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

Diagnosis: Respiratory System
Treatment: Inpatient hospital stay

Diagnosis: Respiratory System-Breathing Problem
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has overturned in whole the health plan's determination.

The patient at the time of service was a former premature infant who presented with rhinorrhea, cough, post-tussive emesis, and difficulty breathing.

He was well until 2 days prior to presentation when he developed cold symptoms. He then developed a cough and increased work of breathing, as well as fever up to 103 degrees Fahrenheit. He was given acetaminophen at home, but then developed an audible wheeze and more difficulty breathing, so he was brought to the emergency department for evaluation.

On physical examination in the emergency department, he was noted to be well-hydrated and in no distress. His lung exam revealed end expiratory wheezes in all lung fields with a prolonged expiratory phase. He was also noted to have belly breathing with supraclavicular retractions. He was given Decadron as well as 2 albuterol nebulized treatments. A chest x-ray and laboratory values were also obtained.

Upon reassessment he continued to have tachypnea with end expiratory wheezes and belly breathing. He also continued to have retractions. He was subsequently given a repeat albuterol nebulized treatment as well as magnesium sulfate. He was then admitted to the hospital for further evaluation and management of respiratory distress.

Upon admission to the hospital, he continued to have wheezing with belly breathing. He was treated with albuterol every 4 hours as well as Prelone, acetaminophen as needed, and continuous monitoring. By the second hospital day he had improved, was stable on room air, and was felt to be ready for discharge to home with follow up as an outpatient.

This is a very young infant with a history of prematurity who presented with respiratory distress and wheezing. He continued to have increased work of breathing despite appropriate and aggressive treatment in the emergency department setting, including bronchodilators, corticosteroids, and magnesium sulfate. He therefore required inpatient admission for continued treatment with bronchodilators and close monitoring with an escalation of care as needed.

The decision making at the time of admission for this patient was consistent with his young age, the presence of respiratory distress that continued despite appropriate therapy, and the need for ongoing treatment in an inpatient setting along with close monitoring for potential deterioration of clinical status.

Indications for hospitalization for bronchiolitis includes continued respiratory distress, which can be manifested by intercostal, subcostal, or suprasternal retractions. This patient continued to have respiratory distress despite having received appropriate treatment, and therefore required an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma. 
Treatment: Inpatient admission. 

The health plan denied: Inpatient admission. 
The determination is overturned. 

The patient is a female with moderate to severe asthma who presented with a rash and shortness of breath. She was well until 6 days prior to presentation when she developed a rash on her face, trunk, and arms. She then developed a dry cough and shortness of breath. Her symptoms were worse with walking and were similar to a prior asthma exacerbation. Her past medical history was significant for asthma since childhood, including 4 prior admissions to the intensive care unit. She also had a history of anxiety and depression. In the emergency department, she was described as anxious and was tachycardic with a heart rate of 110 beats per minute (bpm). She had diffuse expiratory wheezing and little air movement on examination as well as a dry, erythematous rash on her face, trunk, and extremities. She was given 3 albuterol/Atrovent nebulized treatments as well as corticosteroids and Benadryl. Laboratory values were obtained, and intravenous fluids were given. She was placed on 2 liters of supplemental oxygen and was admitted to the hospital for further care.
In the hospital, she was treated with 2 liters of oxygen, continuous pulse oximetry, an additional albuterol/Atrovent nebulized treatment and albuterol every 4 hours as well as continued dexamethasone. She was also evaluated by psychiatry due to a significant trauma history. She was responsive to the treatments and improved over time. She was discharged home with instructions to follow up outpatient. 

At issue is the medical necessity of the inpatient hospital admission. 

