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

Diagnosis: Urinary tract infection. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

According to the documentation submitted, this is an adult with a history of migraines. The patient presented to the emergency room (ER) with complaints of abdominal pain. Urine cultures were positive for extended spectrum beta lactamase (ESBL) urinary tract infection (UTI). The patient was admitted with a UTI. The patient was treated with intravenous (IV) Meropenem. A midline was placed for home IV antibiotics. 

The insurer has denied coverage for the inpatient as not medically necessary. In a Final Adverse Determination letter, they stated that the patient was admitted with a UTI. The patient was hemodynamically stable and not significantly ill. A line was placed for outpatient IV antibiotics. The patient was discharged. The admission is denied based on UnitedHealthcare Community Plan Utilization Review Guideline Observation Services CS201.E, effective July 01, 2022. 

The patient has a past medical history significant for migraines and urinary tract infection (UTI) who was called back to the emergency room (ER) for a positive urine culture that grew extended-spectrum beta lactamase (ESBL) producing Escherichia coli (E. coli). Vitals on presentation included: Temperature 98.0 degrees Fahrenheit (F), blood pressure (BP) 122/83, heart rate 80, respiratory rate 20, and oxygen (O2) saturation 98% on room air. Laboratory values were notable for the following: white blood cell (WBC) count 4.16, hemoglobin (Hgb) 12.6, hematocrit (Hct) 38.2, glucose 91, creatinine 0.53. 

Patient was admitted for ESBL E. coli urinary tract infection. The patient was started on intravenous meropenem. Infectious Diseases consulted. Patient complained of dysuria, urinary urgency and mild right lower quadrant pain. Patient had line insertion for completion of intravenous (IV) Ertapenem daily as an outpatient. 

According to medical records, patient was called back to the emergency department for a positive urine culture with a drug resistant pathogen. Otherwise, patient was afebrile and hemodynamically stable with unremarkable laboratory results including a normal WBC. Moreover, patient reported clinical improvement at home before returning to emergency department. Based on above findings, patient met criteria for observation level of management. 

Prior determination of denial of acute inpatient admission from is upheld. 

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Disease
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who initially presented to the emergency department with chest pain. The pertinent history included sickle cell anemia with multiple related complications. The review of systems was negative for shortness of breath or trouble breathing. The initial examination documented the patient as alert, oriented, with clear lungs to auscultation.  An electrocardiogram (EKG) did not reveal acute ischemic changes. A chest radiograph was unremarkable. Intravenous fluids, empiric antibiotics, and analgesia were provided. The patient was admitted to the hospital with an impression of sickle cell anemia, sickle cell pain, and leukocytosis. The admitting physician documented very low concern for acute chest syndrome or a stroke. The treatment plan included the continuation of home oral medications, intravenous fluids, intravenous Dilaudid as needed, and empiric antibiotics for now. The patient declined placement of intravenous access for parenteral analgesia. The patient left against medical advice. At issue is the medical necessity of an inpatient hospital admission.

Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.
The patient had a history of sickle cell disease with multiple admissions for vasoocclusive crises who presented with concerns of chest pain. Initial evaluation documented the patient alert, oriented, with tachycardia, and without hypoxia. Initial laboratory testing, including troponins, was relatively unremarkable. An electrocardiogram did not reveal acute ischemic changes. A chest radiograph did not reveal an acute cardiopulmonary process. The admitting physician documented very low concern for acute chest syndrome. Treatment plan was essentially supportive care. The patient was documented as declining placement of intravenous access outside of the Mediport for analgesia and left against medical advice shortly after hospitalization. No other issues or complications were documented.
The clinical indications for admission to inpatient care were not met. The patient did not have signs or symptoms of central nervous system acute injury, acute chest syndrome, hypoxemia, emergent surgery needed, splenic or hepatic sequestration, acute ischemia, acute renal failure, aplastic crisis, priapism or other vascular complications, traumatic hyphema, infection requiring inpatient treatment (eg, bacteremia), altered mental status, need for exchange transfusion, inability to maintain oral hydration despite observation care treatment, or pain insufficiently responsive to observation care treatment that requires treatment in an inpatient setting.[2]
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vomiting, Fever
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient who presented with a fever and vomiting. He was well until 3 days prior to presentation when he developed a fever to 102 degrees Fahrenheit (F). He was given ibuprofen but then also developed emesis. He vomited 6 times per day and was not tolerating any oral intake. He also had a decreased urine output and one episode of diarrhea. He was previously seen at an outside hospital for vomiting and was found to have left hydroureteronephrosis and had a normal voiding cystourethrogram (VCUG).
He was given acetaminophen, Zofran, and 2 boluses of normal saline. He was then admitted for continued hydration in the setting of acute gastroenteritis.

