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

Diagnosis: Diarrhea and Vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This patient is a male with uncontrolled type II diabetes, prostate cancer, obstructive sleep apnea and asthma. He presented with two days of acute abdominal pain, vomiting, and diarrhea. Blood pressure was 141/85, heart rate was 87, respiratory rate was 18, temp was 97.9, and oxygen saturation was 95%. Ischemic bowel was considered in the differential diagnosis. He had radiographic evidence of enteritis with marked edema and bowel wall thickening up to two centimeters. Imaging findings were more consistent with enteritis. Surgical consult was requested and the recommendation was to consult gastroenterology and medicine. Lactate level and white blood cell counts were normal. 

The patient was treated empirically with ciprofloxacin and metronidazole. His home insulin was resumed. He was noted to have improved abdominal tenderness on exam. Also, he was noted to have no episodes of diarrhea or vomiting since admission.  

No, the proposed inpatient stay was not medically necessary.

This patient presented with abdominal pain, vomiting, and diarrhea. His imaging showed marked bowel wall thickening and edema, most consistent with enteritis. Initially there was a concern for possible mesenteric ischemia. However, the patient's lactate level and white blood cell counts were normal. Also, the patient was stable on antibiotics and noted to not have further episodes of diarrhea. Surgery was consulted and the patient did not require a surgical intervention. He was also hemodynamically stable. He did not fail a lower observation level of care. Therefore, the proposed inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems - Chest pain
Treatment: Inpatient hospital stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This female patient presented to the emergency department complaining of left shoulder and left-sided chest pain that had started the night before. Her medical history was remarkable for coronary artery disease, diabetes, hypertension, hyperlipidemia, asthma, and panic attacks. Her blood pressure was 146/86 millimeters of mercury (mmHg) with a heart rate of 82 beats/minute. Her room air oxygen saturation was 99%. Her physical exam was remarkable for morbid obesity. An electrocardiogram showed sinus rhythm and was a normal tracing. Her serum troponin level was normal. The patient was admitted to the hospital to rule out acute coronary syndrome. A second troponin level was normal. On the following 2 days, the patient had no complaints. The progress notes indicated that she was being monitored until a stress test could be performed. This was scheduled. However, the patient had a panic attack and requested to be discharged. 

An inpatient level of care was not medically necessary.

This woman, with known coronary artery disease, presented with atypical symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, monitoring at a lower level of care until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers, and a normal electrocardiogram. She did not require intensive monitoring or infusion of intravenous cardioactive medications. There is no indication in the records provided that other potentially life-threatening diagnoses were thought to be likely. The progress notes indicate that the reason for the patient's continued hospitalization was for monitoring until a stress test could be performed. There was no medical reason for the delay in stress testing. 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 both safe and cost-effective 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: Upheld

Diagnosis: Back pain; Chest tightness.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient in this case is a woman.  She presented to the emergency department.  She complained of back pain and chest tightness.  She had been to the ED (emergency department) on four prior occasions in the two weeks before this day.

CT (computed tomography) chest was performed and revealed a posterior mediastinal mass.  The patient's vital signs were unremarkable and labs were also unremarkable, other than the presence of mild leukocytosis.  She was not diagnosed with infection and not started on antibiotics.

The patient was admitted, and while in the hospital, she was seen by hematology/oncology.  They recommended PET/CT (positron emission tomography/computed tomography) and outpatient evaluation to arrange for biopsy.

No, the inpatient admission was not medically necessary.

This patient was admitted because she was found to have a mediastinal mass.  She had no hemodynamic instability, respiratory failure or hypoxia.  She was evaluated and PET/CT (positron emission tomography/computed tomography) imaging along with biopsy were recommended.  There was no indication for inpatient admission in this case, given lack of pain requiring IV (intravenous) pain medication, lack of severe infection or hemodynamic compromise.  She could have been evaluated on an outpatient basis with further imaging and biopsy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ingrown toenail
Treatment: Nail Treatment (17110 x2) 
The insurer denied the Nail Treatment (17110 x2).
The denial is overturned.

