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

Diagnosis:  Removal of wound staples.
Treatment:  Emergency Room (ER) visit.

The insurer denied coverage for the ER visit.  The denial is upheld. 

This is a female patient who presented to the Emergency Room (ER) for removal of wound staples. As per the appeal letter, the patient had fallen and sustained a laceration to the right temple and had undergone a laceration repair. As per ER notes, the patient was stable with no clinical signs of infection or pain. 

Section 4900(c) of the New York State Insurance Law describes an emergency condition as "a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:  1) Placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; 2) Serious impairment to such person's bodily functions; 3) Serious dysfunction of any bodily organ or part of such person; or 4) Serious disfigurement of such person."

As per review of the medical record and literature, ER treatment for staples removal is not considered medically necessary for this patient. The criteria listed in Section 4900 of the New York State Insurance Law are not met. The patient's health was not in serious jeopardy. The patient had staples in place that could have been removed in a physician's office. The staples did not require emergent removal to prevent serious loss of function, disfigurement or damage to an organ system. Staples are routinely removed in an outpatient office setting. The patient had no complaints. The patient was not having pain or signs of infection. Staple removal does not need to be performed in the ER. Thus, the ER visit was not medically necessary.

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

The carrier's denial of coverage for the ER visit should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Joint Problem/Pain
Inpatient hospital

The patient is a male with a past medical history significant for hypertension, atrial fibrillation, mild stable abdominal aortic aneurysm, and morbid obesity who presented to the emergency department with pain in multiple joints and difficulties with ambulation. Reportedly, the patient complained of swelling in digits 1-3 in the right hand, left knee, and ankle. It was associated with a generalized weakness to the point that he was unable to get out of bed. The patient reported a recent cold but otherwise no sick contacts, nausea, diarrhea, dizziness, headache, or vision changes. 

The health plan's determination is overturned. The inpatient hospital stay was medically necessary for this patient at the acute inpatient level of care because of the severity of the patient's condition and the complexity of the services provided. The patient had severe crystal arthropathy that significantly limited his ability to ambulate due to pain and also rhabdomyolysis. As mentioned earlier in this report, the pain was severe enough that the patient had diminished muscle strength in the lower extremities. In addition to that, the patient had rhabdomyolysis diagnosed by a significantly elevated CPK level, which required treatment with intravenous fluids and frequent monitoring of the kidney function. The patient had received appropriate treatment with intravenous fluids for several days and that exceeded accepted limits of the observation level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Complex ankle fracture.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned. 

This is a male patient who presented to the hospital for a scheduled Open Reduction Internal Fixation (ORIF) of the right ankle and a major bone graft.  The patient sustained an injury of the right ankle while playing tennis approximately one week prior to arrival.  The procedure was performed with no complications.  The patient was transferred to the Post Anesthesia Care Unit (PACU) after surgery for further care.  He was admitted for post-operative care.  He received 24 hours of prophylactic antibiotics.  Enteric coated aspirin was given for deep vein thrombosis (DVT) prophylaxis.  The drain was removed and the patient was transitioned to a controlled ankle motion (CAM) boot on the first post-operative date.  Neurovascular and compartment checks were done every 2 hours.  Pain level was reported at a level of 5-7 out of 10.  He was given intravenous (IV) patient controlled analgesia (PCA) Dilaudid, IV Ofirmev 1000 milligrams (mg), and Oxycodone 10 mg.  He ambulated 50 feet with axillary crutches.  On day 2 of admission, compartments were soft and compressible.  Ordered medications were continued.  On day 3 of admission, the patient was able to ambulate 150 feet with axillary crutches.  The patient tolerated physical therapy well and was able to achieve all necessary goals required for discharge.  He was discharged home in stable condition.

The inpatient hospital admission was medically necessary.  The records demonstrate the patient underwent surgery for a complex ankle fracture.  His physician performed ORIF to the distal fibula and posterior malleolus.  There were two large surgical incisions placed with a blood loss of 250 milliliters (mL).

