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

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

The patient is a female with postmenopausal bleeding with anemia. She had a history of hypertension, chronic kidney disease, pulmonary embolism and lymphedema. She was taking Eliquis. Hemoglobin was 11.9. A Pelvic ultrasound showed a thickened endometrial stripe. She was admitted as an inpatient and was placed on a heparin drip. 

Inpatient Hospital Stay is not medically necessary for this patient.
The patient is a female with no significant anemia. She had vaginal bleeding; however, without severe anemia and the need for blood transfusion. Her vital signs were normal, and she had no hemodynamic instability. She could have been managed as an outpatient and scheduled surgery for her bleeding evaluation. There was no reason for inpatient admission. She was on a blood thinner; however, this is typically managed at a lower level of care and the patient transitioned to heparin at home. There are no reasons supported by the medical records for the inpatient admission as the bleeding stopped spotting the following day. She had no continued hemorrhage or need for acute intervention. She had a simple outpatient procedure that could have been performed in an ambulatory center or clinic. She had no pulmonary complications. She could have been observed after surgery in the post-anesthesia care unit (PACU) and discharged home after her outpatient procedure. There was no need for acute, inpatient monitoring as there was no complications after surgery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough, nasal congestion, vomiting
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

This is a toddler female who was admitted for cough, nasal congestion, nausea and vomiting. In addition, the patient had fevers for three days. In the emergency department, the patient's vital signs were temperature (T) 99.1 Fahrenheit (F), 
pulse (P) 147, respiratory rate (R) 24, pulse oximetry (Pox) 100 percent on room air. The patient was noted to be tired, crying without tears, had dry mucous membranes, and was tachycardic. 
Labs were unremarkable aside from a mildly low potassium of 3.2. Viral testing was negative. The patient was given Zofran and intravenous fluids. Upon admission, the patient was continued on intravenous fluids and Zofran, given intravenous potassium, and oral fluids. A urinalysis was normal. On day # (number) 2, the patient was tolerating oral intake and was discharged home.

The proposed inpatient hospital admission was not medically necessary.

The requested hospital stay was not medically necessary. Upon admission, the child was hemodynamically stable with age-appropriate vital signs. Her electrolyte abnormalities were mild. She did not require intensive monitoring, frequent laboratory evaluation, respiratory support, frequent changes to her treatment plan, or any other service which necessitated an acute inpatient level of care. Her care could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems-Malpositioned Teeth
Treatment: Orthodontic treatment
The health plan denied the proposed Orthodontic treatment as not medically necessary. The reviewer has overturned in whole the health plan's determination. 

The patient in question has a Class I malocclusion with moderate crowding and protrusive maxillary incisors. He has a 7-millimeter (mm) overjet and 4 mm (millimeter) overbite. He is treatment planned for 24-36 months of orthodontics to correct the crowding and protrusion, but his health plan rejected the claim on the basis that treatment is not medically necessary.

The health plan has not acted in the best interest of this particular patient. Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. There is strong medical evidence that the correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma.1-Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with (greater than 6 mm) 6+mm overjets, which this patient has. For these reasons, orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Diarrhea
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.  The denial has been upheld.

The proposed treatment was not medically necessary.

The patient is adult male with no significant past medical history, who presented to the emergency department for evaluation of nausea, vomiting, and diarrhea.  On arrival to the emergency department, the patient was afebrile and hemodynamically stable.  He was saturating well on room air.  Initial labs were notable for a white blood cell (WBC) count of 22.  Troponins were 0.11.  Electrocardiogram (EKG) showed normal sinus rhythm without any acute ST changes.  The patient was hydrated with intravenous fluids and was given Zofran.  He was admitted to the inpatient unit and a computed tomography (CT) scan was obtained which did not demonstrate any acute findings.  The patient was started on ciprofloxacin/Flagyl with improvement of his symptoms.  He was ultimately discharged with outpatient follow-up.

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion.  There was no evidence of acute coronary syndrome.  Computed tomography scan of the abdomen did not demonstrate any acute findings.  Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care.  Observation level of care would have been appropriate in this case.       