The patient is a female. She presented primarily for a left foot bunion.  She had 4 out of 10 pain.  She also had an ingrown toenail of the right great toe.  A partial nail avulsion was performed to the bilateral hallux borders.  This was prepped with iodine, and a topical antibiotic was prescribed for postoperative care.

Yes, the Nail Treatment (17110 x 2) was medically necessary.

Ingrown nails of the hallux only are typically treated with a partial nail avulsion, which, from the clinical records, was what was performed.  Routine care involves the paring of long toenails routinely.  That is not performed for pain.  This patient presented with painful hallux nails which are more consistent with onychocryptosis, also known as an ingrown toenail.  This is not a routine condition as a simple long toenail is.  Therefore, the Nail Treatment (17110 x 2) was medically necessary and was not routine.

The procedure performed was not a routine nail service.  It was not performed for a standard elongated toenail, but rather for a painful ingrown toenail, also known as onychocryptosis.  The standard of care is a partial nail avulsion, as was described in the clinical records.  This may be treated with removal of the nail matrix or may be treated without removal of the nail matrix (1, 2).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Periprosthetic fracture resulting from scooter accident.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He was involved in a scooter accident. His past medical history was significant for PSA (polysubstance abuse) detox, bacterial arthritis right shoulder and infection to prosthetic right hip. He was status post several hip procedures on the right.

The patient's x-ray showed an oblique fracture to his right mid femur. He was unable to bear weight. He was evaluated for surgery but transferred to another hospital.

No, the Inpatient admission was not medically necessary.

There was no indication for the admission. The patient was found to have a periprosthetic fracture with a significant history of prosthetic infection and revision. His diagnosis was known. He did not require treatment for an underlying medical condition. His vital signs were stable. He did not require additional imaging or an emergent procedure. There was no evidence of bleeding, acute infection, fever or intolerable pain. The services that were provided were "awaiting transfer" to another facility for definitive management. These findings do not substantiate the admission and level of care provided. There were no extenuating circumstances to warrant the inpatient stay.

The patient could have been treated at an observation level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Head injury.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a man. His medical and surgical histories were negative. While riding an electric scooter, he was struck by an automobile and brought to an emergency room by an ambulance. Extensive evaluation -- by history, examination, laboratories, and imaging -- demonstrated the following injuries: "1. Scalp avulsion with active bleeding; 2. Right lower lip laceration; 3. Right arm abrasion; 4. Left shoulder abrasion; 5. LLE laceration". 

The patient was admitted at an acute inpatient level-of-care for his traumatic injuries. He was made nil per os (nothing by mouth [NPO]); and provided with intravenous fluids, antibiotics; and analgesics. The scalp laceration was washed-out and repaired in the Emergency Room. 

Having returned to his baseline health and function, the patient was discharged home in good and stable condition with prescriptions for oral and topical antibiotics, and oral analgesics; and outpatient surgical follow-up.

No, the proposed treatment, inpatient admission, was not medically necessary.

No, the proposed treatment admission at an acute inpatient level-of-care from was not medically necessary. 

For this patient, extensive evaluation -- by history, examination, laboratories, and imaging -- demonstrated the following injuries:  "1. Scalp avulsion with active bleeding; 2. Right lower lip laceration; 3. Right arm abrasion; 4. Left shoulder abrasion; 5. LLE laceration". 

Of these, only the scalp avulsion was life-threatening and warranted immediate medical intervention. This was completed in the Emergency Room; afterwards, the patient could have been discharged or treated at a lower level-of-care, for he was entirely stable. 

According guidelines from Eastern Association for the Surgery of Trauma: "Triaging patients into a tiered trauma response in-hospital can be very effective and reduce unnecessary resource utilization while maintaining quality of care." [EAST].

After his one and only life-threatening injury (scalp avulsion) was successfully treated, the patient could have been discharged or treated at a lower level-of-care, for he was entirely stable. A system of tiered triage, in accordance with guidelines from the Eastern Association for the Surgery of Trauma, could have been "very effective and reduce unnecessary resource utilization while maintaining quality of care." [EAST].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth abscess.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient admission.
The denial is upheld. 

