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

Diagnosis: GI (gastrointestinal) Bleed
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male who has underlying coronary artery disease (CAD), status/post (s/p) DES (drug eluting stent), systolic heart failure, atrial fibrillation (afib), with very recent AVR (aortic valve replacement) /LAA (left atrial appendage) clip prior to admission on DAPT (Dual antiplatelet therapy), who was admitted for 2 episodes of lower gastrointestinal (GI) bleeding. Bright red blood with clots was noted. He denied abdominal pain but was experiencing heartburn. There was no associated chest pain, shortness of breath (SOB) or dizziness. On exam, the patient's heart rate was 102 beats per minute (BPM). Abdomen was benign. On rectal exam, he had a blood-soaked tissue present in the anal canal. On digital rectal exam (DRE) no blood was retrieved from the rectal vault. 

The inpatient hospital admission was not medically necessary. He just had major heart surgery and was experiencing lower gastrointestinal (GI) bleeding on DAPT - a very concerning presentation. However, he had no signs or symptoms to suggest volume depletion and/or end-organ hypoperfusion. This was followed on labs by a normal hemoglobin and a negative CTA. The follow-up hemoglobin done shortly after admission showed no significant drop with equilibration. At that point it became clear that the patient was not having a clinically significant lower GI bleed. Therefore, a lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: coronary artery disease
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male who presented to the hospital for scheduled procedure - cardiac catheterization. Prior to scheduled procedure, the patient was evaluated as outpatient for dyspnea and fatigue on exertion. He was found to have abnormal electrocardiogram (ECG) with T wave inversion.
It was determined that the patient will benefit from cardiac catheterization. The patient had history of hypertension (HTN) and HLD (hyperlipidemia). The patient also had positive family history for coronary artery disease (CAD). Prior to the procedure, the patient was taking atenolol, atorvastatin and aspirin.

The requested Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented for scheduled cardiac catheterization. The procedure was elective. The patient had symptoms of dyspnea on exertion and fatigue which were felt to be due to stable coronary artery disease. There was no evidence that the patient had unstable angina, congestive heart failure or other symptoms which would justify inpatient admission. The patient was stable upon presentation with normal vital signs, unremarkable physical examination and stable lab values as well as ECG. The patient's cardiac catheterization was done without any unexpected complications, his condition during hospital stay was stable.
His coronary angiography revealed severe 3 vessels disease, and it was stable chronic disease without evidence of acute vessel thrombosis, dissection or other acute life threatening coronary abnormalities. The procedure was done under conscious sedation, not general anesthesia. After the procedure, the patient was transferred to another hospital for coronary artery bypass graft (CABG).
Based on the above, the patient's condition and management did not meet inpatient admission criteria. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  High blood sugar
Treatment:  Inpatient stay
The insurer denied the inpatient stay.  The health plan's determination is upheld.

The patient is a male with a history of diabetes mellitus (DM), hypertension (HTN), hyperlipidemia, coronary artery disease (CAD) status/post (s/p) 2 stents, congestive heart failure (CHF) with reduced ejection fraction (EF), and implantable cardioverter defibrillator (ICD) placement, who presented with high blood sugar levels. He was instructed by his PCP (primary care provider) to go to the emergency room. 

The inpatient hospital admission was not medically necessary. The patient presented due to elevated blood glucose levels secondary to being out of his insulin. He was hemodynamically stable. He had an initial blood sugar of 591 without evidence of diabetic ketoacidosis or hyperosmolar coma. He did not have severe dehydration that required inpatient admission. He did not have nausea or vomiting that was severe or persistent impairing his ability to hydrate. He did not have severe electrolyte or metabolic abnormalities. He did not require an insulin infusion or require blood sugars checks at a frequency that would necessitate an inpatient admission. He had an elevated creatinine that responded appropriately to IV (intravenous) fluids without severe electrolyte or metabolic abnormalities. He could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned



Diagnosis: peripheral arterial disease
Treatment: Peripheral Arterial Revascularization [CPT (current procedural terminology) 37220, 37221, 37224, 37226, 37228]
The insurer denied Peripheral Arterial Revascularization [CPT 37220, 37221, 37224, 37226, 37228]
The health plan's determination is overturned.

