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

Diagnosis: Diabetes mellitus, osteoarthritis, hypertension, atrial fibrillation, coronary artery disease, a coronary artery bypass (CABG) with heart valve leaks, low thyroid function, hyperlipidemia, dizziness, and an unsteady gait

Treatment: Consumer Directed Personal Assistance Program

The insurer denied coverage for Consumer Directed Personal Assistance Program

The denial is upheld

 This case involves a patient dependent on others for completing multiple activities of daily living and instrumental activities of daily living.  The patient was previously approved for 17.5 hours/week.  A request was submitted for an increase to 24.5 hours/week, which was denied.  The patient again received a notice that an increase in hours was denied and that she would remain at 17.5 hours/week.  An assessment was conducted noting that the patient lives with her spouse/partner and son in a private dwelling.  The patient was found to have modified independence in terms of cognitive skills for daily decision making with some difficulty in new situations noted.  She was alert and oriented x3, was able to communicate without significant difficulty, but reported major life stressors related to hospitalizations because of shortness of breath and pulmonary edema.  The patient required maximal assistance with meal preparation, between maximum and total dependence for ordinary housework, maximal assistance for managing finances and medications, set up help only for phone use, and extensive assistance for stair navigation.  She needed maximal assistance for shopping and transportation, supervision for bathing, extensive assistance for personal hygiene and dressing the lower body with limited assistance needed for dressing the upper body.  She required supervision only for walking, locomotion, and toileting transfers.  She was found to be independent for set up help only in terms of toilet use, independent for bed mobility with set up help only needed for eating.  She walked without the use of an assistive device and declined any changes in her activities of daily living status compared to 90 days prior.  Her overall self-sufficiency had deteriorated as compared to 90 days prior and she reported a history of diabetes mellitus, osteoarthritis, hypertension, atrial fibrillation, coronary artery disease, a coronary artery bypass (CABG) with heart valve leaks, low thyroid function, hyperlipidemia, dizziness, and an unsteady gait.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an increase in Consumer Directed Personal Assistance Program (CDPAP): 3.5 hours per day - 7 day(s) per week - for a total of 24.5 hours per week services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: Pre-service dental services free soft tissue graft procedure for teeth numbers 22 and 27

The insurer denied coverage for pre-service dental services free soft tissue graft procedure for teeth numbers 22 and 27

The denial is upheld 

Based on the submitted documentation which includes copies of 2 periapical radiographs, 1 panoramic radiograph, periodontal chartings, two intraoral clinical images, narrative letter and treatment report from Dr. Gordon Davis, and insurer correspondence, it appears that this patient presented for evaluation and management of gingival recession with sensitivity in the areas of #22 and 27 gingiva. Based on the clinical and radiographic findings, the provider recommended the aforementioned services of graft to these sites due to gingival recession, sensitivity and a malformed frenum. The insurer has denied these codes stating that the documentation provided does not support the services and therefore they are deemed not medically/dentally necessary. The provider is appealing the decision on behalf of the patient.

Based on the clinical and radiographic information provided for review the alveolar bone height is acceptable. The radiographs do indicate a level of alveolar bone loss commensurate with the patient's chief complaint and correlate with the periodontal chartings provided for review. However, it seems the main concern is esthetics and sensitivity reduction. Although grafting procedures are used for these purposes, in this case there is no indication that nonsurgical therapies were attempted in order to reduce the sensitivity. At this point, the surgical services would be considered elective and if the patient elects to have these services provided, they would be considered an out-of-pocket expense as the remaining clinical criteria do not support surgical correction of this issue. 

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

Preservice dental services free soft tissue graft procedure for teeth numbers 22 and 27 considered is not medically necessary for this patient. As the clinical documentation do not support this treatment and nonsurgical options are available to address the issues of tooth sensitivity.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for pre-service dental services free soft tissue graft procedure for teeth numbers 22 and 27 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld. 

