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

Diagnosis: Uterine fibroids. 
Treatment: Uterine artery embolization (UAE). 

The insurer denied uterine artery embolization (UAE). 
The health plan's determination is overturned. 

The patient is a female with symptomatic uterine fibroids, heavy menstrual vaginal bleeding, pelvic pain, and abdominal pain, who had a workup confirming recurrent fibroids. She subsequently underwent treatment with uterine artery embolization (UAE). Menstrual cycles were regular; there was no persistent abnormal uterine bleeding. She also had urinary frequency. 

The requested uterine artery embolization (UAE) is medically necessary for this patient. A UAE procedure would be beneficial for her symptoms and imaging findings. 

This patient has fibroids and is a candidate for UAE. There are no contraindications. 
Imaging confirms fibroids. Symptoms are real and concerning and relate to the fibroids. 
The standard of care for treatment of fibroids includes medical management, minimally invasive treatment such as uterine artery embolization, and surgical options, such as myomectomy. A Hysterectomy can always be considered. 

This patient had a pre-procedural evaluation/work-up for her clinical situation, including review of symptoms prior to the UAE and also including review of imaging; she met selection criteria. She has fibroids with vascular flow. The patient had a Pap smear, cytology negative. 

The patient had an endometrial biopsy; the fact that deep endometrial tissue was not found is irrelevant. No malignancy was found and there is no absolute need for a repeat biopsy based on her symptoms. 

The patient is not seeking the procedure to preserve fertility but may be engaging in active attempts to get pregnant. 

According to the literature, there are favorable outcomes for UAE as documented by the multiple studies reviewed. Also, patient satisfaction rates at up to two years following UAE versus surgery (myomectomy or hysterectomy) shows there is no evidence of a difference between the interventions. UAE is a safe, minimally invasive alternative to surgery. 

The patient had a previous procedure several years ago at a different institution by a different provider. A repeat UAE may be performed when there is documentation of continued symptoms such as bleeding or pain, as in this case. Repeat procedures are most appropriate when there are persistent symptoms in combination with findings on imaging of an incomplete initial procedure, as evidenced by continued blood flow to the treated fibroid (as noted). Newer fibroids causing symptoms are also possible.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Motor Vehicle Accident
Treatment: Inpatient Rehabilitation
The insurer denied the Inpatient Rehabilitation.
The determination is upheld.

The patient was admitted to inpatient rehabilitation following hospitalization related to a pedestrian versus car trauma which resulted in a left scapula fracture, left inferior ramps fracture, left acetabular fracture, left iliac wing fracture and lumbar (L) 1 compression fracture. At issue is whether the inpatient rehabilitation (rehab) admission was medically necessary for this patient.

The requested inpatient rehab hospital admission was not medically necessary for this patient.

While the patient had made improvement with therapy, she had plateaued and additional functional progress was minimal. For example, toileting was maximal assistance (MAXA) but actually went back to total dependence. Upper body dressing improved to setup and stayed at setup. Functional transfers remained moderate assistance (MODA). Lower body dressing remained MODA and toilet transfers remained MAXA. While toilet transfers did improve to MODA, this is not enough functional improvement to support continued inpatient rehabilitation stay and patient remained MODA. Also, at the time of discharge, the patient remained totally dependent for toilet transfers. She was totally dependent for toileting. Also, car transfers remained MODA as did lower body dressing. While ambulation improved from 50 feet (') with a front wheeled walker (FWW) with MODA, this was still the same and while 50' FWW with minimal assistance (MINA) was noted, the functional improvement was unreasonable given the timeframe -especially as the patient was upgraded to weight bearing as tolerated (WBAT) for the left lower extremity (LLE) and WBAT for the left upper extremity (LUE). Also, medically the documentation does not support medical necessity for inpatient rehabilitation. While physician oversight was provided, the documentation did not support a medical need for this close oversight. The patient's vital signs were stable. She did report pain but the medications remained unchanged, with the exception of the addition of scheduled Tylenol a few days prior to discharge. Additionally, an orthopedic referral could have been completed as an outpatient. Lastly, wound care noted stage 4 pressure ulcer (PU) on sacrum and noted improvement. Treatment was 2 times (x)/day. The wound care order changed the following month -remained twice a day (BID) treatments, but packing was not noted. Nursing noted "Stage 4 PU healing well on sacrum," but there were no provider notes which specifically addressed the sacral wound nor nursing order changes. Without specific wound care documentation, skilled nursing would not be medically necessary. Therefore, the requested services are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied an increase in personal care service hours. The denial was upheld. 