The health plan's determination of medical necessity is overturned in whole. The requested health service/treatment of inpatient hospital admission was medically necessary for this patient. This is a female who presented with status asthmaticus possibly related to an allergic reaction. She had tachycardia and significant wheezing at the time of presentation along with decreased air movement. She continued to have significant symptoms despite appropriate and intensive treatment in the emergency department setting, and also had a history of several prior admissions to the intensive care unit. She therefore required hospital admission for bronchodilator treatments, corticosteroids, supplemental oxygen, and continuous monitoring, which all require inpatient level care. Her prior history of intensive care unit admissions also increases her risk of poor outcomes. She also required consultation from psychiatry during the admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bone loss
Treatment: Custom Abutment (procedure code D6057) for 
Tooth #2
The insurer denied: Custom Abutment (procedure code D6057) for Tooth #2
The denial is upheld.

The patient is an adult male. The request is for custom abutment for an implant supported crown to replace tooth #2, which was lost in an accident. The health plan denied coverage of the request, citing there being "functional first molar occlusion" and no need to extend the upper arch with tooth #2. The denial is being appealed.

The Custom Abutment (procedure code D6057) for Tooth #2 is not medically necessary.

Based upon the x-rays submitted at this time, there are no lower molars present on the right side. The upper right first molar implant crown (tooth #3) occludes (bites) with the lower second premolar (tooth #29) so it is important that tooth #3 was restored with an implant and crown, as there will be function on tooth #3. However, there are no teeth or implants present in the lower right molar area and there is no mention made from either the provider or the patient that there will be future implants placed there. If there are not going to be crowns placed (on implants) in the lower right jaw, then the need for a crown on a custom abutment, code D6057, for tooth #2 is not indicated at this time, as it will be a functionless tooth. The medical necessity for a custom abutment is not warranted at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The health plan denied: Inpatient Hospital Admission
The determination is: Upheld

The patient is a female with a past medical history significant for type 2 diabetes mellitus, obesity, and former smoker who was brought to the emergency department (ED) by Emergency Medical Services from her primary care physician's office for evaluation of chest pain occurring for 1 day, associated with shortness of breath and diaphoresis. In the ED, her vital signs were stable, with a blood pressure (BP) of 122/74 millimeters of mercury (mmHg). The electrocardiogram (ECG) demonstrated normal sinus rhythm (NSR) and nonspecific ST-T wave changes. The cardiac troponin was normal. The patient was admitted to telemetry service under inpatient level of care for evaluation of chest pain and rule out acute coronary syndrome (ACS). The echocardiogram demonstrated normal cardiac function and normal wall motion. The patient underwent a Lexiscan myocardial perfusion stress test which revealed possible mild apical and septal ischemia versus attenuation artifact. The study was technically limited due to attenuation artifacts. No further inpatient workup was recommended by the Cardiology consultation service. The patient was subsequently discharged home with plans to follow-up with Cardiology as an outpatient. At issue is the medical necessity of the inpatient hospital admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient hospital admission is not medically necessary for this patient. The patient presented to the ED for evaluation of chest pain and rule out ACS. Given that the patient's ECG was nonischemic, the cardiac troponins were normal, the patient did not exhibit ongoing chest pain, and her calculated HEART score was 3 (low risk for short-term adverse cardiac events), evaluation and management could have been rendered at an alternate level of care, according to the well-validated HEART pathway [1, 2]. Furthermore, her stress test results were technically limited due to significant attenuation artifacts decreasing the sensitivity and specificity of the test findings but did not require additional inpatient workup. Finally, given the patient's nonischemic ECG, normal cardiac troponin, and low risk HEART score, an alternate level of care would be supported by the 2022 American College of Cardiology (ACC) expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department [3].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: maxillary and mandibular crowding
Treatment: braces/monthly visits
The insurer denied braces/monthly visits. The health plan's determination is upheld. 

The patient is a male with maxillary and mandibular crowding. Teeth 6 and 11 are unerupted. The orthodontist mentioned in the diagnosis that tooth #6 and #11 are impacted and will require surgical exposure. The patient is treatment planned for Braces and Monthly Visits.