Due to the reasons stated above, there is insufficient clinical data to support medical necessity for admission to inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic wound. 
Treatment: Durable Medical Equipment - Wound Vacuum (E2402RR x 30). 
The insurer denied coverage for Durable Medical Equipment - Wound Vacuum (E2402RR x 30). 
The denial is overturned. 

The patient is an adult male with history of uncontrolled diabetes mellitus (DM) type II with Hb (hemoglobin) A1c of 10.6 who was being followed for a left diabetic wound status post partial 5th ray amputation. The patient was receiving wound vac (vacuum) changed three days a week by home health nurses and was on 6 weeks of intravenous (IV) antibiotics. Photos document the extent of the wound which measures 3.5 cm (centimeters) x 3.5 cm x 0.4 cm.  The notes indicated that the wound was getting smaller and had a healthy wound bed. The literature is vast on the benefits of wound vacs for diabetic foot infections. "VAC therapy significantly decreases the time to complete wound healing, hastens granulation tissue formation, and reduces the ulcer area compared to conventional dressing. [Reference 1]" Furthermore, "the wound environment of a DFU (diabetic foot ulcer) is essential for proper wound healing. Several studies have shown successful use of NPWT/ROCF (negative pressure wound therapy/reticulated open-cell foam) in preparing the wound bed for closure by promoting granulation tissue formation and decreasing the wound size. [Reference 2]" As such, the use of NPWT is imperative in the closure of wounds, especially in diabetic patients who are at risk of further amputation and limb loss.

Durable Medical Equipment - Wound Vacuum (E2402RR x 30) is considered medically necessary for this patient.

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 Durable Medical Equipment - Wound Vacuum (E2402RR x 30) services is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Left Breast Invasive Ductal Carcinoma
Treatment: Proton Beam Radiotherapy
The insurer denied the proton beam radiotherapy.
The health plan's determination is upheld.

The patient is a female with a history of left breast cancer status/post (s/p) breast conserving surgical resection followed by adjuvant systemic therapy. She has been recommended to proceed with a course of postoperative radiotherapy with curative intent.

The proposed proton radiotherapy is not likely to be more beneficial than photon radiation for the patient's left breast cancer. Proton radiation has not been proven to yield superior clinical outcomes in the member's setting. The treating provider has not supplied a proton/photon plan comparison to show that photon-based radiotherapy (in conjunction with a deep inspiration breath hold technique) is unable to provide adequate safety/precision. The provided plan comparison is for a case control patient and is not specific to the patient. The treating provider has not supplied a proton/photon plan comparison specific to this patient to show that she cannot be treated safely/effectively with photon based radiation therapy. The patient has not received prior thoracic radiation, nor does she have a genetic/comorbid condition that would increase her risk for normal tissue toxicity. Photon-based radiation is widely utilized and supported by the National Comprehensive Cancer Network (NCCN) guideline in the member's setting.

The health plan's determination is upheld in whole.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Left Breast Invasive Ductal Carcinoma
Treatment: Proton Beam Radiotherapy
The insurer denied the proton beam radiotherapy.
The health plan's determination is overturned.

The patient is a female with left breast cancer, who underwent a lumpectomy. The plan is to treat breast and comprehensive nodal radiation using Proton beam.

The proposed health service or treatment, proton beam radiotherapy, is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The dose-volume histogram (DVH) comparison of Proton and photon Volumetric modulated arc therapy (VMAT) plan was provided.
Proton delivered lung dose volumetric parameters (V)5 of 51 percent (%) compared to 98% with photon.
Proton delivered lung dose V20 of 22% compared to 37% with photon.
Proton delivered heart mean dose 0.62 Gray (Gy) compared to 9.4 Gy with photon.
These are all Quantec violations and are not acceptable.
There is an increased risk of pulmonary toxicity if treated with photons.
There is an increased risk of major coronary events increased by 35% if treated with photons.
This patient has a curable disease and Proton will avoid cardiopulmonary toxicity and mortality.
Thus, Proton beam is medically necessary and appropriate.

