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

Diagnosis: Chest Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned in part.

The patient has a history of hypertension, hyperlipidemia, diabetes, human immunodeficiency virus (HIV) and gastroesophageal reflux disease (GERD) and presented to the emergency room (ER) with chest pain and dizziness. She also complained of a headache. Her blood pressure was 137/77 millimeters of mercury (mmHg), pulse 73 beats per minute (bpm) and respiratory rate 18. An electrocardiogram (EKG) showed no ischemic changes. The troponin was 0.01.
She was admitted, and treated with nitroglycerin and aspirin, with improvement of the chest pain. A head magnetic resonance imaging (MRI) scan was normal. She ruled out for a myocardial infarction with negative serial troponins. An EKG showed left ventricular hypertrophy (LVH) with inferior T wave inversions. However, there is a note that the leads were misplaced, and after corrected lead placement, the EKG was back to baseline. An echocardiogram (ECHO) showed normal left ventricular function and wall motion. She underwent a cardiac catheterization with no obstructive disease noted. Medical management was recommended and she was discharged. At issue is the medical necessity of an inpatient stay.

Inpatient admission was medically necessary in part. The patient had chest pain, suspected to be anginal, despite negative cardiac enzymes and equivocal EKGs. She had several coronary risk factors. She had persistent symptoms of chest pain, suspected to be anginal, which were relieved with nitroglycerin, but recurred during the admission. She underwent diagnostic coronary angiography. Inpatient admission is indicated for a diagnosis of unstable angina, with new onset chest pain, relieved with sublingual nitroglycerin. The patient meets Milliman Criteria for inpatient admission as she had ischemic symptoms with accelerating tempo of symptoms in the preceding 48 hours.
However, the patient could have been discharged following the cardiac catheterization which did not show any acute obstructive coronary lesions.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Inpatient admission. 

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

The patient is a male. He has a past medical history significant for seizure disorder, asthma, cocaine abuse. He presented for evaluation of sharp, non-exertional chest pain. 

The patient was hemodynamically stable, with normal oxygen saturation on room air. ECG (electrocardiogram) revealed no acute ischemic changes. Troponin was negative. Urine toxicology revealed presence of cocaine. The patient was admitted to inpatient setting to rule out MI (myocardial infarction). Repeat troponin was negative as well. No inpatient stress test or other ischemic work-up was planned. 

The patient was discharged home with a plan for outpatient follow-up. 

No, the Inpatient admission was not medically necessary. 

This patient presented for evaluation of 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 acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission. The care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Covid-19 pneumonia and Hypoxemic respiratory failure.
Treatment: Ambulance transportation service (codes A0428 and A0425 x 10).

The insurer denied coverage for the ambulance transportation service (codes A0428 and A0425 x 10).
The denial is upheld. 

This is a male patient who had been hospitalized with severe Covid-19 pneumonia and had hypoxemic respiratory failure.  The patient's past medical history was significant for diabetes mellitus (DM), hypertension (HTN) and hyperlipidemia (HLD).  The patient improved with treatment and was gradually weaned off from his non-rebreather (NRB) mask.  The patient had been switched to nasal cannula (NC).  The patient's oxygen saturations were 96% on 4 liters of oxygen via NC.  On the day of discharge, the patient was feeling better. The patient's cough and dyspnea had improved.  The patient was afebrile with vital signs showing heart rate (HR) of 71, respiratory rate (RR) of 19, blood pressure (BP) of 119/81, and oxygen saturation of 100% on 4 liters of oxygen via NC.  The patient was in no acute distress (NAD), and was alert and oriented.

The patient's discharge planning was to home with home oxygen for about 2 weeks.  However, as per review of the medical record, this patient did not need an ambulance for transfer because he was on nasal cannula.  The patient was afebrile and hemodynamically stable.  The patient was awake and alert.  The patient had been on NC a few days prior to discharge and was saturating well.  The patient's oxygen saturations were 100% on not very high fraction of inspired oxygen (FiO2), with 4 liters via NC.  This patient could have been safely transported via means other than an ambulance.  Patients on supplemental oxygen are routinely transported to and from hospitals, medical appointments etc. on non-medical vehicles.  Ambulance services are not required for such transportation.  The patient was stable at the time of discharge.

Ambulance transportation service was not medically necessary for this patient.

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 ambulance transportation service (codes A0428 and A0425 x 10) should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prior ectopic pregnancy and prior salpingectomy
Treatment: Infertility Services (Pre-Service)
The insurer denied the Treatment: Infertility Services (Pre-Service).
The denial is overturned. 