Braces and monthly visits are not medically necessary for the patient at this time. He is in the process of losing his remaining primary teeth as they are replaced with permanent teeth. Research indicates the following risk factors for impacted canines in patients over 10 years of age:
1- If there is asymmetry in palpation or a pronounced difference in eruption of canines between the left and right side. (The patient does not have this.)
2- The canines cannot be palpated, and occlusal development is advanced (occlusal development is not advanced - the patient is young, and the second molars are far from eruption.)
3- The lateral incisor is proclined and tipped distally (teeth 7 and 10 are not tipped distally at all)
4- On a panoramic radiograph of the late mixed dentition if the incisal tip of the canine overlaps the root of the lateral incisor. (Neither canine overlaps the root of a lateral incisor on the panoramic radiograph provided.)
The patient does have maxillary and mandibular crowding and treatment may be indicated in the future. However, the patient does not exhibit any of the criteria to suspect his canines are, in fact, impacted. For this reason, braces are not medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: melena, abdominal pain
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male with medical history of peptic ulcer disease complicated by upper gastrointestinal bleeding, diabetes mellitus type 2, hypertension, hyperlipidemia, and benign prostatic hyperplasia. He presented to the emergency department with melena, epigastric abdominal pain, chest discomfort, and dizziness. Vital signs were notable for rapid pulse of 103/minute and low temperature of 35.8 C. Physical examination was notable for flat, tender abdomen. Labs showed elevated white blood cell count of 16.1, low hemoglobin of 12.7 and hematocrit of 39.9%, and elevated blood urea nitrogen of 77. Computed tomography scan of the abdomen and pelvis showed subcentimeter calculus in the superior calyx of the right kidney, significantly calcified lumbar aorta extending into the common iliac arteries without evidence of aneurysm although significant mural calcification is seen. He was treated with intravenous pantoprazole.

The inpatient hospital admission was not medically necessary. In this case, the patient presented with anemia and melena, consistent with inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease). However, there was no sustained tachycardia or hypotension, or documented ongoing visible gastrointestinal bleeding. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset. Esophagogastroduodenoscopy was appropriately performed, and showed a low-risk gastric ulcer, but no high-risk stigmata or active bleeding. He was appropriately treated with proton pump inhibitor therapy, with improvement in symptoms. All of the measures that were undertaken, including monitoring, labs, proton pump inhibitor therapy, and endoscopy, could have been performed without the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity. 
Treatment: Wegovy. 
The insurer denied coverage for Wegovy. 
The denial is overturned. 

This is a patient diagnosed with Obesity. This request is for Wegovy. As reported the patient suffers from dyslipidemia and non-alcoholic fatty liver disease. The patient has tried the weight loss program Noom with no success. The patient also owns a Peloton bike and exercises 4-5 times per week. The patient was able to bring their weight 185 pounds (lbs). Most recently, the patient's weight was 216 lbs with a body mass index (BMI) of 33.83. The patient had a Hemoglobin A1C (HgbA1C) of 5.1%. The patient's provider has requested Wegovy to aid in weight loss. 

Semaglutide is a Glucagon-like peptide-1 receptor (GLP1R) agonist (1) that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity (2-4). Recent studies published in major peer reviewed medical journals have shown safety and efficacy of Semaglutide for the treatment of obesity (5-7). This medication is now available for the treatment of obesity in the form of Wegovy. The standard of care requires that the patient is participating in lifestyle modification. It also requires that the patient has a BMI of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension and/or hyperlipidemia. The patient has a BMI of 33.83 and is participating in lifestyle modification such as the weight loss program, Noom and exercising on their bike 4-5 times per week. The request meets the standard of care and is medically necessary. 

Based on the above, the insurer's denial must be reversed. 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 Wegovy is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Coronary Syndrome

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

Asked to review the case of a patient that presented to the hospital complaining of chest pain radiating to the neck and shoulder accompanied by worsening shortness of breath as well as dysuria. Past medical history was significant for hypertension, ischemic heart disease and Coronary Artery Bypass Graft (CABG).  On arrival to the hospital, vital signs were stable.  Physical examination revealed no significant abnormality. 12-lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST or T wave abnormalities. Serum blood testing revealed elevated troponin levels (26ng/L Nanogram/liter ). The patient was noted to have a positive COVID test and a negative urine culture.  The patient was admitted to the hospital for additional testing and treatment.  Echocardiogram demonstrated a preserved left ventricular ejection fraction. The patient was ultimately treated for reproducible chest pain and sent home on isolation once deemed to be stable.

