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

Diagnosis: Coronary Artery Disease

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This patient has single vessel coronary artery disease and progressive dyspnea and presented for elective cardiac catheterization. Past medical history was significant for Sjogrens syndrome, fibromyalgia, breast cancer status post bilateral mastectomy and hypothyroidism.  Upon arrival, vital signs were stable and no abnormalities were reported on physical examination. Serum troponin level was <0.01 ng/ml [nanogram per milliliter].  The patient underwent percutaneous coronary intervention the day after elective admission. Atherectomy with drug eluting stent was placed in the left anterior descending artery.  Post procedure, the patient was treated with intravenous (IV) fluids for an 8-hour period. Serum troponin levels were noted to be elevated post intervention. Post procedure echocardiogram revealed anteroapical hypokinesis. The patient was discharged home.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented for elective percutaneous revascularization.  She underwent an uncomplicated procedure and atherectomy with drug eluting stents were placed in the mid and distal left anterior descending coronary artery. She was discharged the following day.  This patient had several co-morbidities but presented one day prior to her procedure with no active symptoms and received no active therapies.  Several investigators have studied the safety and cost savings surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (Reference1-4). Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care (Reference 4). In conclusion, inpatient admission was not medically necessary.  The patient could have been managed at a lower level of care.

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Venous insufficiency 
Treatment: Open/Percutaneous Transcatheter Stent Placement 
The insurer denied the Open/Percutaneous Transcatheter Stent Placement. 
The denial is upheld. 

The patient is a female. The patient has bilateral symptomatic venous insufficiency, with leg pain, swelling, heaviness, and varicose veins. She has been advised to undergo venogram with intravascular ultrasound to look for proximal venous compression. Coverage was denied by the health plan because of the lack of studies demonstrating possible proximal venous stenosis, occlusion, or compression. 

No, the Open/Percutaneous Transcatheter Stent Placement is not medically necessary. 

The provider's note states that the patient may have proximal venous obstruction or compression. This is the basis for performing the proposed procedure (venogram with intravascular ultrasound). The provider states that the MR (magnetic resonance) venogram shows prominent gonadal veins, peri-IVC (inferior vena cava) tributaries, and left common iliac vein compression. However, the report of the MR (magnetic resonance) venogram makes no mention of these findings. In addition, a venous duplex study showed no evidence of central venous compression.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld in whole. 

The patient is a male who presented to the emergency department (ED)  with chest pain which he described as midsternal intermittent chest tightness. The pain lasted for 5-10 minutes and recurred 1-2 hours later. The patient also suffered from left sided chest pain migrating to the right shoulder and epigastric area. The pain was associated with nausea and vomiting, palpitations, lightheadedness, shortness of breath, and diaphoresis. The patient initially was seen by his primary care physician (or provider) (PCP) in the office for this chest pain. The electrocardiogram (ECG) in the office was unremarkable. However, because chest pain was worsening, he was sent to the ED. The patient had history of hypertension (HTN), diabetes mellitus (DM) and obesity.
His vital signs in ED revealed a blood pressure (BP) at 113/61, heart rate (HR) was 89, and oxygen (O2) saturation was 97%. His physical examination was unremarkable, he was not in distress, lungs were clear, heart was regular with normal rate and no murmur and abdomen was soft. His ECG revealed sinus tachycardia with the rate of 114 beats per minute (BPM). 

His chest x-ray (CXR) was unremarkable. The patient was given oral Aspirin. He was admitted to the hospital for further evaluation. His DM, HTN, was managed with oral medications. The patient continued to complain of chest pain. 
The patient underwent a nuclear perfusion stress test and the test was abnormal. It revealed a small area of mild anterior wall ischemia. Left ventricular function was normal with an ejection fraction (EF) of 74 percent (%). Cardiology recommended medical management. Metoprolol was added to his medications. His serial troponin was negative. His ECG did not reveal any ischemic changes. 
The patient had history of gastroesophageal reflux disease (GERD) and his pain was considered to be due to GERD. He was started on Pantoprazole. There was some improvement of chest pain. The patient was discharged home. 
At issue is the medical necessity of the Inpatient Stay. 

