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

Diagnosis: Pneumonia.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male with a history of asthma and obstructive sleep apnea who presented to the hospital emergency department (ED) with a complaint of bilateral lower extremity pain with subjective fever and chest tightness for 1 day. Vital signs were temp 102.9 F (Fahrenheit), pulse 127, blood pressure (BP) 124/78, respirations 24 and pulse oximetry 82%. Physical examination revealed dry mucous membranes. Abnormal laboratory values included white blood cell count (WBC) 11.47, calcium 8.0, glucose 134, alanine aminotransferase (ALT) 118 and aspartate aminotransferase (AST) 83. An electrocardiogram (EKG) showed sinus tachycardia. Chest x-ray showed linear atelectasis at the lung bases. The patient was admitted for pneumonia and treated with intravenous antibiotics. Upon admission, pulse was 82, respirations were 20 and pulse oximetry was 97%. The patient's condition improved rapidly and he was deemed stable for discharge on the following day.

The inpatient hospital admission was not medically necessary. This patient presented to the hospital with lower extremity pain, fever and chest tightness for 1 day. He was diagnosed with pneumonia and started on antibiotics. Upon admission, there was no evidence of hemodynamic instability. Other than linear atelectasis, there were no acute imaging findings. There was no evidence of altered mental status. There was no evidence of failure of outpatient therapy. The patient was able to tolerate oral intake. The respiratory rate and pulse oximetry had improved upon admission. Based on the available medical records, the patient did not have any clinical needs that warranted inpatient care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Orthodontic/Dental Procedure. 
The insurer denied braces. 
The denial is overturned.

The patient is a female. She has a Class II Subdivision right malocclusion with crowding and a retrognathic mandible. She has an 8 millimeter (mm) overjet. She is treatment planned for orthodontics combined with 2-jaw orthognathic surgery including a Lefort 1 osteotomy and a mandibular advance to correct the crowding and Class II. The subject under review is the medical necessity for braces.

The health plan's denial is overturned.

The requested treatment with braces is medically necessary for this patient. There is strong medical evidence that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma.1 Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. Orthodontics will make these teeth significantly less protrusive. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated complications and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+mm overjet, which this patient has.2 For these reasons orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left foot cellulitis. 
Treatment: Inpatient level of care. 

The insurer denied coverage for inpatient level of care. 

The denial is upheld. 

Patient has a past medical history significant for diabetes mellitus, stage 4 chronic kidney disease, polysubstance abuse, diabetic neuropathy, status post amputation of right big toe who was referred to the emergency department for purulent drainage and pain to his left foot. The patient's vital signs on presentation included: temperature 97.9 degrees, blood pressure 124/66, heart rate of 76 beats per minute, respiratory rate 18 breaths per minute, and oxygen (O2) saturation 98 percent (%) on room air. Laboratory results included the following: white blood cell count (WBC) 7.33, hemoglobin (HGB) 9.6, hematocrit (HCT) 31.1, creatinine 1.76, glucose 413, and lactate 2.3. The patient was started empirically on intravenous (IV) antibiotics (Unasyn) for left foot diabetic ulcer/cellulitis. His blood glucose was treated with insulin. Podiatry was consulted and dressing changes were provided. The patient remained afebrile and hemodynamically stable. He was discharged to continue on oral antibiotics (Augmentin) as an outpatient. 

According to documentation, the patient returned to the emergency department for chronic left foot cellulitis. Otherwise, the patient was afebrile, hemodynamically stable and had a normal WBC count on laboratory results. Medical records suggest numerous chronic co-morbid conditions including poor adherence to his diabetes management. The patient apparently has had repeated hospital presentations as well as leaving against medical advice. During the current hospitalization, the patient had no evidence of a disseminated infection, and no surgical intervention was deemed necessary. Based on his elevated glucose, the patient met criteria for an observation level of management. 

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

The insurer's denial of coverage for inpatient level of care is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite with gingival attachment loss

Treatment: D8080 braces

The insurer denied coverage for D8080 braces

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometry radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss, in addition to other clinical findings.
The orthodontist has completed the Handicapping Labio-lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. 

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess for severity of malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides six 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
crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by referenced studies.

Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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

The clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care.	

The insurer's denial of coverage for the D8080 braces is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male with alcohol use disorder and psychopathology who was admitted to the acute inpatient service after a syncopal episode. The event was described as falling on to his side with a five to ten second loss of consciousness. At presentation, computed tomography (CT) of the brain was negative for any acute intracranial pathology, orthostatic vitals signs were negative and examination showed the patient was tremulous. Subsequent carotid ultrasound was negative.