This male patient has a past medical history of hypertension and diverticulitis and presented to the Emergency Department (ED) with complaints of left side facial swelling following a dental procedure 3 weeks prior.  The patient's vital signs on ED presentation included: Temperature 37.2 C, Blood Pressure 124/83, Pulse 100, Respiratory Rate 18, Oxygen Saturation 97% on Room Air. The patient's laboratory values were notable for the following: White Blood Cell (WBC) count 11.2, Hemoglobin 13.0, Hematocrit 38.2, Creatinine 0.8, and Glucose 94. The patient was empirically started on the intravenous (IV) antibiotic Unasyn. The patient's computed tomography (CT) scan of the neck showed a large submandibular abscess. Oral and maxillofacial surgery (OMFS) evaluated the patient and determined that his swelling was due to abscess to tooth #19. The patient remained afebrile, hemodynamically stable and clinically improved. The patient was discharged to continue oral antibiotics as an outpatient. 

According to documentation, the patient presented with left submandibular abscess due to a dental source. Otherwise, the patient was afebrile, hemodynamically stable with unremarkable laboratory results except for a slightly elevated WBC count. The patient had no evidence for airway compromise or a systemic infection. The patient denied any fever, chills, or shortness of breath, dysphagia, or dental pain. Based on above findings and literature review, documentation submitted for this review does not support this patient's need for acute inpatient admission. Thus, inpatient admission was not medically necessary for this patient.

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

Based on the above, the medical necessity for the inpatient admission was not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine Headache
Treatment: inpatient Hospital
The health plan denied the inpatient hospital stay.
 The health plan's determination is upheld.

This is a female who was admitted. She presented with complaints of headaches, paresthesias and left-sided weakness for two days. She initially presented to the emergency department. A head computed tomography (CT) scan performed in the emergency department was negative for acute changes.
A brain magnetic resonance imaging (MRI) was performed that revealed a partially empty sella turcica and no evidence of acute stroke. A magnetic resonance angiography revealed that the head and neck were unremarkable.
A computed tomography (CT) scan of the cervical spine was performed and was interpreted as revealing multilevel disc disease.
During her hospitalization, she was seen by neurology, who noted the negative CT scan, MRI and CT angiography of the head and neck. She was diagnosed with probable complex migraine and was noted to have a prior history of transient ischemic attack. She was recommended treatment for migraine, including Fioricet as needed, and an outpatient trial of Ubrelvy or Nurtec.
The patient remained hospitalized on an acute level of care. She was treated for headache and was discharged.
At issue is the medical necessity of the inpatient stay.

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

No. The acute inpatient hospitalization was not medically necessary. The patient presented with headaches and focal neurological symptoms. The differential diagnosis is cerebrovascular (stroke, transient ischemic attack (TIA)) versus migraine. Acute stroke required exclusion and was ruled out while she was still in the emergency department with a negative MRI and cerebrovascular studies.(Ropper et al, O'Carroll et al et al). At that time, there was no need for acute inpatient admission. She had no risk of neurological worsening since there was no stroke.  Her migraine would resolve with appropriate treatment, which could have been provided in the emergency department or under observation status. There is no evidence of any hypertension risk or other hemodynamic abnormalities requiring an acute level of care. There was no documentation that the patient required any other type of inpatient monitoring, including pulmonary or cardiac monitoring. (Siegel et al, Bevers et al). 
There was no other reason documented for admission to acute inpatient care. Therefore, the patient could have been treated at a lower level of care (observation) and discharged once her migraines were controlled. There was no need for acute inpatient hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior open bite
Treatment: Braces
The insurer denied the braces. 
The denial is overturned. 

The patient is a female.  The request is for orthodontic benefits.

The patient has a large "anterior open bite" which is when the upper and lower teeth have a space between them and do not overlap like they should.  This will definitely cause chewing (biting) problems as well as speech issues.  This needs to be corrected with orthodontic treatment.  This case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Moderate maxillary and mandibular crowding,
deep bite, slightly excessive overjet
Treatment: Braces
The insurer denied the braces. 
The denial is upheld. 

The patient is a female. The request is for dental benefits for Orthodontic treatment.

