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

Diagnosis: Evaluation for fertility preservation services.

Treatment: Cryopreservation embryo (89258), invitro fertilization procedure cancelled after aspiration, case rate (S4021), cryopreservation mature oocytes (89337).

The insurer denied coverage for cryopreservation embryo (89258), invitro fertilization procedure cancelled after aspiration, case rate (S4021), cryopreservation mature oocytes (89337).

The denial is upheld.

This is a female patient who was seen via telemedicine by her obstetrics/gynecology (OB/GYN) specialist at a center for reproductive medicine for inquiry about her fertility status and how to preserve it. Prognosis and treatment options with their risks and benefits were discussed. The patient's evaluation by ultrasound showed good antral follicle count. The patient was being treated for chronic back pain and based on the providers' letters, may not be able to carry a pregnancy and may need a surrogate.

As part of education and informed consent before cancer therapy, gonadotoxic treatments and surgeries that may lead to decrease fertility (oophorectomy), health care providers should address the possibility of infertility with patients treated during their reproductive years and be prepared to discuss fertility preservation options and/or to refer all potential patients to appropriate reproductive specialists. Fertility preservation options in females depend on patient age, diagnosis, type of treatment, presence or participation of a male partner and/or patient preferences regarding the use of banked donor sperm and time available.

In this case, this patient is not undergoing any treatment that will affect her future fertility. The patient does not have cancer and will not be receiving any chemotherapeutic agent or radiation therapy that may affect her ovaries. The patient is not undergoing any surgery that will lead to loss of ovarian function. When the patient is ready to conceive, the patient would then be evaluated about her ability to carry a pregnancy and undergo appropriate treatments including possible in-vitro fertilization (IVF) with transfer into a surrogate if needed.

Based on the above, the fertility preservation services by egg freezing are not medically necessary for this patient at this time. 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 cryopreservation embryo (89258), invitro fertilization procedure cancelled after aspiration, case rate (S4021), cryopreservation mature oocytes (89337) is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right total knee arthroplasty for right degenerative joint disease
Treatment: Hospital admission
The insurer denied coverage for the hospital admission.
The denial is upheld. 

This is a female patient with a past medical history of osteoarthritis, morbid obesity, mitral valve regurgitation, glaucoma, and several years of right knee pain who presented to the hospital for preoperative medical evaluation for right total knee replacement. The patient underwent a right total knee arthroplasty for right degenerative joint disease. The patient received pain management and physical therapy post-operatively. The patient was discharged after treatment and once medically stable.

The patient's medical records demonstrate a non-complicated post-surgical course. The patient was able to walk 60 feet on postoperative day 1 (POD 1). There were no problems with her wound. The patient's vital signs were stable. The patient was able to tolerate oral pain medication. The patient did not require treatment or additional testing for underlying medical problems. There was no documentation on how her obesity limited her clinical progress or caused delay. There were no reported complaints referable to mitral valve regurgitation. There was no evidence of bleeding, infection or fever that required an inpatient level of care and monitoring. As per Milliman Care Guidelines (MCG), there was no extenuating circumstance to substantiate the admission and length of stay of this patient. Based on the review of the medical record and literature, the hospital admission is considered 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 hospital admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class I, maxillary spacing, proclined incisors and deep impinging overbite)
Treatment: Braces
The insurer denied coverage for braces. 
The denial is upheld. 

This patient is a female child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, maxillary spacing, proclined incisors and deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 11 points on review by their internal reviewers. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, the HLD index is utilized. This index provides 6 specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage, and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet the insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer, attaining 11 points (5 points overjet, 4 points overbite, and 2 points labiolingual spread).
 
The coverage for braces is not considered 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 braces is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Renal colic
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This is a female patient with past medical history of renal colic and hypothyroidism. The patient presented to the hospital with complaints of left flank pain, fever, chills, nausea, vomiting and blood in urine. The patient was kept on nothing by mouth (NPO) status, and underwent a scheduled procedure, left ureteroscopy with laser lithotripsy, stent placement. The patient tolerated the procedure well without complication, and was transferred to the post-anesthesia care unit (PACU) postoperatively. The patient was admitted to Urology for postoperative monitoring. The patient had mild postoperative tachycardia. The patient improved and was discharged home on oral Tylenol and oral Cipro. 

Based on the review of Milliman Care Guidelines (MCG) Health guideline for Renal Colic + Kidney Stones RRG (M-320), the patient fails to meet clinical indications for inpatient admission. The patient presented to the hospital for a scheduled procedure. 

As per MCG guideline for Urologic Surgery or Procedure GRG (SG-US), the patient meets the discharge parameter within 24-hour postoperatively. The complexity of this patient's procedure was appropriate for an ambulatory surgery setting. There was no postoperative complication that required an inpatient level of care. Thus, the inpatient admission was not medically necessary for this patient. 

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

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

Diagnosis: Overjet. 
Treatment: Braces (D8080) and Monthly Visit x 12 (D8670). 

The insurer denied the Braces (D8080) and Monthly Visit x 12 (D8670). The denial is overturned. 

