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

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

The patient is a male with a history of (h/o) coronary artery disease (CAD) and chronic obstructive pulmonary disease (COPD), who presented to the emergency department (ED) with sudden onset abdominal cramps, profuse watery diarrhea, and muscle cramps. He had diffuse abdominal cramps and complained of having at least 25 loose, watery bowel movements (BM). He also had loose 5 BM in the ED. He was slightly tachycardic but otherwise hemodynamically stable. His labs showed a white blood cell count (WBC) of 10.5, a sodium (Na) of 134, a potassium (K) of 5.5, a blood urea nitrogen (BUN) of 22.5, and a creatinine (Cr) of 2.8. His hemoglobin was 18.7. He was given 2 liters (L) of ringer lactate and started on maintenance intravenous fluids (IVF). He was admitted, and gastroenterology (GI) was consulted. Stool studies were sent as well. GI suspected secretory diarrhea from an infectious source. He was also given Levaquin for a potential bacterial infection. An outpatient colonoscopy was recommended. The patient required intravenous (IV) fluids. He was also given Tylenol that was stopped due to transaminitis. His diarrhea gradually improved. His labs improved, and he was subsequently discharged home.
At issue is the medical necessity of the Inpatient Hospital Admission.

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

The requested health service/treatment of Inpatient Hospital Admission is medically necessary for this patient.
This is a male with a h/o CAD and COPD, who presented to the ED with sudden onset abdominal cramps, profuse watery diarrhea, and muscle cramps. He was tachycardic and had hemoconcentration. He also had acute kidney injury with a serum Cr of 2.8 (his baseline was 0.8 - 0.9). Stool studies were sent, and he was given 2L of IV ringer lactate. He was eventually admitted and maintained on IV fluids. He required IV hydration. He continued to have diarrhea a couple of days into his admission, although the frequency was going down. The patient with persistent diarrhea, abdominal pain, severe dehydration (as indicated by continuous diarrhea and requiring IV hydration) requires an inpatient admission. In addition, the patient had a baseline Cr of 0.8 to 0.9, and he presented with a serum Cr of 2.8. He also had mild hyperkalemia with a K of 5.8. He required IV hydration and further work up, such as a renal ultrasound (US). The patient had severe dehydration from acute gastroenteritis, possible colitis, and was severely dehydrated and also had an acute kidney injury with a 3-fold increase in his baseline serum Cr.

Therefore, the inpatient hospital admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with no significant medical history. She presented to the emergency department with epigastric pain, nausea, vomiting with hematemesis, dark bowel movements, and dizziness since the prior day. She had been taking a lot of ibuprofen for ankle pain. Vital signs were unremarkable. Physical examination was notable for soft, nontender, non-distended abdomen. Labs showed elevated white blood cell count of 14.9, elevated blood urea nitrogen of 20, elevated bilirubin of 1.5, elevated aspartate aminotransferase of 65, and elevated alanine aminotransferase of 89. Stool was positive for occult blood. Urinalysis showed large ketones, trace leukocyte esterase, moderate blood, and few bacteria. She was treated with intravenous pantoprazole drip and intravenous fluids. She was made nil per os (NPO).

The inpatient hospital admission is not medically necessary. 

In this case, the patient presented with melena, hematemesis, and anemia. However, there was no persistent ongoing gastrointestinal bleeding or sustained tachycardia or hypotension, or ongoing bleeding; her hemoglobin remained stable after initial equilibration. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset. Proton pump inhibitor therapy was appropriately initiated. Gastroenterology performed an esophagogastroduodenoscopy, which was appropriate, but no active bleeding or high-risk stigmata were found. All of the measures that were undertaken, including monitoring, transfusion, proton pump inhibitor therapy, Gastroenterology consultation, and endoscopy, could have been performed at a lower level of care.
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 female who was transported to the emergency department (ED) via Emergency Medical Services (EMS) complaining of the abrupt onset of palpitations. The patient was four months postpartum; her pregnancy had been complicated by preeclampsia and postpartum hypertension. Per EMS, her initial blood pressure was 138/68 millimeters of mercury (mmHg) with a heart rate of 166 beats/minute. An electrocardiogram showed sinus tachycardia. The patient was treated en route to the ED with two doses of intravenous adenosine and a dose of intravenous diltiazem. 