No, the proposed inpatient admission was not medically necessary.
The patient had a single event of loss of consciousness that was not accompanied by any emblematic features of seizure. Specifically, there was no motor activity, tongue bite, incontinence or post-ictal confusion to suggest seizure. At presentation, there was no cardiac arrhythmia or abnormality on computed tomography to suggest a serious underlying condition. Neurological evaluation at presentation was consistent with baseline function. Overall, the patient could have been safely and effectively monitored and treated at a lower level of care for a single episode of uncomplicated syncope. (Hussain et al., 2021; Cheshire)

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Stelara. 
The denial is upheld.

The patient is a female with Crohn's disease. Disease is mostly in the left colon. The patient has had disease since childhood. Treatments have included Pentasa, prednisone, 6 mercaptopurine (MP), and antibiotics. Recently she complained of blood per rectum. The patient was started on Stelara. The patient also received treatment with hydrocortisone enemas as well as MiraLAX and Linzess for constipation.
The patient's provider has recommended approval for ustekinumab. This request was denied by the plan. Per the plan criteria it can be approved for moderate to severe Crohn's when other treatments including steroids, immunosuppressants and anti-tumor necrosis factor (TNF) drugs have not worked or cannot be taken.

The health plan's determination is upheld.

Stelara is not medically necessary for this patient. The patient appears to have progressed through non-biologic therapy and is requiring steroids on a regular basis for symptom control. Therefore, use of a biologic at this point is perfectly reasonable. In this case, starting anti-TNF agents is supported by high quality data (Phase III studies and copious supplemental peer-reviewed studies). [1] There is no data to this reviewer's knowledge on the advantage of Stelara over an anti-TNF in this scenario.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Temperature sensitivity
Treatment: Nerve Treatment On Molar Tooth, Tooth 31
The insurer denied the Nerve Treatment On Molar Tooth, Tooth 31
The denial is overturned

The patient is a male. The patient has recurring temperature sensitivity in tooth #31. The health plan denied the requested Nerve Treatment on Molar Tooth, Tooth 31, as not medically necessary.

Yes, the Nerve Treatment On Molar Tooth, Tooth 31, is medically necessary.
Based upon this tooth not having responded to conservative treatments for a length of time, the diagnosis is "irreversible pulpitis." This is when the nerve of the tooth stays sensitive for any given reason. The only fix is to remove the nerve via root canal treatment. Root canal treatment is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. Please see the rationale, above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Exertional Angina

Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.

The denial is upheld.

The patient presented to the hospital complaining of chest pain and dyspnea on exertion. Upon arrival to the emergency department, vital signs were stable with blood pressure (BP) 132/82 and pulse of 60.  No abnormal findings were reported on physical examination.  A 12-lead electrocardiogram (ECG) revealed normal sinus rhythm with sinus arrhythmia and no ST (interval on ECG) or T (interval on ECG) wave abnormalities.  Serum blood testing failed to reveal any abnormality.   A computed tomography (CT) angiogram was performed but assessment of coronary artery occlusion was precluded by calcification of the coronary arteries. The patient was admitted to telemetry and signed out against medical advice (AMA).

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with typical exertional angina and no significant past medical history. His pretest probability of coronary artery disease is intermediate (Reference 1). Utilizing the HEART (history, ECG anomalies, patient age, risk factors, and troponin) score he was considered low risk (Reference 2).  Utilizing the thrombolysis in myocardial infarction (TIMI) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). Risk assessment of patients presenting with chest pain and no significant ST changes on electrocardiogram (ECG) was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction [MI], need for percutaneous coronary intervention [PCI], need for coronary artery bypass grafting [CABG], or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care.

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

The insurer's denial of coverage for the inpatient hospital is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overdose
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male with a past medical history of substance abuse. The patient was taken to the ED (emergency department) following an opioid overdose. The patient had been found unresponsive with drug paraphernalia. He was given naloxone by an ambulance crew with improvement in his mental status. It was suspected that he had overdosed on fentanyl.

In the ED (emergency department), the patient was awake and alert. His vital signs were normal. Testing revealed a low potassium level. Other blood tests were normal. An ECG (electrocardiogram) showed new T-wave inversions in the anterior leads. The patient had no chest pain or difficulty breathing.

Following his ED (emergency department) evaluation, the patient was admitted to the hospital. His admission note indicates that he would be kept on a cardiac monitor. He would be observed for respiratory depression. Serial blood tests would be done to rule out an acute coronary syndrome. The patient was not treated for an acute coronary syndrome. No anticoagulant was given. A psychiatry consultation was requested.

The following day, the patient had no further respiratory depression. Serial cardiac enzymes were normal. His ECG (electrocardiogram) normalized without treatment. A psychiatrist cleared the patient for discharge. He was sent home.

