failed outpatient care with worsening on oral antibiotics. However, she did not have any of the co-morbid conditions listed in the MCG criteria.  On admission, the patient was afebrile and her vital signs (VS) were stable. Her white blood cell count (WBC) was 4.22. She was not septic. She did require immediate initiation of IV antibiotics, but she did not have any of the contraindications listed for outpatient IV antibiotics. As noted in the below criteria, she could have been managed at an observation level of care while outpatient antibiotics were arranged. 

In summary, the patient had cellulitis that required IV antibiotics, but she did not have any contraindications to receiving IV antibiotics at an observation level of care while outpatient antibiotics were being arranged. She was not septic and did not have any significant co-morbidities.  She had no significant past medical history.