The physician placed a drain as output was expected.  The drain was maintained overnight.  He had drainage of over 100 mL on day 2 of admission.  The patient also received 15 dosages of PCA on demand (post-operative day [POD] #1). 

This condition would not support the procedure at the ambulatory level of care.  A person with drainage of such extent would require additional monitoring.  Post-surgical bleeding was expected and had occurred.  A drain and wound could not be properly monitored at a lower level of care. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  The inpatient hospital admission is considered medically necessary for this patient.

The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End-stage renal disease
Treatment: Sevelamer Carbonate 2.4GM POW
The insurer denied the Sevelamer Carbonate 2.4GM POW.
The denial is upheld. 

The patient is a female with end-stage renal disease. Sevelamer carbonate was
prescribed for hyperphosphatemia.

No, the treatment with Sevelamer Carbonate is not medically necessary.

There is no documentation that the patient has failed or has been intolerant to and has no contraindication to Velphoro for treatment of hyperphosphatemia (Velphoro is FDA [Food and Drug Administration]-approved for treatment of hyperphosphatemia in end-stage renal disease).

In summary, sevelamer carbonate is not medically necessary. The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer-malignant tumor/Adenocarcinoma.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer had upheld in whole the health plan's determination.

This is a patient with metastatic lung cancer who was admitted to the hospital. She had been diagnosed with metastatic mass of the left adrenal gland. The patient underwent laparoscopic (robotic assisted) left adrenalectomy. Following surgery, she was provided parenteral analgesia and vital signs were monitored. Pathology confirmed metastatic adenocarcinoma of the left adrenal gland. She was advanced to a diet. On the following day, the patient was clinically stable. She was tolerating a diet, pain was controlled with oral medications, and was considered to be clear for discharge from the hospital.

No, the requested health service of inpatient stay was not medically necessary for this patient.  This patient had a metastatic left adrenal mass (adenocarcinoma) and underwent robotic left adrenalectomy. In this case the operation was performed without adverse incident. The patient was appropriately monitored in the post-operative period with vital sign assessment. She remained clinically stable in the post-surgical period. The care and treatment provided could have been rendered with a lower level of care. A lower level of care with overnight monitoring would have been appropriate in this circumstance. This lower level of care would have been consistent with Milliman Care Guidelines (MCG).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blurred vision, atypical chest discomfort, and slurred speech
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient, a male, with a past medical history significant tobacco and cocaine abuse, presented to the ER for evaluation of blurry vision and slurred speech intermittently, of several months to one year duration. The patient was hemodynamically stable. In addition, the patient complained of diffuse chest pain, which was sharp, non-exertional, associated with fatigue and radiated to the back. Cardiac enzymes were negative. ECG revealed no acute ischemic changes. Head CT was negative for CVA (cerebrovascular accident) or bleeding. 

The patient was seen in consultation by neurology and MRI of the brain was recommended to rule out multiple sclerosis. Patient was admitted to telemetry to rule out ACS (acute coronary syndrome) and TIA (transient ischemic attack). He was seen in consultation by cardiology as well. A nuclear stress test was obtained and was negative for ischemia. MRI of the brain was unremarkable. During hospitalization patient had an episode of an allergic reaction to unknown agent and was treated with Benadryl and steroids with resolution of symptoms. He remained hemodynamically stable with no respiratory compromise during this episode. The patient signed out AMA (against medical advice).

No, the proposed Inpatient admission is not "medically necessary".

This patient presented for evaluation of blurry vision and slurred speech, which was present intermittently for several months, as well as atypical chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. There was no evidence of CVA or intracranial bleeding or mass. There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. Ischemia was ruled out by stress testing.  Neurology suspected possible multiple sclerosis and an MRI was obtained, which was unremarkable as well. During hospitalization patient had an episode of an allergic reaction to unknown agent and was treated with Benadryl and steroids with resolution of symptoms. He remained hemodynamically stable with no respiratory compromise during this episode. 