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

Yes, the Braces (D8080) and Monthly Visit x 12 (D8670) are medically necessary. 

The patient's two upper front teeth, the central incisors, #s 8 and 9, stick out severely. They are very prone to trauma, where they could fracture because of their position. In addition to this, being out of position also means that when the patient brings his lower jaw forwards during the chewing cycle, there is no "anterior guidance." This means that the lower teeth will not mesh properly with the upper teeth, and this will cause the patient's teeth to grind together in a destructive fashion over time. The patient needs orthodontic treatment to retract his upper front teeth into their proper position. The Braces (D8080) and Monthly Visit x 12 (D8670), therefore, are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial arrhythmias, LV dysfunction. 
Treatment: Inpatient admission. 

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

The patient is a female. She was electively scheduled for an EP (electrophysiology) ablation due to atrial arrhythmias, LV (left ventricle) dysfunction, and poor response to beta blockers. She has history of hypertension, GERD (gastroesophageal reflux disease), cardiomyopathy, and atrial fibrillation. A previous echocardiogram showed an EF (ejection fraction) of 35% and LVH (left ventricular hypertrophy). 

Ablation was performed without complications. The patient was admitted to recovery then to the floor for, "continued care and monitoring." The patient placed on sotalol and resumed outpatient medications. Atypical chest pain was noted, and patient was monitored without any intervention. Her hemodynamic status was stable throughout, and she was discharged. 

The inpatient admission was not medically necessary, as inpatient level of care was neither indicated nor provided. 

This was an elective, uncomplicated EP (electrophysiology) ablation. The patient was always hemodynamically stable with normal vital signs. The EKG (electrocardiogram) was without ischemia. The patient had normal LV (left ventricle) function, and no significant ventricular ectopy. The only care given after the uncomplicated procedure was monitoring, IVF (intravenous fluids), starting sotalol and resuming routine medications. This care provided meets the definition of outpatient care without any indication for a higher level. 

While observation is recommended when starting sotalol, this can be performed safely in a lower level of care than inpatient. The overnight stay for observation and telemetry does not change that determination. No untoward effects were noted, and no change in therapy, testing, or care was required. 

The letter of appeal was carefully considered, but it offered no evidence to support a higher level of care. The only care that was provided was telemetry, which is frequently performed in observation and outpatient status. The patient was admitted for monitoring and routine care post EP (electrophysiology) ablation. There was no "complex" care that was required in this patient's care post procedure. While there was always a potential for an adverse event with initiating sotalol, no side effects occurred, and no actual treatment was needed. In the appeal letter it referenced from Milliman Care Guidelines the need for admission if there is a high risk of adverse effects. Neither the ablation procedure nor the medications prescribed met that criterion of high risk. 

Since all of the testing and therapy that were actually performed would be appropriate, safe and guidelines-consistent in an outpatient setting, inpatient level of care was not medically necessary.
 
The denial was consistent with guidelines and usual community care. Post-cardiac care as described is routinely performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal- Diverticulitis
Treatment: Inpatient hospital stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has overturned in whole the health plan determination.

The patient was admitted to the hospital. The patient was referred to the emergency room (ER) after an outpatient colonoscopy  was done to evaluate diverticulitis. In the ER the patient appeared uncomfortable and was tender to palpation in the left lower quadrant (LLQ) with rebound. On labs the white blood cell count (WBC) was 11.1 with left shift. The patient underwent a computed tomography (CT) scan of the abdomen which revealed inflammation of the sigmoid colon with a small adjacent collection. Interventional Radiology (IR) was unable to drain. The patient was started on intravenous (IV) antibiotics (Ceftriaxone and Flagyl). The patient was significantly improved the next day.  There was much less pain, no nausea or vomiting, the WBC count was down to 7.6. The patient was able to advance diet and there were no new complications - the patient was discharged the following day.

The requested inpatient hospital admission was medically necessary for this patient.
Under normal circumstances,  most cases of diverticulitis that are uncomplicated can be managed in a setting that requires less resources than inpatient care. However, this patient had an adjacent fluid collection in association with the diverticulitis. It is possible the procedure caused a perforation at the site of weakened bowel wall. There is significant potential the collection could have rapidly enlarged with the development of a widening perforation at the site of weakened bowel. This patient required IV antibiotics and if the patient had acute worsening would have had a much better outcome while being followed in an acute inpatient setting (it is the difference between requiring a colostomy and having a single stage operation). For these reasons, the inpatient hospital admission was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Existing crowns.
Treatment: All White Glass Crowns on Teeth #8 and #9 (D2740).

The insurer denied the All White Glass Crowns on Teeth #8 and #9 (D2740). The denial is upheld. 

The patient is a male requesting dental benefits to replace existing crowns on teeth #'s 8 and 9.

No, the proposed all white glass crowns on teeth #s 8 and 9 are not medically necessary.

There is no recurrent decay seen on the x-ray under or around the existing crowns on teeth #s 8 and 9. There is no fracturing of either tooth or either crown. There is no need to replace these crowns. No medical necessity is seen.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain. 
Treatment: Inpatient admission. 