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. 
The patient presented with chest pain with elements suggesting non cardiac chest pain. He did have coronary risk factors. However, his vital signs were normal, his physical exam was unremarkable, his cardiac enzymes negative and his ECG was without acute changes. His stress nuclear test has minor abnormalities and cardiology did not feel that the patient had indications for coronary angiography. His chest pain was felt to be most likely due to gastrointestinal cause. The patient's condition, his labs results, imaging studies and his management did not meet the need of an inpatient admission. 
Per Gulati et al, "Patients with stable angina or noncardiac chest pain that is not life-threatening should be managed as outpatients." 
Therefore, the Inpatient Stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High blood pressure, osteoarthritis, diabetes mellitus type II with neuropathy, acid reflux, constipation, high cholesterol, and glaucoma 
Treatment: Increase Social Daycare to Three Days per Week 
The insurer denied the Increase Social Daycare to Three Days per Week. 
The denial is upheld. 

This male has medical conditions including high blood pressure, osteoarthritis, diabetes mellitus type II with neuropathy, acid reflux, constipation, high cholesterol, and glaucoma.  He is receiving 20 hours per week of personal care service.  His wife also receives 15 hours per week of personal care service and one day per week of Social Day Care.  The patient is appealing denial of increase Social Daycare to three days per week to reduce social isolation and increase social and community engagement.  The Plan approved one day Social Daycare.  The request was denied because there are no medically necessary reasons.  The patient lives with his spouse.  They share a personal assistant.  The patient's spouse attends daycare one day per week.  Uniform Assessment System (UAS) evaluation completed shows normal cognition and does not show indicators of possible depressed, anxious, or sad mood. 

No, the proposed treatment is not medically necessary. 

Adult daycare centers offer a heterogeneous group of services that provide for the daily living, care, nutritional, and social needs of an older adult.  This patient lives with his wife and shares personal assistance services (PAS).  He receives 20 hours per week of personal care services.  He is appealing denial of increase in Social Daycare to three days per week to reduce social isolation and increase social and community engagement.  The Plan approved one day Social Daycare.  The Uniform Assessment System (UAS) evaluation completed shows the patient has normal cognition and no indicators of possible depressed, anxious, or sad mood.  The documentation does not support social isolation of the need for medical services that are not being met with current 20 hours personal assistance services (PAS) and one day Daycare.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole.

The patient is a male with a history of hypertension and diabetes who presented to the hospital with left arm and leg cramping and weakness. The patient reported that the symptoms started 1 month before this presentation and then resolved but returned in the last few days. Vital signs in the emergency department (ED) were stable, with normal blood pressure and heart rate. On exam, the patient is alert and oriented, with unequal pupils due to a childhood injury. The cardiopulmonary exam was unremarkable. Neurologically the patient was alert and oriented x4, with mild left arm and leg weakness.
Computed tomography (CT) scan of the head showed no evidence of acute intracranial hemorrhage or acute appearing infarct. Computed tomography angiography (CTA) of the carotids and circle of Willis showed mild internal carotid origin calcification but no large vessel occlusion. There are degenerative changes of the cervical spine noted on the imaging of the CT neck. Chest x-ray was clear.
The medical team admitted the patient under a transient ischemic attack (TIA) diagnosis. He was given aspirin, atorvastatin 80 milligrams (mg), brain magnetic resonance imaging (MRI) was ordered, and a neurology consultation.
The neurologist assessed the patient, documented 4 out of 5 strength in the arm and the leg, and agreed with pursuing brain MRI. They also ordered a carotid duplex and echocardiogram as well as thyroid stimulating hormone (TSH) and B12. The patient did not wish to pursue MRI in the hospital and did not wish to be further hospitalized. An outpatient MRI was scheduled, and the patient was released home. The final discharge diagnosis is a spasm of the left side of the body.
The question at hand is whether inpatient hospitalization is warranted.

The health plan's determination is upheld.

Based on the provided documentation, the patient's symptoms are subacute to chronic, and he is outside of the window for tissue plasminogen activator (TPA) or clot retrieval if a cerebrovascular accident (CVA) caused the symptoms. There is no documented National Institute of Health (NIH) score, as the patient's symptoms are mild and not quite congruous with a CVA. Discharge diagnosis is a spasm of the left side of the body. This type of presentation can be managed under a lower level of care.
The patient did not have an acute stroke. The patient had a questionable recurrent TIA but remained hemodynamically stable, without acute focal abnormalities found on brain imaging. The patient felt relatively well and was released within 24 hours of hospitalization, without the need for parenteral anticoagulation. As a result, criteria for admission to inpatient care for TIA are not met.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chest pain

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission.