The patient is a female who had a medical history of moderate persistent asthma and seasonal allergies. She presented with wheezing, shortness of breath that started earlier in the day, and a dry cough that persisted for one and a half weeks. The patient had visited urgent care the previous week and was diagnosed with the flu, although she did not take Tamiflu and instead used Tylenol. Her symptoms improved until the morning of her presentation when wheezing recurred. She reported experiencing diaphoresis at night. A dry cough with occasional scant white phlegm was noted. 

The inpatient hospital stay was not medically necessary for this patient. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care. Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. In general, she responded to treatment adequately within the first several days, which would correspond to a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient hospital
The insurer denied the inpatient stay.
The health plan's determination is overturned.

This is the case of a young female with moderate persistent asthma who presented to the emergency department (ED) with cough and difficulty breathing. Symptoms began the day prior to arrival. Additional symptoms include congestion and rhinorrhea. There was no fever, gastrointestinal (GI) illness, or ill contacts. The mother tried albuterol at home with some non-sustained improvements. Past medical history includes prior hospitalization for Asthma with respiratory support (bi-level positive airway pressure (BiPAP)). Current medications are Symbicort and Singulair.

The inpatient hospital admission was medically necessary.
This young child with known asthma, multiple prior hospitalizations and ED visits, and subspecialty involvement presented to the ED with respiratory distress. She was placed on asthma treatment pathway and showed response; however, symptoms remained such that inpatient hospitalization was medically necessary for further care.
According to the medical records provided, inpatient hospitalization was medically necessary for this child with respiratory distress and known asthma. Despite adequate ED treatment, symptoms persisted and warranted escalation of care with IV magnesium sulfate and continued albuterol every 2 hours. Thus, inpatient hospitalization was necessary for close monitoring of vital signs and respiratory care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

 
The patient is an adult male who presented to the emergency department (ED) with complaints of shortness of breath (SOB) for 2 days. The patient also complained of Viral Upper Respiratory Infection symptoms - cough, Chest Pain, Myalgias. The patient had been exposed to a friend who had respiratory metapneumovirus infection. The patient has a history of Hookah smoking.

Vital signs at presentation: Temperature 36.5 degrees Celsius, Heart Rate 114, Blood Pressure 142/73, Respirations 22 and oxygen (O2) saturation 94% (percent) on room air. The patient was in no acute distress. Lungs had occasional wheezes; heart sounds were normal. The patient was alert and oriented x (times) 3 (person, place and time).

The patient was treated with intravenous (IV) Steroids, bronchodilators (BD) and magnesium.
Azithromycin was added. The patient was admitted to the hospital for treatment of Asthma exacerbation and Viral Tracheobronchitis.

Chest x-ray (CXR) showed no acute Infiltrates. White blood cell (WBC) count was 8.7. Electrolytes within normal limits (WNL). The patient was continued on steroids, nebulizers, and oral (PO) Azithromycin. The patient remained stable after admission and was discharged in a few days.

This patient did not need acute inpatient hospitalization. He was stable to be placed in observation while diagnostic testing and treatment were initiated.  Observation can be for up to 48 hours.
He was afebrile and hemodynamically stable. No pneumonia on CXR. The patient was tolerating PO (per oral). The patient could have been admitted to Observation and treatment continued. The patient remained stable and could have been discharged after a period under observation with close follow-up in an outpatient setting.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status Post Eye Procedure
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult male with history of retinal detachment for whom coverage of an inpatient hospital admission is the subject of review. Coverage was previously denied by the health plan, as the patient was not identified as having been unstable following retinal surgery, and he went home the same day. A note dated prior to admission documents the patient complaining of sudden loss of vision four weeks previously. The patient's vision was noted to be "hand motions," and an afferent pupillary defect was identified in the affected eye. He was referred to a retinal specialist.

The inpatient admission was not medically necessary.

The MCG (Milliman Care Guidelines) Guidelines note that hospital admission is needed for appropriate care of the patient with acute glaucoma, severe eye inflammation, eye infection, ocular injury or trauma, optic neuritis, central retinal arterial occlusion, or ocular visual findings with suspected etiology that requires evaluation or treatment beyond scope of observation care. No documentation from retinal consultation, operative report, or brief hospital stay are provided to support that that above criteria are met. There is no history of the patient being hemodynamically unstable or having uncontrolled pain. No complications from surgery are identified. As such, it is not noted that treatment beyond the scope of observation care was needed. Inpatient level of stay is not established as medically necessary based on the information provided for review.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral Lower Leg Wounds

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld. 