Given the clinical information provided in the record submitted for review, there was no medical necessity for this admission and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer.
Treatment: Proton Beam Therapy.
The insurer denied the Proton Beam Therapy.
The determination is upheld.


This patient has a Gleason 8 adenocarcinoma of the prostate post prostatectomy. He has a rise in the prostate-specific antigen (PSA) to 0.34 nanograms/milliliter (ng/ml). He had a positron emission tomography (PET) scan that revealed two pelvic nodes suspicious for metastases. Radiation therapy is recommended to the pelvis to attempt long term control and proton beam approach is requested. At issue is the medical necessity of proton beam therapy.
The requested treatment of proton beam therapy is not medically necessary for this patient. The use of proton beam radiation therapy as definitive treatment for prostate cancer has medical literature with relatively short follow up with proton beam therapy as monotherapy for prostate malignancies. These studies show equivalent control rates to other types of radiation therapy for the shorter follow up periods. There are also retrospective studies with large numbers of patient that have shown worse gastrointestinal (GI) side effects as compared to photon beam radiation therapy with intensity modulated radiation therapy (IMRT). There is a lack of randomized studies regarding proton beam radiation therapy alone as treatment for prostate cancer that shows equivalent outcome or any improvement over other forms of radiation therapy such as photon IMRT.  Until the current randomized trials ongoing are published in peer reviewed medical literature, this treatment for prostate cancer is not considered a standard of care treatment option and is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld.

The patient is a woman with history of diabetes, hyperlipidemia and hypertension who was admitted to the hospital with right upper quadrant pain that had been ongoing for a few days. She stated the pain was worsened with eating. She also reported nausea but denied vomiting. Review of systems was negative for fevers, chills, chest pain and shortness of breath. Vital signs showed blood pressure 160/71, heart rate 58, and temperature 97 Fahrenheit. On physical exam, heart was regular, breath sounds were normal and the abdomen was soft with mild right upper quadrant tenderness to palpation. Labs showed white blood cell (WBC) 8.4, hemoglobin 14.0, platelets 274, glucose 200, creatinine 0.7, sodium 138, calcium 9.3, magnesium 1.9, alanine aminotransferase (ALT) 79, and aspartate aminotransferase (AST) 37. Imaging demonstrated fatty liver. The patient was admitted with right upper quadrant pain and concern for gallbladder disease. 

The inpatient hospital admission was not medically necessary. The patient was offered the option of following up as an outpatient with surgery when she initially presented with abdominal pain. In addition, it appeared that she did not have acute cholecystitis based on imaging and a HIDA (hepatobiliary iminodiacetic acid) scan that was later performed confirmed no evidence of cholecystitis. Her symptoms resolved and she was discharged from the hospital without a surgical procedure. She could have been cared for at a lower level of care.

The reason is that the patient presented with abdominal pain but had no evidence of sepsis and no definitive evidence of cholecystitis on abdominal imaging. In addition, when the patient was seen by surgery, she was offered the option of hospital admission or outpatient follow up with surgery. These factors indicate that she did not require inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/musculoskeletal
Inpatient hospital

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

This case describes a female patient with a complaint of right knee pain and known osteoarthritis. She was admitted to the hospital for elective right total knee replacement. The surgery was successful with no documented complications of the operation. The patient, however, struggled with dizziness after the operation which limited her ability to participate in supervised physical therapy after surgery. She was deemed stable for discharge to a rehabilitation facility. At issue in this case is the medical necessity of the inpatient hospital admission for this patient.

The Inpatient Hospital Admission was not medically necessary for this patient. The entire episode of care for this patient could have been managed at a lower level of care. The medical records in this case document that this patient underwent a successful right total knee replacement surgery. There were no documented complications of the operation and her labs and vital signs were within normal limits after surgery.