The patient is a female trying to conceive for the past two years. She had a previous ectopic pregnancy and a prior salpingectomy. She conceived previously on a cycle of Clomid and timed intercourse.  The provider plans to proceed with Letrozole intrauterine insemination (IUI) cycle. There is no evidence that the patient has undergone any intrauterine insemination (IUI) since the birth of her child.

Yes, the proposed infertility services are medically necessary.

Based on the submitted information, this patient has a missed fallopian tube due to a prior ectopic and she has unexplained infertility (normal semen analysis, normal ovarian reserve, and patent remaining tube). There is no evidence submitted that the patient has undergone any fertility treatment following her last delivery.

The request was initially denied based on medical necessity criteria that states more than two intrauterine insemination (IUI) cycles in females between a certain age range are not indicated. However, there is no information submitted by the Plan or the provider that this patient underwent any intrauterine insemination (IUI) cycle following her delivery.

While in vitro fertilization (IVF) will offer this patient increase odds of a live birth especially given her missed fallopian tube, intrauterine insemination (IUI) is still a good option.

According to the American Society for Reproductive Medicine (ASRM), "When considering treatment options for couples with unexplained infertility, it is prudent to consider simple treatment before complex treatment and to balance what is known about effectiveness against the cost and adverse effects of different treatments". Patients with unexplained infertility are usually treated with controlled ovarian stimulation with Clomid or Letrozole. If the patient fails an average of three cycles of controlled ovarian simulation and intrauterine insemination (IUI) then the next step will be in vitro fertilization (IVF).

This patient did not fail to respond to an adequate trial of Clomid/Letrozole therapy and insemination. Based on the above, the requested Letrozole and insemination is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Gastroparesis.
Treatment:  43999 - Gastric peroral endoscopic myotomy.

the insurer denied the 43999 - Gastric peroral endoscopic myotomy.  The denial is upheld. 

The patient is a female.  She has the diagnosis of gastroparesis.  Given the patient's refractory condition, the provider has requested the provision of a gastric peroral endoscopic myotomy (G-POEM) as definitive treatment for this condition.  The patient has tried and failed diet and medicines as treatment for this condition.  This has been a chronic condition for this patient, as is reflected in the provided records.  A complete and extensive medical record was provided, which has these details.

No, the health plan should not cover the 43999 - Gastric peroral endoscopic myotomy.

There is insufficient medical literature or society support to show that this modality has a positive effect on healthcare outcomes equal to or superior to currently available and accepted treatments.

No, the 43999 - Gastric peroral endoscopic myotomy is not likely to be more beneficial.

There is insufficient medical literature or society support to show that this modality has a positive effect on healthcare outcomes equal to or superior to currently available and accepted treatments.  Accepted treatments include dietary changes, promotility agents, and in severe cases either a venting gastrostomy tube and/or a feeding jejunostomy tube.  Medication options include cholinergic drugs, which act on acetylcholine nerve receptors, erythromycin, metoclopramide, a medicine that helps empty the stomach, serotonin antagonist drugs, which act on serotonin receptors.  A surgical procedure that creates an opening between the stomach and small intestine to allow food to move through the digestive tract more easily (gastroenterostomy) is also an option.  The literature also notes the options of a gastric sleeve as an option at this time, as well.  Once again there is insufficient evidence that a G-POEM is effective.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Gastroparesis.
Treatment:  43999 - Gastric peroral endoscopic myotomy.

The insurer denied the 43999 - Gastric peroral endoscopic myotomy.  The denial is overturned.

The patient is a female with gastroparesis refractory to medical therapy.  Her MD is
requesting treatment with G-POEM (gastric peroral endoscopic myotomy).

Yes, the health plan should cover the 43999 - Gastric peroral endoscopic myotomy.

Yes, the 43999 - Gastric peroral endoscopic myotomy is likely to be more
beneficial.

The patient has gastroparesis and has failed standard treatment.

Xu et al. concluded that G-POEM is a safe and effective treatment option in patients
with refractory gastroparesis, with a long-term efficacy of 81.6%.

Mekaroonkamol et al concluded that G-POEM has shown a promising outcome as
a minimally invasive option for treatment of refractory gastroparesis.  In experienced
hands in high volume center, it is technically feasible with a low risk of adverse
events.  It significantly reduces gastroparesis symptoms at least in up to 18-month
period, with nausea/vomiting being the most-responsive symptoms.  In addition, it
can improve quality of life and reduce hospitalization rate.

In a metanalysis, Meybodi et al stated that their findings suggest that G-POEM is an
effective therapeutic intervention for management of patients with refractory gastroparesis in
terms of clinical response and scintigraphic studies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Trauma to left ankle.
Treatment:  Inpatient admission.