The patient is a woman with coronary artery disease, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), peripheral arterial disease, and status/post (s/p) right above knee amputation. The patient has had previous left superficial femoral artery (SFA) angioplasty and stenting.
The patient was diagnosed with atherosclerotic heart disease of native coronary artery without angina pectoris, essential hypertension, mixed hyperlipidemia, peripheral vascular disease, chronic obstructive pulmonary disease, and s/p right above knee amputation (AKA) with prosthesis.

Peripheral Arterial Revascularization [CPT 37220, 37221, 37224, 37226, 37228] is medically necessary for this patient.
The patient has peripheral arterial disease with a history of right lower extremity amputation and previous left SFA angioplasty and stenting. The patient was found to have left lower extremity arterial disease on duplex ultrasound requiring treatment. The patient requires treatment she is at high risk of thrombosis/occlusion of her left SFA. The requested treatment is medically necessary and standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II Division 1 malocclusion 
Treatment: braces/monthly visits
The insurer denied braces/monthly visits.
The health plan's determination is overturned. 

The patient in question is a young male with a Class II Division 1 malocclusion with maxillary and mandibular crowding. He has 6-millimeter (mm) overjet and 5mm overbite. 

Braces and monthly visits (12) are medically necessary for this patient. Teeth number (#) 8-9 are protruding forward within the dental arch. This makes them more prone to trauma. In fact, these teeth have already been damaged and restored, likely due to their protrusion.
This patient, like fifteen percent of the population, exhibits an Angle's Class II bite. Patients with a Class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+mm overjet, which this patient has. For these reasons, the requested orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Cardiac
Inpatient hospital

Diagnosis: supraventricular tachycardia (SVT)
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

This case involves a woman with hyperthyroidism complicated by supraventricular tachycardia (SVT) 1 month before this presentation. She presented back to the hospital for palpitations. Treatment for the underlying SVT included Lopressor 50 milligrams (mg) 4 times a day. The patient's Apple Watch detected fluctuating heart rates between 60-100, with palpitations. A trial of 3 times daily Lopressor to prevent bradycardia resulted in intermittent palpitations for 2 days, with heart rates between 120 and 180. The patient also takes Xanax and methimazole. Examination showed a pulse rate of 73, blood pressure of 99/47, and normal temperature. The lung exam is unremarkable, with no edema of the lower extremities.

The inpatient admission was not medically necessary. The patient did not have an unstable supraventricular tachycardia (SVT) documented during the hospital stay. Cardiac function is preserved. Cardiology recommended no further testing and switched the patient to a nonselective beta-blocker due to tachycardia induced by Graves' disease. The patient tolerated this conversion medication and was discharged home with an event monitor and instructions on how to manage episodes of SVT with vagal maneuvers.
Inpatient admission is not indicated, as the patient did not require continuous infusion of antiarrhythmic medications, adenosine, cardioversion, or vasopressors. This was not an unstable SVT. A lower level of care was appropriate to address the patient's problems and needs without needing inpatient conversion.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied Braces.
The determination is overturned.

The patient is a male with a buccal (reverse) crossbite on tooth number (#)13 and a deep bite. He has severe maxillary and mandibular crowding. He presents with a skeletal Class I malocclusion. He is treatment planned for 24-30 months of orthodontics with extraction of four first premolars. At issue is the medical necessity of braces.
Because tooth 13 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 to correct than the patient's existing orthodontic problem. For these reasons, treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection (UTI)

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

The patient was a full term baby who was previously healthy and had no past history of illness or underlying conditions. The patient was seen in the emergency room (ER) the previous day for a fever and a viral infection. At that time the infant was diagnosed with an upper respiratory infection (URI) but the intermittent fever was continuing. The cough also continued and the infant was brought back to the ER. There was a decrease in oral intake. There was no change in urine output and the infant was still making 6 plus wet diapers. The review of systems was otherwise negative.

On exam in ER the infant was alert well appearing and smiling. There was no distress and temperature was 100.5 degrees F (Fahrenheit) rectally. Systems exam was normal. No signs of dehydration were noted. It is documented that in the ER the infant remained hemodynamically stable and was feeding well.

Labs: 
Urinalysis revealed White blood cells (WBC) >100 leukocytes. WBC was 31,500 and bicarbonate was 15.
 
The infant was given two normal saline boluses and one dose of ceftriaxone. The infant was started on intravenous (IV) fluids.