Upon arrival in the ED her blood pressure was 100/67 mmHg with a heart rate of 139 beats/minute. Her room air oxygen saturation was 100% (percent). An electrocardiogram showed sinus tachycardia at 135 beats/minute without acute changes. Her serum troponin and brain natriuretic peptide (BNP) levels were normal. A chest x-ray was unremarkable. Chest computed tomography (CT) angiography showed no evidence of pulmonary embolism. There was possible mild pulmonary edema. The patient's urine toxicology screen was negative. She was treated with intravenous fluid, a dose of intravenous diltiazem and oral metoprolol and admitted to the hospital. She reported significant anxiety due to family stressors. She received several doses of intravenous metoprolol and twice daily oral metoprolol was prescribed. She had intermittent tachycardia associated with anxiety attacks. She was seen in consultation by a psychiatrist who diagnosed the patient with anxiety and acute stress reaction and recommended treatment with alprazolam and Zoloft. Oral metoprolol was continued. An echocardiogram was performed and was normal. The patient's heart rate was in the 70s. She was discharged. Medical necessity for an inpatient admission is at issue. 

The health plan's determination is upheld. 

Based on the documentation provided an inpatient stay was not medically necessary. This patient presented complaining of palpitations. Her rhythm was sinus tachycardia which was attributed to anxiety and acute stress reaction. She was hemodynamically stable and other potentially serious causes for her tachycardia, such as sepsis, acute blood loss, decompensated heart failure, thyrotoxicosis and toxins, were ruled out. An echocardiogram showed a structurally normal heart. Her heart rate was controlled with beta-blockers and anxiolytic medication. While the patient was very anxious, she was not delusional, psychotic or suicidal. Sinus tachycardia as a response to emotional stress, while uncomfortable and alarming to the patient, is benign. Treatment of this patient's tachycardia did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of desmoid tumors status/post (s/p) colon resection who was admitted with complaints of (c/o) back pain no longer responsive to his Fentanyl patches. His vital signs were unremarkable. The physical exam was notable for acute distress and writhing in pain. Lab work was notable for leukocytosis. A computed tomography (CT) scan showed multiple large masses involving the anterior abdominal wall and lateral to the liver. The patient was diagnosed with back pain and treated with observation admission for intravenous (IV) pain medication administration. The patient was noted to be resting comfortably during transportation to observation unit. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

No, the requested health service/treatment of inpatient emergency admission was not medically necessary for this patient. This patient presented to the ED (emergency department) with c/o back pain without associated bladder dysfunction or saddle numbness. The patient did not have any acute fractures, or dislocations. The patient did not have an abdominal aortic aneurysm, aortic dissection, cauda equina syndrome, epidural abscess or hematoma, acute spinal fracture, meningitis, osteomyelitis, progressive neurologic deficits, fever, or discitis. The patient had known cancer and received IV pain medications with good response in the observation unit, and this could have been safely provided at a lower level of care than inpatient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid obesity
Treatment:  Wegovy 1.75mg/0.75ml (milligrams per milliliter) pen injections
The insurer denied the  Wegovy 1.75mg/0.75ml (milligrams per milliliter) pen injections
The denial is overturned.

This female has morbid obesity.  She is appealing denial of initial approval of Wegovy.  The patient's past medical history includes hyperlipidemia and impaired fasting glucose.  Clinical record shows the patient started Wegovy with ten pound weight loss over approximately one month.  She was working out regularly. Her body mass index (BMI) was 33.3.  A note shows the patient remains on Wegovy and is exercising regularly.  Her body mass index (BMI) was 28.6.  The patient states she has been participating in NOOM (weight loss program) for approximately over one year.

Yes, the proposed Wegovy is medically necessary.
Wegovy is medically consistent with accepted medical standards of medical practice.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Wegovy is indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of 30 kilograms per meter squared (kg/m2) or greater (obesity) or 27 kilograms per meter squared (kg/m2) or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type II diabetes mellitus, or dyslipidemia).

Medically necessary services are typically those which are:
1) safe 
2) effective
3) generally accepted national standard of medical practice 
4) not provided primarily for convenience of the patient or the practitioner 
5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The requested Wegovy is medically necessary because it is consistent with accepted medical standards for this patient who has a body mass index (BMI) greater than (>) 27 with comorbid conditions of hyperlipidemia and impaired fasting glucose.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crowding; overjet.
Treatment: Braces and monthly visits.
The insurer denied the braces and monthly visits.
The denial is overturned.