The patient is a female with a past medical history significant for hypertension, hyperlipidemia, breast cancer, osteoarthritis of the knees and hips, postherpetic neuralgia and aortic insufficiency. The patient currently lives alone in her own apartment. She currently receives services to help with most instrumental activities of daily living (IADL) and many activities of daily living (ADL). The patient is receiving personal care services for 8.5 hours per day times () 7 days a week for a total of 59.5 hours a week.

The health plan's final adverse determination denial notice states the patient does not meet the criteria for an increase in Personal Care Aide Level 2 services because the service is not medically necessary. The health plan denied additional services stating the patient requires maximal assistance for dressing upper and lower body, personal hygiene, bed mobility, walking, locomotion, bathing, toilet transfer, toilet use, meal preparation and medication management (she needs physical help to complete most parts of this task, like someone to lean on or helping her lift a body part, however, she can complete some parts of the task by herself).

At issue is the medical necessity of the increase in personal care aide level 2 services for live-in per diem, 24 hours per day.

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

The requested health service/treatment of increase in personal care aide level 2 services for a live-in per diem, 24 hours per day, is not medically necessary for this patient.

The patient is female with multiple problems including generalized debility, ambulatory dysfunction along with osteoarthritis. Based upon information provided, the patient has services 8.5 hours a day. These services are adequate to meet the patient's IADLs and ADLs. There are no additional services which would be medically necessary noted that could not be addressed in the allotted time. In order for services to be considered medically necessary, the personal care aide must be performing a service such as a necessary ADL or IADL. There are no nocturnal services noted that cannot be addressed within the current allowed service time.

Therefore, the requested health service for an increase in personal care aide level 2 services, for live-in per diem, 24 hours per day, is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld. 

The patient is a male who presented to the emergency department complaining of three hours of left-sided chest pain and left arm tingling. His medical history was remarkable for coronary artery disease, myocardial infarction, and percutaneous coronary interventions. His blood pressure was 136/74 millimeters of mercury (mmHg) with a heart rate of 70 beats/minute. His respiratory rate was 16 breaths/minute with a room air oxygen saturation of 98%.

His cardiac exam was unremarkable. An electrocardiogram showed sinus rhythm with nonspecific T wave (repolarization of the ventricles) changes anteriorly. His serum troponin level was normal. The patient was treated with aspirin, Plavix and heparin and admitted to the hospital to rule out acute coronary syndrome.

Myocardial perfusion imaging showed no evidence of ischemia. He was discharged.

At issue is the Inpatient stay for medical necessity.

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

The requested health service/treatment of inpatient stay was not medically necessary for this patient.

This male patient, with known coronary artery disease, presented with chest pain that was thought to be suspicious for acute coronary syndrome (ACS). The patient was hemodynamically stable, with normal cardiac biomarkers, and no diagnostic electrocardiographic changes. He was in sinus rhythm without evidence of decompensated heart failure. He did not require intensive monitoring or acute intervention. The care this patient received did not require an inpatient stay. This has been shown to be safe and in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.

Therefore, the health service of inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male with an unremarkable past medical history who presented to the emergency department with complaints of persistent nausea and vomiting as well as upper abdominal pain, which started approximately 1 week before the presentation. The patient was already evaluated in the emergency department 2 days before the current admission and discharged home. During his previous evaluation, the patient had an unremarkable computed tomography (CT) scan of the abdomen.

The patient reported that he tried to use Zofran and Pepcid at home but was not able to keep them down. The patient stated that he did not tolerate liquids or solids for many days.

The patient was admitted to the hospital with intractable nausea, vomiting, and abdominal pain.

During the hospital stay, the patient received treatment with intravenous fluids. It was suspected that his symptoms were secondary to cannabis hyperemesis syndrome. The patient's diet was advanced, and he tolerated it without difficulties before discharge. The patient was counseled to decrease the daily use of cannabis. As his clinical condition significantly improved, the patient was discharged home.

The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld. 

The inpatient hospital stay was not medically necessary for this patient.