No, the Inpatient admission was not medically necessary.
Following this patient's ED (emergency department) evaluation, he was clinically stable. He had normal vital signs and normal mental status. There were no signs of ongoing opioid toxicity. He was admitted for monitoring and because he had an abnormal ECG (electrocardiogram). The patient received no treatment for an acute coronary syndrome. Serial blood tests were ordered.

There was no severity of illness to justify an inpatient admission. The patient had an abnormal ECG (electrocardiogram) with no symptoms of an acute coronary syndrome.

There was no intensity of services required by the patient to justify an inpatient admission. He required monitoring and serial cardiac enzymes. A regular diet and oral medications were ordered. A psychiatry consultation was planned.

At the time this patient was kept in the hospital, it would have been reasonable to believe that this limited plan of care could be accomplished with a short stay in the hospital. For this reason, an inpatient admission was not medically necessary. The patient could have safely been managed at a lower level of care.

Yes, the health plan did act reasonably in denying coverage for this inpatient admission.
The patient was clinically stable at the time he was admitted. A limited plan of care was anticipated for him. He could have safely and effectively been managed at a lower level of care. An inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient stay. 
The denial is overturned in whole. 

This patient is a female, who presented with acute gastrointestinal (GI) symptoms (abdominal pain, nausea, and loose stools) in the setting of leukocytosis. She failed emergency department (ED) treatment with intravenous (IV) analgesics, both opioid and non-opioid analgesics, antiemetics. A diagnostic computed tomography (CT) scan was negative for acute intra-abdominal pathology, but a pelvic ultrasound revealed an enlarged left ovary containing complex and simple cyst. Surgical consultation recommended against any surgical intervention.
She was admitted for further management of intractable pain, and nausea. She received IV fluid and antiemetics and completed infectious stool studies workup. Her symptoms responded within 24 hours, and she was discharged home.
At issue is the medical necessity of the Inpatient stay.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Inpatient Stay was medically necessary for this patient.
This is a patient with acute GI symptoms, presumed secondary to acute gastroenteritis. She failed initial pain control in the ED. Her clinical presentation required inpatient care detailed as administration of IV fluids, IV analgesics, and antiemetics. Furthermore, leukocytosis and abnormal pelvic ultrasound also suggest possible genitourinary etiology of her pain and possible but less likely late evolving appendicitis. In addition, it was medically prudent to admit her for serial clinical monitoring for further workup including infectious workup. These inpatient level of care measures of IV fluid and IV analgesics cannot be prudently provided under another level of care other than inpatient and this is the standard of care.
Therefore, the requested health service/treatment of Inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient has a past medical history (PMH) of diabetes mellitus type 2 (DM2), hypertension (HTN), hyperlipidemia (HLPD), coronary artery disease (CAD), renal cell carcinoma (RCC), peripheral artery disease (PAD), and prior osteomyelitis who was admitted with complaints of (c/o) right foot ulcers that were increasing in size and developed purulent drainage. The vital signs were remarkable for hypertension. The physical exam was notable for the right foot with an open Wagner type 2 ulcer and localized erythema to the dorsum of the right foot. Lab work was notable for C-reactive protein (CRP) 33, erythrocyte sedimentation rate (ESR) 60, white blood cell count (WBC) and lactate within normal limits (WNL). A right lower extremity (RLE) radiograph showed no evidence of osteomyelitis or fracture. The patient was diagnosed with RLE cellulitis and treated with intravenous (IV) antibiotics, frequent wound dressings, and expert consultations. After evaluation by infectious diseases, due to lack of systemic signs of infection, it was recommended that the patient transition to oral therapy and follow-up as an outpatient. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. The patient presented to the emergency department (ED) with c/o right foot ulcers that were increasing in size and developed purulent drainage. The patient was afebrile, did not appear toxic, had no unstable comorbidities, have a limb-threatening infection, there was no septicemia, life-threatening infection, necrotizing fasciitis, leukocytosis, features of systemic inflammatory response syndrome (SIRS), animal or human bite with extensive damage, high risk location (face, neck, hand, genitals), pain out of proportion to clinical findings, crepitus, neutropenia, severe immune-suppression, marked systemic toxicity or worsening symptoms, or inability to take oral medications. This patient was treated with intravenous (IV) antibiotics with swift transition to oral antibiotics, and this could have been safely provided at an observation level of care. The management of non-severe cellulitis infections with frequent reevaluation to assess response to therapy could have been provided at a lower level of care.

Regarding the provided Milliman Care Guidelines (MCG), the patient did not have hemodynamic instability, altered mental status (AMS), failure of outpatient treatment, limb-threatening infection, significant immunosuppression, bacteremia, suspected necrotizing infection, cutaneous gangrene, orbital infection, preseptal or perianal infection, severe pain requiring inpatient management, inability to maintain hydration, or compartment syndrome.