The denial is upheld. 

This male patient has a history of hypertension, diabetes, and high cholesterol.

This patient presented with two minutes of atypical chest pain and lightheadedness. His pretest probability of coronary artery disease is low. (Reference 1) Utilizing the HEART (history, ECG [Echocardiogram] anomalies, patient age, risk factors , and Troponin) score he was considered low risk. (Reference 2) Utilizing the TIMI (thrombolysis in myocardial infarction) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST changes on electrocardiogram (ECG) was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low 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.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care.

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

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

Diagnosis: Congestive Heart Failure (CHF).

Treatment: inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient has a history of hypertension, and CHF (congestive heart failure). He presented to the emergency department (ED) with complaints of worsening shortness of breath (SOB) and swelling of his feet. He had been non-compliant with his medications. At presentation to the hospital, vital signs were temperature (T) 98, heart rate (HR) 99, respiratory rate (RR) 20, blood pressure (BP) 162/101 and oxygen (O2) saturations of 92% (percent) on room air (RA). The patient was noted to be using some accessory muscles for respiration. He was alert and oriented times 3. The lung exam revealed some decreased air entry and wheezing. There was edema of the lower extremities was noted.  
Labs were significant for sodium (Na+) 133, blood urea nitrogen (BUN)/ creatinine (Cr) 16/1.49, Troponin 0.05, B-type natriuretic peptide (BNP) 13000. EKG (electrocardiogram) showed sinus tachycardia, left ventricular hypertrophy (LVH), premature ventricular contractions. Chest X ray revealed right pleural effusion with atelectasis/infiltrate in right lung base. 

The patient was placed on BiPAP (bilevel positive airway pressure) initially but did not tolerate it, so he took it off. He was treated with intravenous (IV) Lasix. Started on empiric antibiotics Vancomycin/Rocephin. The patient was treated with IV hydralazine initially for elevated blood pressure. He was admitted to the hospital for treatment of CHF. 

As per the Nursing note in ED, the patient was alert and oriented times three and in no acute distress. He denied SOB or chest pain with ambulating and had refused further BiPAP. The patient also refused the previous night. Oxygen saturation was 98% on RA. Repeat chest X-ray revealed some improvement of prior findings. The patient was feeling better and decided to go home. He signed out AMA (against medical advice).
Lungs were described as clear to auscultation. The patient was not hypoxic and did not require oxygen. The patient was sent home on oral medication.

This patient did not need acute hospitalization. His symptoms of elevated BP were related to noncompliance with medications. He could have been placed in observation status while diagnostic testing and treatment were initiated. The patient could have been treated with IV diuretics initially; myocardial infarction was ruled out. The patient was feeling better, was not hypoxic and lungs were clear. He was feeling well and at baseline and wanted to go home. Decided to sign out AMA. This patient could have been placed in Observation and subsequently discharged home after a period under observation on oral meds with close follow up in outpatient setting.

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: head trauma

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission.

The denial is upheld. 

This male patient has a history of polysubstance abuse.

Based upon the information provided, the inpatient admission was not medically necessary as the patient could have been treated on an observation status without an acute inpatient admission as this procedure- repair of scalp laceration as well as diagnostic X rays did not require an inpatient admission. Furthermore, he did not have any focal findings and the x rays did not reveal any acute process. Pain management could have been done in an observation status. Ativan for potential withdrawal could have also been given in an observation status. The patient did not meet criteria based upon Milliman Care Guidelines (MCG) guidelines as noted by the insurer as there were no associated risk factors that would have necessitated inpatient surgery. In addition, Clinical Institute Withdrawal Assessment of Alcohol Scale measures 10 symptoms and scores of less than 8 to 10 indicate minimal to mild withdrawal. The patient's Glasgow Coma Scale/Score (GCS) score was 15 as well. Thus, the patient did not require acute admission for this but rather observation.

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

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

Diagnosis: Bruising and Idiopathic Thrombocytopenic
Purpura
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient in this case is a female who presented to the emergency departments with a complaint of bruising on her left leg, right arm and left hip. She had no known trauma.  She had a history of idiopathic thrombocytopenic purpura (ITP). 