In the hospital, he was kept on intravenous fluids with continuous monitoring. He continued to have intermittent fevers. He improved over time and he was tolerating oral intake and was felt to be stable for discharge to home with follow up as an outpatient. The hospitalization from is under review for medical necessity.

The requested health service/treatment of inpatient stay was medically necessary for this patient. This is a young male child who presented with repeated episodes of vomiting, decreased oral intake, and diarrhea. He had dry mucous membranes and a very high urine specific gravity, indicating dehydration. He also had a fever and a history of hydronephrosis, raising concern for a possible urinary infection. He received appropriate fluids in the emergency department but continued to require additional intravenous fluids to maintain his hydration status. He, therefore, required hospital admission for ongoing treatment with intravenous fluids along with close monitoring for potential deterioration of clinical status.
According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care Guidelines, 26th edition, Vomiting, Pediatric, hospitalization is indicated for children with vomiting who are unable to maintain oral hydration that persists despite observation care. This patient had numerous episodes of vomiting and was not tolerating oral intake. He continued to require intravenous fluids despite receiving appropriate hydration in the emergency department. He, therefore, required hospital admission for ongoing treatment with intravenous fluids and monitoring.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Throat pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

Patient is an adult with past medical history significant for obesity who was referred to the emergency department with complaints of throat pain and difficulty swallowing. 

Vitals on presentation included: Temperature-101 degrees F, Blood Pressure-134/92, Pulse-105, Respirations -20, oxygen (O2) saturation-100% on room air. Laboratory values were notable for the following: White blood cells (WBC)-13.7, Hemoglobin (Hgb)-14.7, Hematocrit-44.4, glucose-100, creatinine-0.62.

Patient was empirically started on intravenous antibiotics (unasyn) for possible tonsillitis and steroids for dysphagia. Computed tomography (CT) scan showed right tonsillar enlargement and mild narrowing of the oropharyngeal airway. Infectious Diseases consulted. Patient remained afebrile, hemodynamically stable, and clinically improved. She was discharged to continue oral antibiotics (Augmentin) as an outpatient. 

According to documentation, patient presented with worsening difficulty with swallowing. She was febrile, tachycardic (heart rate-105). Laboratory results showed an elevated WBC. Additionally, patient was evaluated in the emergency department prior to returning to the hospital. Based on above findings including failure of outpatient intervention, hospital admission was medically necessary for administration of intravenous antibiotics and steroids. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I occlusion; maxillary spacing; mandibular 
crowding
Treatment: D8080 Braces, D8670 Monthly Visit
The insurer denied: D8080 Braces, D8670 Monthly Visit
The denial is upheld.

The patient is a female. The request is for orthodontic benefits with monthly follow up visits. The patient has a Class I occlusion with maxillary spacing and mandibular crowding. 
The prior denial was due to a handicapping index score of 13.

The proposed braces and monthly visits are not medically necessary.

The patient does not have a handicapping malocclusion that affects eating, speaking or swallowing. The patient scored a 13 on the index scale. The Handicapping Labio-Lingual Deviations Index (HLD) is a method for measuring malocclusion; it is based on a series of measurements that represent the degree to which a case deviates from normal alignment and occlusion. In this case, orthodontic benefits are not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive system/Gastrointestinal-Abdominal Pain
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has overturned in whole the health plan's determination. 