The patient is a female. The request is for dental benefits for orthodontic therapy (Braces) and monthly visits.

Per the provider's dental clinical summary, the patient presents with skeletal class I relationship, moderate maxillary and mandibular crowding, severely excessive overjet. Tongue thrust habit, finger sucking habit, open bite.

The health plan denied the claim for braces because the patient did not score a 26, the score necessary for braces approval on the Handicapping Labio-Lingual Deviation (HLD) Index Report. The provider appealed the claim because of the diagnoses of the conditions with which the patient presented.

Yes, the proposed treatment of orthodontic therapy (braces) and monthly visits are medically necessary.
As stated in the dental clinical summary and evidenced in the photos, the patient has a 4-mm (millimeter) open bite. The upper and lower teeth do not come in contact when the mouth is closed.

The seal that is made when the anterior teeth comes together is critical for swallowing, proper speech (enunciation of certain letters--patient may develop a lisp), proper chewing function, and maintaining proper alignment of the teeth in the arch.

Therefore, given the above, the braces and monthly visits are medically necessary.

No, the health plan did not act reasonably, with sound medical judgement and in the best interest of the patient.
If the open bite is not treated, the patient may develop flaring of the teeth, speech problems, difficulty with proper chewing, premature posterior teeth wear, and inability to swallow effectively.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female. She has a history of constipation and recurrent ileocolic intussusception, with a recent admit for intussusception. She was seen in the ED (emergency department) for abdominal pain. She initially presented that morning and had a normal KUB (kidney, ureter, bladder (x-ray)) and ultrasound so was discharged home after a surgery evaluation. She returned later that evening and was noted to have ileocolic intussusception on ultrasound.

IV (intravenous) access was obtained, and surgery was consulted. A CBC (complete blood count) and BMP (basic metabolic panel) were unremarkable. The intussusception was reduced with an air-contrast enema. A repeat ultrasound confirmed the reduction. She was admitted for further monitoring.

The patient was started on a liquid diet and advanced to a full diet. She was given Tylenol as needed. She was discharged to home.

No, the Inpatient admission was not medically necessary.
The child was admitted for an intussusception. While an intussusception is an abdominal emergency, her condition had already been treated prior to her admission. In addition, she was hemodynamically stable, had no documented signs of dehydration, and had adequate pain control with oral medication. She did not require cardiorespiratory monitoring, intravenous medications, respiratory support, intravenous hydration, or any other service which necessitated an acute inpatient level of care. The interventions during her hospital stay, which included over the counter pain medications and advancement of diet, could have been provided at a lower level of care. The requested acute inpatient admission was not medically necessary.

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

The health plan acted appropriately and in the patient's best interest to deny a level of care that was not necessary for her health condition as it is in the patient's best interest to appropriately apply the plan resources.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anorexia nervosa.
Treatment: Non-emergency air/ground ambulance transport.
The insurer denied Non-emergency air/ground ambulance transport. 
The health plan's determination is overturned.

This case involves a young adult female diagnosed with an eating disorder with severe anorexia nervosa and comorbid symptoms of anxiety, depression and passive suicidal ideation. The patient has a history of treatment in multiple eating disorder programs without sustained benefit or remission of symptoms, and she has had general medical complications in the context of worsening symptoms of the eating disorder and comorbid psychiatric conditions including major depressive disorder, generalized anxiety disorder and posttraumatic stress disorder (PTSD) with a history of childhood sexual abuse as a precipitating factor with the eating disorder. Medical complications include cardiac disease with long QT syndrome and sick sinus syndrome and abnormal electrocardiogram (EKG), slow transit constipation and gastroparesis, malnutrition with placement of a percutaneous endoscopic gastrostomy (PEG) tube for feeding due to restrictive intake, orthostatic hypotension (postural orthostatic tachycardia syndrome (POTS), and electrolyte abnormality with hypokalemia, as well as a body mass index (BMI) at 14.5 with weight at 81.9 lbs. and height at five feet and three inches.

The Non-Emergency Air and Ground Ambulance Services from private residence to  Acute Center for Eating Disorders was medically necessary for this patient.