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

The patient is a male. He presented to the emergency department with generalized abdominal pain and worsening right lower quadrant (RLQ) abdominal pain for 10 hours.  

The patient's physical exam revealed tenderness in the RLQ (right lower quadrant). White Blood Cell Count (WBC) was elevated at 17.84. CT (computerized tomography) abdomen revealed appendicitis. Surgery was scheduled for the next morning. 

The patient was given IV (intravenous) antibiotics, IV (intravenous) pain medications, IV (intravenous) antiemetics, IV (intravenous) Pepcid, and IV (intravenous) fluids. He was given oral pain medication, Prilosec, and Neurontin. 

The patient developed tachycardia and was monitored on telemetry and was given a bolus of LR (lactated ringer), resolving the tachycardia. 

After surgery, the patient was not tolerating regular diet due to nausea. His WBC (white blood count) was elevated to 20.22. He received IVF (intravenous fluids), IV (intravenous) antibiotics, IV (intravenous) morphine. 

The following day the patient vomited three times. The patient's WBC (white blood count) elevated higher to 21.64. He needed another IV (intravenous) started. He continued to receive IV (intravenous) antibiotics. 

The patient's nausea and vomiting repeated overnight. His WBC (white blood count) decreased but was still elevated at 19.0. 

The patient evidenced no pain, nausea, or vomiting. His WBC (white blood count) was down to 13.96. The patient was discharged. 

Yes, the Inpatient admission was medically necessary. 

Vomiting is not normal following surgery. This patient required IV (intravenous) fluids and medications above and beyond a normal case of appendectomy.  He was not able to take in by mouth adequate amount in order to sustain himself outside the hospital until the day of discharge.  His WBC (white blood count) was very high for two days after the operation. These extenuating circumstances justify inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/ Injuries. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This patient is a male child who was brought to the Emergency Department (ED) as he had been running and pushing his mechanical scooter and fell, landing on his right-side and striking his head. The patient lost consciousness for approximately 10 minutes. Upon waking, the patient vomited three times. A level 2 trauma was activated. The patient had no severe headache, neck pain, chest pain, abdominal pain, or back pain. The patient was awake, alert, and oriented. There was no evidence of distress. The patient had an abrasion to the right temporal region. There was no scalp swelling or tenderness. There was an abrasion to the right posterior elbow and right medial superior ankle. The patient was to undergo a computerized tomography (CT) scan of the head, chest X-ray, and X-rays of the bilateral right elbow and right knee. The patient's CT of the head was unremarkable. The patient's chest X-ray was normal and the extremity X-rays were negative for fracture. The patient was to be admitted to the trauma service for further evaluation. 

As per literature review, inpatient care rather than observation is required only if the patient's medical condition, safety, or health would be significantly and directly threatened if the care was not in an intensive setting. A patient must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be provided safely and effectively only on an inpatient basis. After reviewing this case, it is not felt that the patient's illness, intensity, or discharge criteria required an inpatient level of care and/or acuity. 

The inpatient hospital admission is not considered medically necessary for this patient. 

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

The carrier's denial of coverage for the inpatient hospital admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Mental Health. 
Inpatient hospital. 

Diagnosis: Suicide attempt. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a man with a history of hypertension, asthma, prior suicide attempt, and depression who was admitted to the hospital. He presented to the emergency department after a suicide attempt. He had taken multiple doses of pain medication and blood pressure medication. He was found to have an elevated alcohol level of 197. His son reported that he had been seen multiple times over the past 10 days for alcohol intoxication and a withdrawal seizure. He had also attacked his spouse and had her arrested. Labs showed white blood cell count (WBC) 8.2, toxicology showed alcohol 197, Troponin 0.01, lactate 3.2, pH 7.42, and aspartate aminotransferase (AST) 52. An electrocardiogram (EKG) showed normal sinus rhythm. Chest x-ray showed mild pulmonary parenchymal changes and no evidence of pneumonia. Vital signs showed temperature 37.1 Celsius, blood pressure 133/70, and respiratory rate 20. Oxygen saturation was 89%. The patient was admitted for alcohol withdrawal and suicide attempt. 

The inpatient hospital admission was not medically necessary. The patient presented with alcohol intoxication in the setting of alcohol abuse and concerns for a suicide attempt. Concerns about suicide were resolved after the first day of his presentation and he was assessed by psychiatry as having competence to leave against medical advice. Patients with alcohol withdrawal are at increased risk of complications such as delirium tremens and withdrawal seizures. However, possibly because of early treatment in the emergency department, this patient had a stable hospital course and did not require an inpatient level of care. 

The patient did not present with evidence of active alcohol withdrawal and had no evidence of hemodynamic or physiologic abnormalities from a potential suicide attempt, such as significant acidosis or EKG abnormalities. In addition, there was no evidence of sepsis, acute stroke, or acute seizures. Although the patient did have a history of withdrawal seizure in the past, because the patient was stable during this hospitalization, he could have been cared for safely and effectively at a lower level of care.