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

This is a male who sustained a fall.  He injured his left ankle.  He was evaluated in the emergency department (ED) and was found to have a displaced bimalleolar fracture.  He was noted to be in distress and obese.  He required several doses of intravenous (IV) Morphine.  He was then admitted for definitive management to his fracture.  He underwent open reduction internal fixation (ORIF) to the left ankle.  He received medications and physical therapy (PT) after the operation.  

No, the inpatient admission was not medically necessary.

The patient was admitted to the hospital, and he received hospitalist consultation and Orthopedic consult.  He underwent surgery.  There was no reason why the patient could not have been evaluated on a timelier basis.  There was a delay in evaluation and subsequent surgical procedure.  The records do not show a preoperative problem, which could not have been resolved on a timelier basis.  The patient's post-surgical course was non-complicated.  He required a single dose of Morphine on post-operative day one (POD #1).  The NP reported "pain controlled."  The patient did not require treatment for other associated medical conditions.  His vital signs were stable.  He was ambulatory with crutches.  There were no problems with his wound.  He was able to tolerate oral medication.  These findings do not substantiate necessity for an acute admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Body mass index 51 kg/m2; gastroesophageal reflux disease; hypertension.
Treatment:  Weight Loss Surgery.

The insurer denied the  Weight Loss Surgery.  The denial is upheld. 

This patient is a female with a body mass index of 43.6 kilograms per meter squared (kg/m2), which has increased to a body mass index of 51 kilograms per meter squared (kg/m2).  Weight related co-morbid conditions include: gastroesophageal reflux disease (GERD) and hypertension (HTN).  The patient is status post (s/p) gastric bypass procedure.  Psychological and dietary evaluations were obtained with clearance.  Medical clearance was obtained.  There are no anatomic complications of the prior gastric bypass.

No, the proposed weight loss surgery is not medically necessary.

The requested procedure (limb lengthening) is considered to be unproven for treatment of morbid obesity after bariatric surgery.  Although there are a few case reports/series, there is no high level literature to support the safety, efficacy and durability of limb lengthening.  There is no standardization for the procedure at this time.  Subsequent complications, need for further revisions and significant nutritional complications have been described.  It should therefore be considered only in the setting of a clinical trial with Institutional Review Board (IRB) approval at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Achalasia.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

This is a female patient who presented with achalasia, scheduled for a peroral endoscopic myotomy (POEM) of the esophagus. The patient had a Heller myotomy and fundoplication in the past. In this case, she presented with recurring symptoms of dyspnea. Her esophagogastroduodenoscopy (EGD) revealed residual esophagogastric outlet obstruction. She had an uneventful peroral endoscopic myotomy. 

As per literature review, surgical observation for 24-hours was reasonable for this patient, and could have been converted to inpatient status if a complication were to have occurred. A complication leading to mediastinitis could have been detected by clinical signs, monitoring of vitals and/or contrast study. The patient could have been observed with pain management and monitoring in an overnight observation setting without an acute inpatient admission. Based on the review of the documents submitted for this appeal, there was no clinical finding that warranted inpatient admission for this patient. Thus, the 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.

The medical necessity for the inpatient admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Renal Stone
 
Treatment: CPT codes 52332, J2710, J7642, and J1100 and all associated codes

The insurer denied coverage for CPT codes 52332, J2710, J7642, and J1100 and all associated codes. The denial is reversed. 

This patient is a male with history of renal stones.  He presented to the Emergency Department (ED) with complaints of left flank pain for four days.  The patient had been treated at another hospital a short time prior to this presentation where a CT scan revealed a 5 mm renal stone.  ED triage revealed temperature of 97.90F, heart rate 95, and blood pressure 140/93.  The patient was admitted to the Urology Unit for operative treatment of a 5 mm stone.  The patient was kept nothing by mouth (NPO) and given intravenous (IV) fluids, IV antibiotics, and taken to the Operating Room (OR) for cystoscopy, left ureteroscopy (URS), left stent insertion.  The patient appeared to tolerate the procedure well without complications, and was given IV fluids/analgesics.   The patient was discharged home on three days of oral Keflex.  

The insurer has denied coverage for CPT codes 52332, J2710, J7642, and J1100.  The appeal on behalf of the hospital is noted and read in detail.  This patient did have an obstructing left ureteral stone and had failed medical management instituted at the initial hospital he presented to.  Urologic intervention is medically necessary for a patient with an obstructing ureteral stone who fails medical management or medical expulsive therapy.  Because of technical factors, left ureteroscopy and stone removal could not be accomplished but the patient had successful placement of left ureteral stent, which should resolve his obstruction and hopefully relieve his pain.  The procedure was medically necessary in spite of no unstable medical condition or severe systemic disease. 