The health plan did not act reasonably, with sound medical judgment and in the best  interest of the patient.  This patient presented with chest pain, dyspnea and an elevated serum troponin level.  The patient's pretest probability of coronary artery disease was high (1).  Utilizing the HEART score she was considered intermediate risk (2). Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (3).  Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation at a higher level of care. Serial troponin measurement, echocardiography and ischemia work up were warranted prior to discharge. The patient was ultimately diagnosed with COVID that likely contributed to a type 2 myocardial infarction (4). In conclusion, admission to the hospital was medically necessary. In conclusion, given the patient's presentation and multiple cardiac risk factors, inpatient hospital admission was appropriate.

Based on the above, the insurer's denial must be reversed. 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 inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Endocrine/Metabolic/Nutritional/Other/high blood sugar levels
Inpatient Hospital/inpatient emergency admission
The health plan denied the requested inpatient emergency admission as not medically necessary. 
The health plan's determination is overturned.

This patient is a male who has no past medical history. He presented with nausea, vomiting, and generalized weakness. The patient has had a 30-pound weight loss. He was tachycardic. He complained of polydipsia and polyuria. The patient had dry mucous membranes. His glucose was 733. His Beta hydroxybutyrate was 2.1, the Anion gap was 19 (9 - 15), the sodium was 124 with a blood urea nitrogen (BUN) of 21 and a creatinine of 2.29. A blood gas was negative for acidosis. The patient was diagnosed with the hyperglycemic hyperosmolar state and was treated with normal saline and regular insulin. The patient was treated in the Intensive Care Unit (ICU) with an insulin infusion. Calculated serum osmolality was elevated at 296.
At issue is the medical necessity for the requested health service/treatment of an inpatient emergency admission.

The denial is overturned, in whole, as the request was medically necessary, as described above.

Yes. Acute inpatient admission for patients with symptomatic diabetes is necessary when the patient has evidence of ketoacidosis or a hyperosmolar state. [1-6] Observation is generally sufficient for patients with ketosis or vomiting that resolves after hydration. [7-9]
The patient had ketosis with a hyperosmolar state. The patient required an insulin infusion. The requested admission was consistent with generally accepted standards of medical practice. The request is, therefore, medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Incontinence/Urinary/Bladder Control
Treatment: Injection of periurethral bulking agents
The health plan denied: Injection of periurethral bulking agents
The determination is: Overturned.

The patient is a female who had stress incontinence treated with surgery. Initially, she experienced relief of symptoms but subsequently developed worsening leakage. She was re-evaluated and underwent a Bulkamid placement for intrinsic sphincter deficiency per attestation of the attending physician.
At issue is whether or not the proposed health service or treatment, injection of periurethral bulking agents, is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The health plan's determination regarding the proposed health service or treatment is overturned, in whole.

The proposed health service or treatment, injection of periurethral bulking agents, is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Bulkamid is an endorsed procedure for this specific medical problem per guidelines of the American Urological Association (AUA). It is not an experimental procedure.
The AUA states, "Clinicians should counsel index patients considering surgery for stress urinary incontinence (SUI) regarding the efficacy and safety of each of their options, which may include the following: (Strong Recommendation; Evidence Level: Grade A) Mid-urethral sling (retropubic, transobturator, or single-incision sling), autologous fascia pubovaginal sling, Burch colposuspension, and bulking agents. The role for bulking agents may best be considered in patients who wish to avoid more invasive surgical management, who are concerned with the lengthier recovery time after surgery or who experience insufficient improvement following a previous anti-incontinence procedure."
Literature endorses the safety and efficacy of the therapy for SUI management.
 Authors state, "Available data support the use of Bulkamid and Macroplastique, which has shown a short-term efficacy of 30 percent (%)-90% and 40%-85% respectively, and long-term efficacy of 42%-70%, and 21%-80%, respectively. Bulkamid appears to have a more favorable safety profile, with no cases of erosion or migration of product associated with its use."