The health plan's determination regarding the proposed health service or treatment is overturned in whole.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Left Breast Invasive Ductal Carcinoma
Treatment: Proton Beam Radiotherapy
The insurer denied the proton beam radiotherapy.
The health plan's determination is upheld.

This patient is a female with left breast invasive ductal carcinoma post lumpectomy. She completed chemotherapy. Radiation therapy to the left breast and nodal regions is recommended to decrease her risk of recurrence and the proton beam approach is requested.

The proposed treatment proton beam radiotherapy is not more likely to be more beneficial than any standard treatment for the insured's life threatening disease. The recommended proton beam radiation therapy for this patient is considered not medically appropriate nor necessary as there are lack of any significant studies published in peer reviewed literature supporting the benefits and safety of proton beam radiation therapy as compared to standard of care photon beam radiation therapy. There are ongoing clinical trials accruing patients comparing proton beam radiation and photon beam radiation for this clinical scenario that needs to mature and be evaluated and published in peer reviewed journals to assist in determining the benefits and safety of proton beam radiation therapy. Until these studies are completed and published in peer reviewed journals, the requested proton beam radiation therapy for this patient is considered not medically necessary.

I uphold in whole the health plans determination regarding the proposed treatment.
Appeal type: Medical necessity
Decision: Overturned

The patient presented with diffuse abdominal pain and vomiting. The patient was afebrile, and the vital signs were stable. There was no abdominal rebound or guarding. The white blood cell count (WBC) was 23.5. A Computed Tomography scan was read as acute cholecystitis. The surgeon advised treatment with intravenous (IV) antibiotics. Toxicology was positive for opiates and cocaine. The patient eloped. 

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Obstruction (Milliman Care Guidelines (MCG) M-555) include having acute cholecystitis. This needs to be manifested by all 3 of the following. There needs to be right upper quadrant (RUQ) abdominal pain, systemic signs of inflammation such as a WBC count over 10,000, and a cholecystectomy is not planned during this admission. In this case, the patient had upper abdominal pain, a WBC count of 23,500 (23.5), and a surgical recommendation to treat with IV antibiotics. 

This patient had acute cholecystitis and met the MCG criteria for inpatient admission for Gallbladder or Bile Duct Inflammation or Stone. The patient was treated with intravenous (IV) antibiotics until the patient eloped. 

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 hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholecystitis 

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned

The patient presented with diffuse abdominal pain and vomiting. The patient was afebrile, and the vital signs were stable. There was no abdominal rebound or guarding. The white blood cell count (WBC) was 23.5. A Computed Tomography scan was read as acute cholecystitis. The surgeon advised treatment with intravenous (IV) antibiotics. Toxicology was positive for opiates and cocaine. The patient eloped. 

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Obstruction (Milliman Care Guidelines (MCG) M-555) include having acute cholecystitis. This needs to be manifested by all 3 of the following. There needs to be right upper quadrant (RUQ) abdominal pain, systemic signs of inflammation such as a WBC count over 10,000, and a cholecystectomy is not planned during this admission. In this case, the patient had upper abdominal pain, a WBC count of 23,500 (23.5), and a surgical recommendation to treat with IV antibiotics. 

This patient had acute cholecystitis and met the MCG criteria for inpatient admission for Gallbladder or Bile Duct Inflammation or Stone. The patient was treated with intravenous (IV) antibiotics until the patient eloped. 

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 hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Myocardial infarction

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is overturned
 

This is a case of an adult that presented to the hospital complaining of left foot and ankle pain for four days. Past medical history was significant for dilated cardiomyopathy with a left ventricular ejection fraction (LVEF) of 15-20% (percent), persistent atrial fibrillation, implantable cardioverter defibrillator (ICD), cerebrovascular accident (CVA) and schizoaffective disorder. On presentation to the hospital vital signs were stable: Blood pressure 117/93 and pulse 86. The physical exam revealed pedal edema left 3+ (plus), right 1+ to the ankle. A 12-lead electrocardiogram (ECG) revealed atrial fibrillation with a controlled ventricular rate, intraventricular conduction delay and a QT (interval on an ECG) of 469 milliseconds. Serum blood testing revealed an elevated high sensitivity troponin of 479 nanograms per liter (ng/L). Serial testing demonstrated persistent elevation. The patient was admitted to the hospital for observation and testing. An Echocardiography revealed a severely depressed LVEF. Imaging studies of the left ankle demonstrated no fracture. The patient was diagnosed with type II (2) myocardial infarction and treated with decongestive therapies and discharged home after several days.