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

CPT codes 52332 (cysto/stent insertion) J2710, J7642, J1100 (anesthesia codes) were medically necessary for this patient.  Code 52332 pertains to stent placement, the other codes pertain to the medications utilized in general anesthesia. 

The carrier's denial of coverage for CPT codes 52332, J2710, J7642, and J1100 and all associated codes is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Skin Disorders. 
Treatment:  Inpatient Hospital admission. 
The insurer denied inpatient hospital admission.  
The denial is upheld.

The patient is a female who presented for dermatolipectomy, bilateral thighs secondary to excess soft tissue on bilateral thighs. She had a prior medical history significant for migraines, asthma, vertigo, refractory gastroesophageal reflux disease status post reoperative bypass, and morbid obesity status post gastric sleeve. Her prior surgeries included abdominoplasty, breast reduction, and bariatric surgery.

The plastics and reconstructive surgeon performed a bilateral medical thigh lifts with thigh liposuction under general endotracheal anesthesia without issue. The estimated blood loss was 25 cubic centimeter (cc). Postoperatively, she was monitored in the post anesthesia care unit (PACU). The intravenous (IV) fluid, and oxygen continued from surgery. The ACE bandages to bilateral thighs with Jackson-Pratt (JP) drains were in place. Her vital signs, level of consciousness, pain, circulation checks, and signs and symptoms of bleeding were monitored. She was medicated with IV Dilaudid three times for postoperative pain with relief. Upon meeting PACU discharge criteria she was transferred to the floor. She was admitted. According to the hospital, the admission was required because the patient had itching that required treatment with Benadryl. The patient was subsequently discharged the next day.

The health plan's determination is upheld.

The inpatient admission was not medically necessary for this patient.

The records document that the patient underwent uncomplicated liposuction and resection of excess thigh tissue. Blood loss was minimal. She had an uneventful postoperative course. She required a dose of Benadryl for itching but this medication could have been given orally. Her pain was well controlled. She had one episode of emesis but was later able to tolerate a meal. She did not have any clinical scenarios that would have made inpatient care medically necessary.

Additionally, the patient did not meet any of the criteria for inpatient admission based on Milliman Care Guidelines, 24th Edition, "General Admission Criteria". 

She had pain following the surgery but was hemodynamically stable. Her pain was controlled with analgesics. She did not have any significant physiologic or surgical complications following the procedure. She could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Musculoskeletal/Orthopedic (pes planus and abnormal gait). 
Treatment:  Orthotics (removable foot inserts). 

The insurer denied (Orthotics) removable foot inserts.  The denial is upheld. 

The patient is a male who presented to the podiatry office with his mother for evaluation of his toe-walking. The mother states there were no complications at birth and was a full term normal delivery. The patients mother states that the patient has been a toe-walker for most of his life and she just recently became concerned about it. On examination, the patient demonstrated a flat footed steppage gait with some toe-walking noted. The x-rays revealed a greatly reduced calcaneal inclination angle (0) and open growth plates. The patient was diagnosed with pes planus and an abnormal gait. The patient was prescribed physical therapy and custom molded orthotics. The issue is the medical necessity of the removable foot inserts.

The requested treatment of removable foot inserts in this particular patient is not considered medically necessary.

The patient presented mainly with the complaint of toe-walking. It was found on physical exam that the patient has a pes planus foot type. The patient did not have any related conditions. He did not complain of any pain. He was not treated with any conservative treatment such as change in activities, anti-inflammatory medications, prefabricated orthotics, stretching of calf muscles and plantar surface before recommending custom molded orthotics. His pes planus foot type was a secondary condition found and not the main complaint. Thus, the removable foot inserts are not considered medically necessary in this particular patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder.
Treatment: Root canal, post and core, crown for teeth #'s 6 and 28. 
The insurer denied Root canal, post and core, crown for teeth #'s 6 and 28.
The determination is overturned.

The patient presented  for evaluation and treatment of teeth number (#) 6 and 28. The provided information includes previous letters of appeal and denial, a full mouth radiographic images, one page of claim forms. At issue is the medical necessity of the planned treatment of porcelain fused to metal crown for tooth #6 and 28, root canal therapy anterior tooth #6, root canal therapy premolar for tooth #28, and pre fabricated post and core for tooth #6 and 28.

The requested health service/treatment of root canal, post and core, and crown for teeth #'s 6 and 28 are medically necessary for this patient. Based on the radiographic documentation teeth #6 and 11 have lost most of the current crowns to decay, and the pulp has been involved with evidence of periapical periodontitis as well as pulpal infection. Currently the infected tooth structure requires removal, endodontic treatment to remove the infection, and buildup and crown to return the teeth to function.