The patient is a male with medical history of diabetes mellitus type 2. He presented to the emergency department with nausea, vomiting, abdominal pain, photophobia, and headache. He had presented the day before with fatigue and dark-colored urine and had flu-like symptoms. He had been on Augmentin. Right upper quadrant ultrasound showed gallbladder wall thickening and pericholecystic fluid. Computed tomography scan of the abdomen and pelvis showed hepatosplenomegaly with acute peripancreatic fat stranding and free fluid suspicious for acute interstitial edematous pancreatitis, but no necrosis or fluid collections. Computed tomography scan of the head showed no acute intracranial abnormality. He was treated with intravenous fluids. He underwent a lumbar puncture. General surgery consultation recommended hepatobiliary iminodiacetic acid (HIDA) scan. He was febrile overnight and had general myalgias and fatigue. HIDA scan was normal. Gastroenterology consultation suspected viral infection. Infectious Disease consultation recommended testing for infection. Magnetic resonance imaging with magnetic resonance cholangiopancreatography was done. Testing for C. Burnetii antibodies suggestive of Query (Q) fever was positive. Esophagogastroduodenoscopy showed esophageal polyps, changes suspicious for gastritis, and nodular mucosa in the duodenal bulb. Computed tomography scan of the chest showed small to moderate right and trace left pleural effusions with adjacent atelectasis, mild scattered nonspecific ground glass opacities in the remainder of the lungs which may be infectious or inflammatory, and no lymphadenopathy in the chest. Hematology consultation noted acute febrile illness likely infectious etiology which would explain hepatosplenomegaly and atypical lymphocytes on peripheral smear. Echocardiogram showed normal left ventricular ejection fraction and trace pericardial effusion. He was discharged on doxycycline.
The inpatient level of care is supported. In this case, the patient presented with nausea, vomiting, abdominal pain, abnormal imaging, and elevated liver enzymes. He had persistent headache and fevers after presentation, and testing was ultimately suggestive of Q fever infection with Coxiella burnetii, which can have significant clinical sequelae. Until he was diagnosed and began to respond to antibiotic therapy (well into the admission), his elevated liver enzymes, hepatosplenomegaly, headache, and fever were concerning for multiple potential serious underlying diseases, and close monitoring was warranted at the inpatient level of care; a short stay at a lower level of care would not have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke/CVA (cerebrovascular accident). 
Treatment: Hospital Admission. 
The health plan denied the hospital admission. 
The determination is upheld. 

The patient is a female with past medical history of hypertension (HTN) who was admitted with complaints of left-handed weakness. Her vital signs were notable for a pulse of 119 beats per minute (bpm). The physical exam was notable for left hand weakness and a National Institute of Health Stroke Scale (NIHSS) score of 1. The lab work was unremarkable. A computed tomography (CT) scan of the head and computed tomography angiography (CTA) of the head/neck were negative for acute ischemia. Magnetic resonance imaging (MRI) of the brain showed scattered foci of restricted diffusion within the corona radiata of right frontoparietal lobe. The transthoracic echocardiogram (TTE) showed no shunt. The patient was diagnosed with acute cerebrovascular accident (CVA) and was treated with acetylsalicylic acid (ASA), statin, telemetry, and permissive HTN. Physical therapy (PT)/occupational therapy (OT) determined no needs. Neurology evaluated the patient and recommended a TEE with bubble study, but the patient refused. The patient was discharged in stable condition. At issue is the medical necessity of the hospital admission. 
The health plan's determination of medical necessity is upheld in whole. 
The requested health service/treatment of hospital admission is not medically necessary for this patient. This patient presented to the emergency department with complaints of left-handed weakness. The patient's MRI did demonstrate some acute ischemia, and her NIHSS score was 1, indicating that the patient on presentation, at most, had suffered a minor stroke, and the only neurologic finding on admission was left-hand weakness. Furthermore, the patient did not have a crescendo transient ischemic attack (TIA), there was no known extracranial embolic source such as atrial fibrillation or artificial heart valve, known carotid stenosis, disabling stroke, altered mental status, or hypertensive encephalopathy. The patient remained hemodynamically stable during the stay, was treated with standard medications for TIA/CVA, had minimal symptoms on admission, and was discharged in stable condition. As such, the patient could have been safely and appropriately treated at an alternate level of care. 
Regarding the provided criteria, the patient did not have a NIHSS score greater than 2, evidence of hemorrhagic transformation, altered mental status, dysphagia, significant arm leg or weakness, aphasia, gait impairment, mass/edema/large acute infarction on imaging, hemodynamic instability, cardiac arrhythmia, respiratory abnormality, severe HTN, prolonged cardiac telemetry needed, vasculitis, or pregnancy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I occlusion. 
Treatment: Braces. 
The insurer denied braces. 
The health plan's determination is upheld. 

The patient in question is a male with a Class I occlusion with minimal overbite and 4 millimeter (mm) overjet. He has mild maxillary and mandibular spacing. He is treatment planned for braces to correct his malocclusion. 