In this case, the patient is diagnosed with severe symptoms of anorexia nervosa including comorbidity with anxiety and depression and trauma history, as well as passive suicidal ideation and extensive, life-threatening general medical complications of malnutrition. The transfer from her home an acute care facility was clinically appropriate and medically necessary in this case scenario. The patient had failed to benefit from treatment at multiple other facilities without sustained benefit and worsening clinical course. The treatment facility was the most appropriate treatment facility to address the multiple general medical complications associated with the eating disorder and to provide the general medical services and comprehensive behavioral health and psychiatric services that were medically necessary and clinically appropriate for this patient. The transport by air ambulance was also medically necessary due to the need for monitoring and support during the transport, as outlined in the clinical summary. Transport by ground transport and commercial airline was not feasible and dangerous in this case scenario. The receiving treatment facility is the closest treatment facility that is/was capable of addressing the medical needs of the patient, and the air ambulance transport (including ground transport) was in the patient's best interest and appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied comprehensive orthodontic treatment. 
The denial is upheld.

The patient is a female with maxillary and mandibular spacing and several unerupted permanent teeth. The orthodontist mentioned in the diagnosis that # (number) 6 and #11 are impacted. The patient was treatment planned for comprehensive orthodontics, but the plan was denied due to lack of medical necessity.

The health plan's determination is upheld.

The patient is an adolescent and in the mixed dentition phase of development. Neither teeth #6 nor #11 appear to be erupting at a poor angle on the radiograph, and it is too early to determine if it will require an exposure as maxillary canines usually erupt at 11-12 years of age.1 There is still much time to see if the tooth will erupt successfully on its own without orthodontic intervention.
Orthodontic treatment is not medically necessary for the patient at this time. She is in the process of losing her remaining primary teeth as they are replaced with permanent teeth. Research indicates the following risk factors for impacted canines in patients over ten years of age:2
1) If there is asymmetry in palpation or a pronounced difference in eruption of canines between the left and right side. (The patient does not have this, as shown in the panoramic radiograph.)
2) The canines cannot be palpated, and occlusal development is advanced. (Occlusal development is not advanced - there are several primary teeth remaining and the second molars are far from eruption.)
3) The lateral incisor is proclined and tipped distally. (Photographic evidence does not indicate proclined lateral incisors.)
4) On a panoramic radiograph of the late mixed dentition if the incisal tip of the canine overlaps the root of the lateral incisor. (Neither canine overlaps the root of a lateral incisor on the panoramic radiograph provided.)
The patient does have maxillary spacing and treatment may be indicated in the future. However, the patient does not exhibit any of the criteria to suspect these canines are, in fact, impacted. For this reason, orthodontic treatment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD
Treatment: LINX Procedure
The insurer denied the LINX Procedure
The determination is upheld.

The patient has a history of Cesarean section and a body mass index (BMI) of 32.5 who is reported to have heartburn and foam regurgitation symptoms. The records indicate the medications, listed as Prilosec 20 milligrams (mg) daily, do help her. Endoscopic findings include no evidence of esophagitis or hiatal hernia. Biopsies demonstrated mild chronic reflux esophagitis, negative for Barrett's or dysplasia.
The DeMeester score was 72.4 indicating significantly abnormal esophageal acid exposure. The notes indicate the patient and provider were interested in pursuing the LINX procedure for treatment of the patient's GERD.
At issue is whether the proposed health service or treatment Laparoscopy and esophageal sphincter augmentation procedure (LINX procedure) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

No, the LINX procedure is not likely to be more beneficial than standard treatment for the patient's GERD. Standard treatment with proton pump inhibitor medication, or laparoscopic fundoplication remain effective therapies, and the LINX procedure has not proven to be more beneficial. The body of literature in support of the LINX procedure offers insufficient long term data with adequate numbers of patients and a paucity of control groups. Questions regarding longer term risk of erosion and dysphagia remain unanswered.
As Schivas writes in a 2020 review of 35 studies with meta-analysis, "The findings of our review suggest that magnetic sphincter augmentation (MSA) has the potential to bridge the treatment gap between maxed-out medical treatment and LF. However, further studies with longer follow-up are needed for a better elucidation of these results" (1).
The LINX procedure has not proven more effective than medication therapy or surgical fundoplication in sufficient long term and controlled studies.
As Zhuang writes in a 2021 meta-analysis, "MSA was an effective and safe therapy for GERD. Well-designed randomized trials that compare the efficacy of MSA with other therapies are needed" (2). The vast majority of studies are short term cohort studies (3) and leave questions about longer term outcomes unanswered when compared to standard therapy. The LINX procedure is not considered medically necessary.