The patient has a skeletal class I, with moderate maxillary and mandibular crowding, deep bite, slightly excessive overjet. She has impacted maxillary right canine and both maxillary second premolars.

No, the proposed treatment of orthodontic (Braces) therapy is not medically necessary.

X-rays and photos reveal that there is adequate space for the right maxillary canine to erupt. Measures can be taken to ensure that this space is maintained to allow this to occur naturally.

The severity of a deep bite and moderate crowding is not evidenced by the photos reviewed.

If the patient's age was closer to the middle or top range of the average eruption time then orthodontic treatment could be considered.

There is still adequate time for the normal eruption process to continue to unfold.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Venous insufficiency. 
Treatment: Procedure code 36475: Endovascular Ablation Therapy of Incompetent Extremity Veins. 

The insurer denied coverage for procedure code 36475. 

The denial is overturned. 

This is a male patient with a medical history of venous insufficiency who was seen for a vascular follow-up.  The patient continued to have symptoms to the right leg and complained of pain with heaviness with extreme discomfort.  The patient has severe bilateral reflux, according to the physician, that has been treated conservatively with compression stockings.  The patient has developed ulceration to the right ankle and continues to complain of swelling with pain.  Upon physical examination, the patient had large varicose veins bilaterally with large tributaries.  There was moderate to severe chronic venous changes noted.  There was 5 millimeter (mm) ulceration with erythema.  The patient was recommended to participate in ablation therapy.  The patient's diagnostic study showed that the patient has evidence of reflux greater than 0.5 seconds bilaterally within the great saphenous vein (GSV) and common femoral vein (CFV).  There is also venous insufficiency of greater than 0.5 seconds within the left sapheno-femoral junction (SFJ) and right short saphenous vein (SSV). 

Based on the review of the medical record and literature, endovascular ablation therapy of incompetent extremity veins is considered medically necessary for this patient.  This patient presented with a long-standing history of right leg edema, pain, heaviness, and bulging veins.  Conservative management with compression stockings and elevation and rest had failed.  Appropriate non-invasive workup with a venous reflux study documented >1 second of reflux throughout the right great saphenous vein (GSV) beginning at the proximal, mid, and below knee segments.  In addition, there appears to be reflux in the left great saphenous vein (GSV) and the right short saphenous vein (SSV) as well.  These clinical and imaging results clearly show that the patient's right GSV ablation is warranted and should be approved. 

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

The carrier's denial of coverage of procedure code 36475: Endovascular Ablation Therapy of Incompetent Extremity Veins should be overturned.  The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Obstructive sleep apnea.
Treatment: The implant of an upper airway stimulator device to treat obstructive sleep apnea (procedure codes 64568 and 0466T).
The insurer denied coverage for the implant of an upper airway stimulator device to treat obstructive sleep apnea (procedure codes 64568 and 0466T).
The denial is upheld. 

This is a male patient who is currently diagnosed with obstructive sleep apnea. The apnea hypopnea index was 18. He was initially diagnosed by polysomnogram. His polysomnogram eliminated the possibility of central sleep apnea or complex sleep apnea. He had failed or was intolerant to continuous positive airway pressure (CPAP) the gold standard of care for patients with obstructive sleep apnea.  He was unable to tolerate it due to claustrophobia. There were limited alternative treatment options. The patient underwent a sleep endoscopy which confirmed he did not have complete concentric collapse of the upper airway syndrome. His BMI (body mass index) was 35.6.  However, it was noted that a BMI of 32 or under is not a Food and Drug Administration (FDA) label requirement or criteria for this procedure.  

The scientific evidence in peer-reviewed literature supports overall health improvement with treatment of obstructive sleep apnea with the upper airway stimulator device in patients who meet the strict criteria for this implant.

Generally speaking, patients with a lower BMI (less than 32) are the best candidates for this procedure. This patient has a BMI equivalent to 35.6.

The requested service is not likely to be more beneficial than other sleep apnea treatments for this patient.

The carrier's denial of the implant of an upper airway stimulator device to treat obstructive sleep apnea (procedure codes 64568 and 0466T) should be upheld.