Braces are not medically necessary for this patient. 
The patient has some minor spacing. His overbite, while minimal, is appropriate and there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows he does not have a traumatic deep bite. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage).
There is no medical reason to correct his malocclusion with braces. While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. However, this patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, braces are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Articulation disorder; phonological disorder
Treatment: Speech Therapy (92507)
The insurer denied: Speech Therapy (92507)
The denial is upheld.

The patient is a pre-school male with articulation disorder and decreased speech intelligibility defined in the medical records as a phonological disorder (F80.0). The child has been receiving skilled speech therapy interventions at a frequency of once per week. The request for continuation of skilled speech therapy interventions has been denied by the health plan due to lack of medical necessity. The denial is being appealed.

The requested health service is not medically necessary.

Clinical records do not point out the disorder of speech organs or neurological or congenital abnormalities requiring skilled goal-oriented speech therapy interventions. This child did not undergo surgery or have organic pathology affecting speech and language function. Medical records do not point out developmental challenges. There is no evidence of extenuating circumstances requiring utilization of skilled speech therapy interventions in outpatient settings. Speech therapy for 
phonological disorder can be provided based on individualized education plan. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pancreatitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient has a history of alcohol abuse and pancreatitis. They presented with abdominal pain, nausea, and vomiting and were hemodynamically stable. There was upper abdominal tenderness but no abdominal rebound or guarding. The lipase was 949 (normal to 393). The computed tomography (CT) scan showed evidence of acute pancreatitis. She was kept nothing by mouth (NPO) and given intravenous (IV) fluids and antiemetics. 

Medical necessity was determined using Milliman Care Guidelines (MCG) M-250 for Pancreatitis. Clinical indications for admission include having acute pancreatitis as manifested by 2 of the following: abdominal pain, serum lipase greater than 3 times the upper limit of normal, and imaging findings indicative of acute pancreatitis. The patient had upper abdominal pain and a CT (computed tomography) scan suggestive of acute pancreatitis. The lipase was slightly less than 3 times the upper limit of normal. 

This patient had evidence of acute pancreatitis. She had abdominal pain and an imaging study that was indicative of acute pancreatitis. This met the MCG criteria for admission for Pancreatitis. She also had a significantly elevated lipase of 949 that improved while in the hospital. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Small for Gestational Age
Treatment: Genotropin 
The insurer denied coverage for Genotropin.
The denial is upheld.

This is a patient diagnosed as small for gestational age (SGA). This request is for Genotropin. As reported, the patient was born at 38 4/7 weeks gestation with a birth weight of 2.58 [kilograms] kg and birth length of 45.7 [centimeters] cm (SGA for length). As per visit notes, the patient's mom states that the patient has started having a little bit of acne; the patient is still premenarchal. The patient's height velocity is reported to be 3.3 [centimeters/year] cm/yr. The patient's breasts and pubic hair were at tanner 1. The patient's bone age was 9y [years] 6m [months] at CA [chronological age] 9y9m. The patient's weight was 23.3 kg.

Growth hormone (GH) for the treatment of children who are SGA and who fail to exhibit catch-up growth is standard of care. This indication has approval from the Food and Drug Administration (FDA) support from consensus guidelines and randomized controlled trial evidence to support its use. The most recent and most relevant consensus guidelines are those of the combined meeting of the International Societies of Pediatric Endocrinology and the Growth Hormone Research Society. Here it is recommended that if a patient fails to exhibit catch-up growth by either two or four years, that GH therapy be initiated. At age 4 years this is defined as < (less than) 2 standard deviations (SD). The diagnosis of SGA is made at birth. The diagnosis of SGA with failure to catch up is made after a growth point at age 2. This diagnosis can be made at any time after age 2 assuming that the patient has not had catch up growth to above -2SD [standard deviations]. For example, if a patient is found at age 8 and is still has still not caught up, then this patient would qualify for the SGA indication. 

The patient's height was 125.7 cm (-1.87 SDS) with height velocity over 1y3m of 4.9 cm/yr. The patient improved from a height 119.6 cm (-2.03 SDS) compared to the above after a year.

The patient was born SGA. The patient has caught up. The patient's height is not > (greater than) 2SD below the mean on the most recent documentation as required by generally accepted standards of medical practice. 

Based on the above, the insurer's denial of Genotropin is upheld. The health care plan acted reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for Genotropin services is not substantiated.