The patient presented to the hospital with a 1-week history of nausea, vomiting, and significantly decreased oral intake. However, at the time of admission and during the entire hospital stay, the patient remained afebrile and hemodynamically stable. He had moist mucous membranes and no clinical signs of profound dehydration. His initial laboratory evaluation revealed only mild dehydration because of mild hypernatremia. Because of the mild dehydration, the patient had a slightly elevated lactic acid level, but subsequently, the lactic acid level came down.

It was reported that the patient recently had a CT scan of the abdomen and pelvis as well as abdominal ultrasound that did not demonstrate any acute changes that could explain the findings.

The patient's symptoms were attributed to cannabis hyperemesis syndrome; therefore, the patient was consulted on decreasing marijuana use.

Overall, this patient remained in stable clinical condition and had no clinical findings that would justify admission at the acute inpatient level of care.

This patient did not require any diagnostic tests or interventions that would necessitate admission at the acute inpatient level of care.

Since the patient reported symptoms that were not relieved as an outpatient, the admission for monitoring to treat mild dehydration and ensure improving oral intake was reasonable, however this could have been accomplished at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied the inpatient stay. 
The denial is upheld in whole.

The patient is a female who presented to the emergency department complaining of chest pain, exertional dyspnea and palpitations. Her medical history was remarkable for hypertension, hyperlipidemia, obesity, gastroesophageal reflux disease, esophagitis and gastritis. Her blood pressure was 123/78 millimeters of mercury (mmHg) with a heart rate of 94 beats/minute. Her respiratory rate was 16/minute with a room air oxygen saturation of 97%. Her physical exam was unremarkable. An electrocardiogram showed sinus rhythm without acute changes. Her serum troponin, brain natriuretic peptide (BNP) and D-dimer levels were normal. Her serum potassium level was 2.6 millimoles per liter (mmol/L); her magnesium level was 1.2 mmol/L. Her total serum calcium level was low, but her ionized calcium level was normal. She was hypoalbuminemic and had mild hypophosphatemia. Chest X-ray showed no acute pathology. She was treated with intravenous magnesium and oral potassium with normalization of her potassium and magnesium levels. She was also treated with aspirin, a statin and pantoprazole. She was admitted to the hospital to rule out acute coronary syndrome. Serial troponin levels were normal. The patient's symptoms were thought to be due to esophagitis and gastritis. She was discharged. Medical necessity for an inpatient stay is the subject under review.

The health plan's determination is upheld in whole.

This patient presented with atypical symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, monitoring until ACS could be ruled out was a reasonable approach. On the other hand, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. Based on her HEART score, she was at low risk for major adverse cardiac events. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Abdominal Pain/Stomach Pain
Treatment: Inpatient Hospital
The health plan denied the requested inpatient hospital stay as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with a medical history of iron-deficiency anemia and neck pain. She presented to the emergency department with intermittent abdominal pain and occasional hematochezia. Vital signs were notable for tachycardia with pulse rate of 114/minute. Physical examination was notable for increased bowel sounds, positive guaiac, and external hemorrhoids. Labs showed low hemoglobin of 7.9, a low hematocrit of 29.2%, an elevated platelet count of 437, and unremarkable chemistry panel. A chest x-ray was unremarkable. She was treated with intravenous fluids, Famotidine, and Ondansetron. A gastroenterology consultation concluded that the abdominal pain could be secondary to gastritis, and anemia warranted assessment for gastrointestinal malignancy and lower gastrointestinal bleeding; the recommendation was to monitor blood count, assess iron status, clear liquid diet, nothing by mouth after midnight, bowel preparation, and plan for esophagogastroduodenoscopy and colonoscopy the next day. She underwent a laparoscopic left hemicolectomy with splenic flexure takedown and low anterior resection. She was discharged with a plan for oncology follow-up. At issue is the medical necessity for the inpatient level of care.

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

Yes, the inpatient level of care is supported as medically necessary. The patient presented with symptomatic colorectal cancer, and had imaging showing free air after colonoscopy, which can be due to colonic perforation - a risk which is increased in the setting of colorectal cancer [1,2]. After concern for perforation during colonoscopy versus free air due to submucosal ink injection, she appropriately underwent laparoscopy [1,2]. This was followed by hemicolectomy and low anterior resection to address colorectal cancer [3,4]. She then had significant drop in hemoglobin, requiring a transfusion. Continued hospital care was appropriate to await return of bowel function before discharge [3,4]. The care provided could not have been provided without the inpatient level of care given the severity of disease, drop in hemoglobin after surgery, need for nothing by mouth status, and the length of stay. For these reasons, the inpatient level of care is supported for the duration of the hospital stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative colitis.
Treatment: Budesonide ER 9mg  TAB DR - ER, Pre-service.
The insurer denied the Budesonide ER 9mg  TAB DR - ER, Pre-service.
The denial is upheld. 