A lower level of care after total joint replacement surgery has been endorsed and supported by the peer-reviewed orthopedic literature as documented by Rutherford and colleagues in Orthopedic Clinics of North American and by Otero and associates in the Journal of Arthroplasty. In their study, Otero and colleagues concluded that "Increased length of stay is associated with increased complication and readmission after joint arthroplasty for patients with a hospital stay of 3 or more days."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission
The proposed treatment was medically necessary.
The patient is a female.  At the time of admission to the hospital, she had a past medical history significant for gastroesophageal reflux disease (GERD) and family history of coronary artery disease (CAD).  The patient presented to the emergency room (ER) for new onset chest pain, associated with diaphoresis. The patient was found to have dynamic electrocardiogram (ECG) changes, ST elevation in V2, V3, and a ST elevation myocardial infarct (STEMI) code was called. The patient's ECG did not meet the criteria for STEMI and the decision was made to treat her medically. Initial troponin was negative, repeat troponin was mildly elevated. 

The patient was admitted to telemetry. An echocardiogram was obtained and revealed normal wall motion. Another set of troponin was obtained and was negative again, so rather than an angiogram, a nuclear stress test was obtained and was negative for ischemia. The patient was discharged home with a plan for outpatient follow-up.

The patient presented with symptoms of new onset angina, diaphoresis and given episodes of chest pain at rest, clinical suspicion for the diagnosis of unstable angina. The patient had risk factors for coronary artery disease, including family history of CAD. The ECG was abnormal with ST segment deviation, suspicious for ischemia/infarction. Troponin was abnormal with the second set elevated, suggestive of myocardial damage. Given the presentation, ECG changes, positive troponin, as well as clinical suspicion for an acute coronary syndrome/unstable angina, it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Dental
Dental/Orthodontic Procedure

Diagnosis: Anterior Crossbite.
Treatment: Braces.
The insurer denied braces. 
The health plan's determination is overturned. 

The patient in question is female with an anterior crossbite on tooth 7. She presents with a skeletal Class I malocclusion with minor crowding in the maxilla and minor crowding in the mandible. She is treatment planned for orthodontics to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity.

The braces (comprehensive orthodontic treatment) and adjustments for braces (periodic orthodontic treatment) are medically necessary for this patient. This patient presents with an anterior crossbite on tooth 7, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: lower leg swelling.
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 emergency department (ED) with bilateral leg swelling. The patient has a past medical history of diabetes mellitus (DM), seizures, meningioma, and post multiple resections. The patient reported that his swelling is spreading up to his hips and abdomen. The patient also noted shortness of breath, usually with jogging. In the ED, his initial blood pressure (BP) was 181/104, repeated blood pressure (BP) was 147/95, heart rate (HR) 70 beats per minute (BPM), and temperature 98.3.

His physical examination revealed mild crackling in the lower lobes bilaterally. There was mild edema in the lower abdomen. His lower extremity (LE) revealed pitting edema. The patient was admitted to the hospital with diagnosis of congestive heart failure (CHF) versus acute nephrotic syndrome. 

The Inpatient Hospital Admission was not medically necessary for this patient. The patient presented with edema of lower extremities and lower abdomen. He had mild shortness of breath and his BP was elevated. The work up revealed presence of nephrotic syndrome and not congestive heart failure. The patient responded to IV diuretics well and was subsequently switched to oral medications.

The patient's condition and management did not reach level of inpatient admission. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coxsackie Virus; Dehydration.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is overturned. 

This female infant patient has Goltz Syndrome and presented to the Emergency Department (ED) on after an evaluation and referral by her pediatrician due to a concern for fever, rash and dehydration secondary to suspected hand-foot-mouth disease. The initial diagnostic evaluation included elevated C-reactive protein (CRP), lactic acid, pyuria, and low bicarbonate (HCO3) levels. The patient was admitted, rehydrated with intravenous (IV fluids) and was discharged the next day tolerating oral (PO). 

This patient has a known genetic condition and was clinically dehydrated (decreased urine output, decreased PO intake, and no tears when crying) with abnormal laboratory findings including elevated CRP, pyuria, elevated lactate, and low HCO3 levels. The patient received appropriate inpatient medical care and her treatment was medically necessary. The patient required hospitalization. 

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

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