A decision was made to admit and administer IV antibiotics. The record is lacking in any explicit Medical Decision Making to support this plan of management. 

Admission at an inpatient level of care for IV antibiotics was not indicated. There was no evidence of inability to take fluids or medications orally, kidney injury, vomiting, or sepsis syndrome. The elevated WBC was attributable to the presumed urinary tract infection (UTI). The best course of action was to send blood for culture, administer a single dose of ceftriaxone for presumed UTI, and  correct the metabolic acidosis and dehydration in the ER. If the metabolic acidosis did not correct within 2-3 hours, admission for continued therapy for dehydration could be indicated. If it was corrected, the infant could have been safely followed as an outpatient on oral antibiotics while awaiting results of the blood and urine cultures.

"Most children older than two months with UTI who are not vomiting can be safely managed as outpatients as long as close follow-up is possible"  [Shaikh, N et al.]. The referenced article clearly delineates the usual indications for hospitalization as any of the following: 

Age under 2 months, clinically apparent urosepsis (such as toxic appearance, hypotension, poor capillary refill), immunocompromised febrile patients, vomiting or inability to tolerate oral medication, lack of adequate outpatient follow-up, or failure to respond to outpatient therapy. None of these apply in this case.

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Opzelura
The insurer denied: Opzelura
The denial is upheld.

The patient is an adult male with atopic dermatitis. He has been treated with topical steroids, including betamethasone, triamcinolone, fluocinonide, and clobetasol, prednisone, 
mupirocin, and Dupixent. He has been well controlled on Rinvoq and uses Opzelura as spot treatment to stubborn areas. The provider is requesting Opzelura. The health plan denied coverage of the request, as it requires a trial and failure to Eucrisa or topical calcineurin inhibitor. The health plan does not allow coverage of Opzelura if it is used in combination with Rinvoq or other biologics. The denial is being appealed.

The requested Opzelura is not medically necessary.

Topical calcineurin inhibitors are still within standard of care as a steroid sparing therapy for atopic dermatitis. This patient has no contraindications to these and Eucrisa. Therefore, Opzelura 
is not medically necessary. Topical calcineurin inhibitors do not cause cutaneous atrophy that can lead to striae, nor any of 
the other side effects listed in the appeal letter. Those are caused by topical corticosteroids.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: back pain
Treatment: Intracept Procedure
The insurer denied the Intracept Procedure
The health plan's determination is upheld.

The patient is a female who has lower back pain for about a year and half. She previously underwent conservative treatments including anti-inflammatory analgesics, rest, and physical therapy. Physical examination was unremarkable except tenderness over the lumbosacral spine and pain with forward flexion.

The Intracept Procedure is not medically necessary.
The Intracept system was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. The magnetic resonance imaging (MRI) report showed multilevel disc bulge and facet arthropathy with no documented Modic changes. Truumees's study supported the efficacy of Intracept procedure for vertebrogenic pain. However, the patients with radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded.
Given current available medical records, and the inclusion and exclusion criteria of the clinical studies, it is unlikely that this patient will benefit from the proposed Intracept Procedure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: large bilateral varices 
Treatment: Endoluminal Radiofrequency Ablation of leg veins 
The insurer denied Endoluminal Radiofrequency Ablation of leg veins 
The health plan's determination is overturned. 

The patient is a man with large bilateral varices for many years who has been experiencing worsening daily edema and left > (greater than) right skin changes in the foot/ankle. The patient reported scaling and itching over the left lateral ankle and a poorly healing injury to the medial left calf/shin. He reported wearing compression stockings daily. The patient was noted to have large varices on the bilateral lower extremities and brownish skin discoloration and scaling in the left medial calf and lateral ankle.
The patient was diagnosed with symptomatic varicose veins and chronic venous insufficiency and was recommended to continue compression stocking use and to have a lower extremity venous ultrasound.

The Endoluminal Radiofrequency Ablation of leg veins is medically necessary for this patient. The patient has symptomatic lower extremity varicose veins and venous insufficiency requiring treatment. He has had successful treatment of his left lower extremity and requires treatment of his right lower extremity. Treatment of the patient's right lower extremity varicose veins and venous insufficiency is medically necessary. The patient will benefit from the treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder mass.
Treatment: Inpatient stay.