The patient is a male. He has been diagnosed with ulcerative colitis. He was previously treated with mesalamine, steroids, and infliximab. He is currently on Entyvio. His physician prescribed Ulceris (budesonide) 9 mg (milligrams) daily.

No, the treatment with Budesonide is not medically necessary.

Budesonide has been shown to be effective and safe in adult patients with ulcerative colitis (1-2). However, there have been no randomized clinical trials or large observational clinical studies to show the effectiveness of budesonide in children with ulcerative colitis. Thus, use of budesonide in children with ulcerative colitis would not be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-Hip problem/Pain
Treatment: Pain Management-RFA(radiofrequency ablation)
The health plan denied the RFA as not medically necessary. The reviewer has upheld in whole the health plan's determination.  

The patient has  chronic, right hip pain secondary to osteoarthritis.
Radiofrequency ablation (RFA) of the sensory articular branches of the right obturator and femoral nerve (hip joint RFA) is proposed.

RFA of the right hip joint is not medically necessary for this patient.
In this case the patient complains of right hip pain secondary to osteoarthritis.  The physical examination is significant for pain provocation with abduction of the hip and a positive Patrick's test.  Diagnostic hip injection reduced pain.  RFA performed on one occasion reduced pain for several months. Despite a report of temporary success with the initial RFA, it is the consensus among qualified objective experts regarding the inherent nature of hip joint RFA that further clinical studies, clinical outcomes research, or clinical trials are necessary to determine its safety, efficacy and anticipated outcomes as compared with the standard means of treatment or diagnosis of the condition in question. Based on peer-reviewed medical literature and relevant medical society guidelines, hip joint RFA is not considered standard of care in the United States for the management of hip joint pain secondary to osteoarthritis.
A review of hip joint RFA states "Radiofrequency treatments for the sensory innervation of the hip joint have the potential to reduce pain secondary to degenerative conditions. Ongoing concerns remain regarding the anatomic targets, as well as quality, procedural aspects, and monitoring of outcomes in publications on this topic. Randomized controlled trials of high methodological quality are required to further elaborate the role of these interventions in this population" [1].
A review of hip and knee joint RFA states "More quality research studies are needed to establish the efficacy and safety of these procedures in patients with refractory hip and knee pain" [2].

The 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee states (in part) "Radiofrequency ablation is conditionally recommended for patients with knee osteoarthritis (OA). A number of studies have demonstrated potential analgesic benefits with various ablation techniques but, because of the heterogeneity of techniques and controls used and lack of long-term safety data, this recommendation is conditional" [3]. RFA of the hip joint is not listed as a recommendation in the guideline [3].

Reliable evidence shows that the consensus among qualified objective experts regarding the inherent nature of hip joint RFA is that further clinical studies, clinical outcomes research, or clinical trials are necessary to determine its safety, efficacy and anticipated outcomes as compared with the standard means of treatment or diagnosis of the condition in question.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overjet
Treatment: Braces
The insurer denied the braces. 
The denial is overturned. 

The patient is a male. The request is for dental benefits for orthodontic treatment (Braces). The patient presents with excessive overjet, greater than 9mm (millimeters) and micrognathia of the mandible.

Yes, the proposed treatment of orthodontic therapy (Braces) is medically necessary.

As evidenced by the patient's study models and x-rays, the Patient has an extremely excessive overjet of greater than 9mm (millimeters). Normal overjet is 1-3mm (millimeters).

Any significant overjet beyond the normal puts the Patient at risk for increased trauma due to the protrusion of these upper front teeth, sleep apnea, speech impediments and possible damage to the soft tissue (gums) from the position of the lower front teeth contacting the upper gums.

Therefore, given the above, the braces are medically necessary.

The severity of the overjet, if left untreated can have a severe long term negative impact on the Patient's ability to have normal chewing and speech function.