This is a patient with a past medical history significant for opioid disorder, alcohol abuse, gastroesophageal reflux disease (GERD), urinary tract infection (UTI), and pyelonephritis who presented to the emergency department with complaints of painful bilateral lower leg wounds.

Vitals on presentation included: Temperature 98.7 Fahrenheit (F), blood pressure (BP) 151/84, pulse 86, respiratory rate (RR) 18, oxygen (O2) saturation 96% (percent) on room air (RA). Laboratory results included the following: white blood cell count (WBC) 6.8, hemoglobin (HGB) 12.4, hematocrit (HCT) 39.0, creatinine 0.84, glucose 102.

The patient was admitted for possible wound infection. The patient was started on intravenous (IV) antibiotics (vancomycin and Zosyn) but could not receive due to lack of intravenous access. A chest X-ray (CXR) was negative, X-ray of tibia/fibula showed no bony abnormalities in the lower legs or feet. The patient was started on oral antibiotics (Augmentin) and methadone maintenance. The patient remained afebrile and hemodynamically stable. The patient was discharged on oral antibiotics to continue outpatient management.

According to documentation, the patient was admitted for possible wound infection secondary to drug abuse. Otherwise, the patient was afebrile, hemodynamically stable, with unremarkable laboratory results including a normal WBC. The patient had no evidence of disseminated infection and no surgical intervention was required. Based on the above findings, the patient met criteria for observation level of management. The patient did not meet criteria for acute hospitalization.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other - Leg pain and blood vessel blockage
Treatment: Ambulatory surgery

The health plan denied: Ambulatory surgery
The determination is: Overturned

This patient is a female with multiple medical problems including atrial fibrillation, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes, hyperlipidemia, hypertension, and peripheral arterial disease.
The patient was evaluated for claudication in both legs. The patient was noted to have non-palpable pedal pulses with mild edema at the ankles. Lower extremity arterial studies performed demonstrated an ankle brachial index (ABI) of 0.51 on the right and an ABI of 0.39 on the left, compatible with moderate peripheral arterial disease and severe peripheral arterial disease, respectively.
The patient was diagnosed with peripheral arterial disease and was ordered an arterial ultrasound of both legs with the plan for angioplasty or stenting. The patient was seen for follow up. A lower extremity arterial ultrasound demonstrated right mid-thigh superficial femoral artery (SFA) occlusion, a right ABI of 0.63, greater than 75 percent (%) left mid-thigh SFA stenosis, left distal SFA occlusion, and a left ABI of 0.63. The physician recommended treatment of her right leg with an angiogram with possible angioplasty and stenting.
At issue is the medical necessity of the outpatient procedures: ambulatory surgery.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of outpatient procedures: ambulatory surgery is medically necessary for this patient.
The patient has lifestyle-limiting lower extremity claudication requiring treatment. The treatment, angiogram with possible angioplasty and stenting, is medically necessary and is the standard of care for the treatment of lifestyle limiting lower extremity claudication. The patient will benefit from the treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left upper quadrant abdominal pain

Treatment: CPT code 74181 - magnetic resonance imaging (MRI)

The insurer denied coverage for: CPT code 74181 - MRI

The denial is: Upheld

The patient was having left upper quadrant (LUQ) abdominal pain. The patient was given non-steroidal anti-inflammatory drugs (NSAIDs) for costochondritis, but the pain persisted. An abdominal ultrasound was not diagnostic. The patient had a telehealth visit and was complaining of pain in the left rib area. It is reported that this pain is worsened by walking, lying supine, or forward flexion of the spine. An magnetic resonance imaging (MRI) of the abdomen was ordered. 

Milliman Care Guidelines (MCG) A-0044 lists clinical indications for an abdominal MRI. These indications include staging for cancer, evaluation of the gallbladder, an abdominal mass, pancreatic disease when a computed tomography (CT) scan is contraindicated, and a splenic lesion seen on CT scan. 