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

The patient is a female with a right shoulder mass. She presented for elective surgical resection of this right shoulder mass. This was a lipomatous tumor that was resected surgically from the right shoulder. The procedure was successful with no documented complications. The patient was stable the following day. Her Jackson-Pratt (JP) drain was removed from the right shoulder, and she was deemed stable for discharge home. 

The inpatient hospital admission was not medically necessary for this patient. The provided medical records in this case document that this patient underwent elective resection of a lipomatous tumor from her right shoulder. The care rendered in this case was consistent with the current standard of care and with the recommendations of the peer-reviewed literature as documented by Won and colleagues in 2019 and by Morioka and associates in 2020. The surgery was successful with no documented complications. The patient had normal vital signs and lab values following this operation. Her JP drain was removed, and she was deemed stable for discharge home on that date. Based on the provided documentation and the peer-reviewed literature, the inpatient hospital admission in this case was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient presented with abdominal pain and vomiting. The patient was afebrile and hemodynamically stable. The admitting history and physical states that the abdomen was soft but had tenderness. An ultrasound showed gallstones and gallbladder wall thickening. There was no leukocytosis. The liver enzymes were normal. There was a plan to do a cholecystectomy but the operating room (OR) schedule was full. The surgery was rescheduled but the patient eloped. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-555 for Gallbladder or Bile Duct Inflammation or Obstruction. Clinical indications for admission include having acute cholecystitis if all of the following indications are met: systemic signs of inflammation, abdominal pain, and a cholecystectomy is not anticipated. In this case, there was abdominal pain but there were not systemic signs of inflammation and a cholecystectomy was anticipated. The patient also did not have hemodynamic instability, common bile duct obstruction, severe dehydration, or bacteremia. 

This patient had gallbladder disease and required a laparoscopic cholecystectomy. This could have been performed as ambulatory surgery. The patient did not have sepsis or evidence of a severe systemic infection. The patient did not meet MCG criteria for admission for Gallbladder or Bile Duct Inflammation or Obstruction. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

The denial is upheld. 

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:	Pregnancy	

Treatment: 	C- section delivery

The insurer denied inpatient admission

The denial is overturned

The patient was admitted at 40.3 weeks gestation for a scheduled repeat c-section. The patient had a prior c-section. She underwent surgery. Her post operative course was uneventful and she was discharged home 3 days later.

It has always been the standard of care to admit patients for delivery. This patient was pregnant and was scheduled for a repeat c-section.

The American College of Gynecology (ACOG) recommends postpartum discharge 48 hours after a vaginal delivery or 72 hours after cesarean delivery (excluding the day of delivery).

ACOG guidelines were followed in this case. The patient was delivered and discharged within the 72 hours period as per the standard of care.

Note that the patient had an indication for a c-section as she had a prior c-section.

Inpatient admission to the hospital for three days is considered medically necessary for this patient.

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 an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Decay

Treatment: D2750 White Glass with High Gold Content Crown, Tooth 14, D2750 White glass with High Gold Content Crown, Tooth 15

The insurer denied: D2750 White Glass with High Gold Content 
Crown, Tooth 14, D2750 White glass with High Gold Content Crown, Tooth 15

The denial is partially approved.

The patient is an adult female. The request is for new (replacement) crowns on teeth #14 and #15. The patient's provider notes that there is recurrent decay under the crown margins, and the gums are being irritated. The health plan denied coverage of the request due to decay not being found. The denial is being appealed.

The requested health service is medically necessary, in part.

Specifically, the requested health service is medically necessary for tooth #15, but the requested health service is not medically necessary for tooth #14. The X-rays are helpful in determining need for new crowns. However, the photos do not have the correct angle in the mouth and are not close enough to the crown margins to show any supposed recurrent decay at the margins. The photos are taken too far away from the tooth to determine if decay is present at the margins. Decay is seen on the X-rays under the distal margin of the crown on tooth #15. A new crown will be needed for tooth #15. No decay is seen on any X-ray of tooth #14. Also, no decay is seen at the margins of the existing crown on the poor-quality photos of tooth #14. A photo taken parallel with the crown margin may show the reported decay. The angle in the presented photos makes it hard to see the area in question. It is hard to determine if the dark area under the crown on tooth #14 is decay in the photos presented. Therefore, the requested health service is medically necessary for tooth #15, but the requested health service is not medically necessary for tooth #14.