The patient's vital signs were unremarkable and physical examination was notable for a few bruises.  Laboratory studies were notable for a platelet count of 34.  She was admitted for treatment of worsening idiopathic thrombocytopenic purpura (ITP).  She was treated with dexamethasone, 40 milligrams daily, and her platelet count improved from 34 up to 73. She was discharged with instructions to take one more day of dexamethasone 40 milligrams.  No other acute medical issues were noted during this hospitalization.

No, the proposed inpatient admission was not medically necessary.
This patient was noted to have thrombocytopenia with a platelet count of 34 associated with bruising but not associated with bleeding. She was treated with oral dexamethasone.  She had no hemodynamic instability and did not have any acute infection or significant anemia.  She did not require acute care inpatient admission and could have been treated on an outpatient basis with oral dexamethasone.  The acute care inpatient admission in this case was not medically necessary.

Yes, the health plan act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Missing teeth. 
Treatment: Implant Services (D6010) on Teeth 4, 6, 11, 13, 20, 22, 27, 29. 

The insurer denied the Implant Services (D6010) on Teeth 4, 6, 11, 13, 20, 22, 27, 29. 
The denial is upheld. 

The patient is a female. The case is a standard New York Appeal request to review the medical necessity of proposed multiple dental implants for an adult female patient in order to restore / anchor dental prosthetics to replace her missing dentition. She currently wears dentures, but has a gag reflex. 

No, the Implant Services (D6010) on Teeth 4, 6, 11, 13, 20, 22, 27, 29 are not medically necessary. 

The case is a standard New York Appeal request to review the medical necessity of proposed multiple dental implants for an adult female patient in order to restore / anchor dental prosthetics to replace her missing dentition. She has been missing teeth for a number of years. She currently wears dentures, but has a gag reflex, making tolerance of dentures difficult. Her dentist is proposing multiple implants, to support implant supported / retained prosthetics. There is no clinical detail provided on how the patient tolerated impressions for prior dentures, eventually enabling her to have been fitted for dentures that were functional in the past. There is no detail provided on patient weight loss, or gastrointestinal (GI) issues, related to her gag reflex, and purported difficulty with eating. The proposed treatment is but one of a few alternative treatment options available, but no other options are evidenced to have been offered or discussed, from the materials enclosed with this submitted appeal request. The information provided in the appeal fails to substantiate medical necessity, as alternative methods are available, and the details on the patient's medical issue (gag reflex) are scant and do not offer a full detail on the degree of medical disability / dysfunction attributable to the gag. As such, the original denial is upheld. 

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient. Alternative treatments / options are available.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right Corneal Ulcer

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission.

The denial is overturned.

The patient was admitted for management of a right corneal ulcer.  The patient initially saw an Ophthalmologist and was diagnosed with right corneal ulcer.  The patient was advised to go to the emergency room for evaluation and management of right corneal ulcer, with concerns that she would not be able to provide eye care for herself. 

Visual acuities were count finger in the right eye (OD) and hand motion in the left eye (OS).  Exam showed 2+ (more) injection, 4.5 x 3.5 millimeter (mm) round corneal ulcer in inferior-central visual axis, 50% (percent) thinning with underlying infiltrate 3x3mm, inferior triangular shaped infiltrate noted below ulcer extending to the limbus, 2+ Descemet's folds and microcystic edema OD.  Diagnosis of right corneal ulcer was noted.  Cultures were sent.  Inpatient admission was recommended given severity of the infection, vision loss and concern for patient's ability to appropriately administer treatment.  Fortified tobramycin and vancomycin was started.  Ciprofloxacin, doxycycline and vitamin C (ascorbic acid) was started.

Exam showed hemorrhagic chemosis temporal, 1-2+ injection, prior area of 60% thinning with corneal ulcer glued over bandage contact lens, and trace fibrin lot inferior nasally OD. Another exam showed hemorrhagic chemosis inferior-temporally, ciliary flush, prior area of 60% thing with corneal ulcer glued over bandage contact lens OD.

Further examinations showed hemorrhagic chemises inferior-temporally, glue came off contact lens, 70-80% thinning, underneath area of thinning with primarily diffuse fibrin but minimal infiltrate OD.  Cornea was reglued. There was hemorrhagic chemosis temporally, 1+ injection.  prior area of 60% thinning with corneal ulcer is glued over bandage contact lens OD. 

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

Based on the above, the medical necessity for the full hospital admission is substantiated. The insurer's denial is overturned.