This patient is reported to have upper abdominal pain extending to the left rib area. The submitted medical records do not contain a physical examination of the abdomen. There is no record of a possible mass on examination or a report from an abdominal CT scan. The patient did not meet MCG criteria for an abdominal MRI. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for current procedural terminology (CPT) code 74181 - magnetic resonance imaging (MRI), a special kind of picture of the stomach without contrast is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post heart stent
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult female who was hospitalized for dyspnea on exertion. The patient complained of dyspnea on exertion while climbing 1-2 (one to two) flights of stairs for 2-3 (two to three) months. Her past medical history was significant for known coronary artery disease with PCI (percutaneous coronary intervention) with DES (drug-eluting stents) 6 months ago, 
hyperlipidemia and diabetes. The patient's vitals were reportedly stable. Treatment included Aspirin, Plavix, telemetry, IV (intravenous) fluids, cardiac catheterization with coronary angiography, and successful PCI (percutaneous coronary intervention) with stent to the LAD (left anterior descending) artery. There were no procedural complications, and she was discharged to home. The requested coverage for an inpatient hospital admission was denied as not medically necessary and the patient is appealing the decision.

The requested health service of an Inpatient Hospital Admission is not considered medically necessary. 

Based on the peer reviewed medical literature, including the provided MCG (Milliman Care Guidelines) and criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no procedural related complications, clinical decline or inadequate response to treatment which required an inpatient hospital stay. The care this patient received, including a successful cardiac catheterization, such as in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment is not "medically necessary".
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of Breath
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient with a past medical history (PMH) of morbid obesity, heart failure with reduced ejection fraction (HFpEF), hypertension (HTN), alcohol abuse, and diabetes mellitus type 2 (DM2) who was admitted with complaints of (c/o) numbness and weakness in the bilateral hands and feet associated with lower extremity (LE) swelling and shortness of breath (SOB) and orthopnea with a reported history of diuretic non-adherence. His vital signs were notable for pulse 97, peripheral capillary oxygen saturation (SpO2) 83 percent (%). The physical exam was notable for no apparent distress (NAD), bilateral LE edema 2 plus (+), no jugular vein distention (JVD). Lab work was notable for brain (or B-type) natriuretic peptide (BNP) 1369, transaminitis, ethanol (EtOH) 364. Imaging studies included a chest x-ray (CXR) which showed cardiomegaly and moderate pulmonary venous hypertension (PVH), a computed tomography (CT) scan of the head showed no acute findings, a CT scan showed anasarca and findings concerning for possible cirrhosis. The patient was diagnosed with acute on chronic HFpEF and treated with diuresis, strict intake/output (I/O), Clinical Institute Withdrawal Assessment (CIWA), and electrolyte repletion. The patient was discharged in stable condition. At issue is medical necessity of an inpatient level of care.
The admission was medically necessary at an acute inpatient level of care. This patient with a known history of heart failure presented to the emergency department (ED) with complaints of (c/o) worsening LE swelling and SOB and orthopnea with a reported history of diuretic non-adherence, as well as difficulty ambulating. The patient was found to have new hypoxia with a room air saturation less than 90 percent (%) and requiring 2 liters (L) of oxygen, per emergency department (ED) documentation, while the patient did not require oxygen at home. In addition, the patient was found to have anasarca and likely new-onset liver failure/cirrhosis, which further complicated the patient's clinical picture and stability. Finally, the patient's Ottawa Heart Failure Risk Scale (OHFRS) Heart Failure Risk Score was 2, indicating a 9.2% risk of serious adverse event and that the patient was not low-risk. The patient was diagnosed with an acute congestive heart failure (CHF) exacerbation and likely new onset liver failure complicated by anasarca and new difficulty ambulating/completing activities of daily living (ADLs), as well as clinical concern for alcohol withdrawal in light of alcohol abuse and treated with diuresis, strict I/O, CIWA, and electrolyte repletion and this could not have been safely and appropriately provided at a lower level of care.