This patient presented with a type II myocardial infarction. His HEART (a risk calculation) score put him in a high-risk category, consistent with a high risk of future cardiac events. He was admitted and ultimately treated with anticongestive therapies. Based on his high-risk score using both the HEART and thrombolysis in myocardial infarction (TIMI) risk stratification, the admission for work up was medically necessary. Risk assessment of patients presenting with chest pain and ST (interval on an ECG) changes on the ECG as well as negative cardiac enzymes was performed by Sanchis. Using their risk stratification schema, this patient would have a high risk of future myocardial infarction or death within one year. In conclusion, acute care hospital admission was medically necessary.

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: Overturned

Diagnosis: right index finger infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
The patient is a pre-teenager with benign past medical history who presented to the emergency room with complaints of right 4th digit pain, swelling, and pus discharge. The patient fractured their finger approximately one-week prior playing sports.

Vitals on presentation included: Temperature 36.8 degrees C (Celsius), Blood Pressure 119/74, Pulse 88, Respiratory Rate 16, and oxygen (O2) saturation 98% on Room Air. Laboratory results included the following: white blood cell count (WBC) 10.4, Hemoglobin-13.0, Hematocrit-38.5, creatinine-0.66, glucose-125, erythrocyte sedimentation rate -44, and C reactive protein (CRP)-30.80.

The patient was evaluated for a physeal distal phalanx fracture of his right ring finger. He was evaluated as an outpatient in urgent care prior to presentation. An X-ray confirmed an open displaced fracture of the distal phalanx. The patient was started on intravenous antibiotics (cefazolin). He underwent an incision and drainage procedure and percutaneous pinning. Wound cultures grew methicillin-sensitive Staphylococcus aureus (MSSA). The patient remained afebrile, hemodynamically stable, and clinically improved. He was discharged to continue oral antibiotics (Keflex) as an outpatient. 

According to documentation, the patient was admitted with a worsening right index finger infection. He was afebrile and hemodynamically stable. Laboratory results were notable for elevated WBC and inflammatory markers. Imaging studies confirmed that the fracture was now "displaced." Based on the above findings, including failure of outpatient management and need for surgical intervention, hospitalization was medically necessary.

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: Overturned

Diagnosis: Substance use

Treatment: Inpatient rehabilitation

The insurer denied coverage for inpatient rehabilitation

The denial is overturned

 
This adult male was transferred to inpatient substance rehabilitation treatment from inpatient substance detoxification treatment. He reportedly was drinking 1 pint of Hennessy cognac per day and using multiple bags of intravenous (IV) heroin per day. He reportedly had a past overdose by heroin mixed with fentanyl and required Narcan and hospitalization. He reportedly had 5 relapses after 5 treatment episodes and his longest abstinence was 10 years during incarceration. He reportedly had a diagnosis of Opioid and Alcohol Dependence. He reportedly also had comorbid depression and anxiety. He reportedly had hypertension. 
   
The medical records provided enough specific evidence to support that the patient required this level of care. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case this patient was considered in need of 24-hour substance rehabilitation treatment as he lacked sufficient motivation and substance-free social supports to remain abstinent in an ambulatory setting, as evidenced by the fact that he had no abstinence time reported except when incarcerated. This patient was considered a high-risk patient due to a past overdose of heroin mixed with fentanyl and he had comorbid psychiatric issues including depression and anxiety.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he met criteria for inpatient substance rehabilitation treatment as he reportedly was using large amounts of alcohol daily and large amounts of heroin daily. This reportedly put him at high risk medically for overdose again and for other medical problems and withdrawal. Without this structured and supervised therapeutic inpatient substance rehabilitation treatment, he likely would have relapsed immediately as evidenced by relapse after each treatment episode previously.

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 substance use - inpatient rehabilitation treatment, 6 days, is substantiated.