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

Diagnosis: Chest Pain.

Treatment inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This patient presented to the hospital complaining of back and shoulder pain as well as some chest pressure.  The pain was constant for several hours and was exacerbated when lying supine and improved with upright positioning.  Past medical history was significant for hypertension, COVID (coronavirus) 19 infection more than one year earlier, uterine fibroids and motor vehicle accident (MVA) with recurrent left shoulder pain.  On arrival to the hospital vital signs were stable: BP (blood pressure) 120/80, pulse 70.  Physical examination revealed no significant abnormality.  Twelve-lead electrocardiogram (ECG) revealed normal sinus rhythm without specific ischemic abnormalities. Serum blood testing revealed no significant abnormalities including a troponin level of <0.01ng/ml [nanogram per milliliter]. Echo and stress testing were ordered. The patient was ultimately discharged on antihypertensive therapy.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with atypical chest pain and a past medical history of hypertension. Her pretest probability of coronary artery disease is low (Reference 1). Utilizing the HEART (history, ECG, age, risk factors, and troponin) score, she was considered low risk (Reference 2). Utilizing the thrombolysis in myocardial infarction (TIMI) risk score she 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 (interval on ECG) changes on 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 full hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroesophageal Reflux Disease (GERD)

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

The patient has a history of coronary artery disease, hypertension and schizoaffective disorder that presented to the hospital complaining of chest pain.  Chest pain occurred while waiting for the subway train. Described as sharp left sided and pleuritic in nature. Multiple previous admissions for chest pain revealed no evidence of cardiac ischemia.  Upon arrival to the emergency department (ED) vital signs were stable and no abnormal findings were noted on physical examination. 12 lead electrocardiogram revealed normal sinus rhythm without ischemic changes.  Serum troponin levels were not elevated twice(< (less than) 0.01 ng/ml [nanogram per milliliter]).  The patient was ultimately diagnosed with gastroesophageal reflux disease and discharged home with cardiology follow up.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient. Full hospital admission was not medically necessary for this patient that presented with chest pain.  His pretest probability of coronary artery disease is intermediate (Reference 1).  Utilizing the HEART [history, electrocardiogram (EKG), age, risk factors, and troponin], score he was considered intermediate risk (Reference 2). Risk assessment of patients presenting with chest pain and no significant ST (interval on EKG) changes on EKG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have an intermediate 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. These findings are concerning and warrant management and evaluation that includes serial troponin measurement, echocardiography and ischemia work up prior to discharge. However, numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care (References 4,5).  They found no significant difference in outcome at 30 days between the two groups.  Fernando Bellolio et al. noted that patients presenting with chest pain, that were managed in an observation unit had similar 30 day myocardial infarction rates as those admitted to the hospital (Reference 5).  Admission to the hospital to treat an acute cardiac event was not medically necessary.  In conclusion, this patient could have been managed at a lower level of care.
	
Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Cosentyx sensoready pen 
The insurer denied Cosentyx sensoready pen 
The determination is upheld.

The patient has moderate to severe psoriasis of the scalp, neck, and labia. The patient has a history of chronic canker sores, so Methotrexate has been avoided. For safety concerns by the parents and dermatologist, cyclosporine has been avoided. Topical triamcinolone, betamethasone, and mometasone have been tried and failed.
At issue is the medical necessity of Cosentyx.

The requested Cosentyx is not medically necessary.
Although phototherapy is acceptable for use for many psoriasis patients, the location of this patient's psoriasis (such as the scalp and labia) precludes phototherapy from being efficacious (hair-bearing area) or safe for use (sensitive skin of the labia prone to burning). However, Cyclosporine is Food and Drug Administration (FDA)-approved for psoriasis, and is therefore an appropriate alternative to the requested Cosentyx for this particular patient at this time. Cyclosporine is not noted to have any increased risk of canker sores, either causing or aggravating these painful lip/oral lesions. Therefore, cyclosporine should be considered as a medically appropriate and indicated treatment at this immediate time.
Modern dermatology literature [1-4] supports use of the health plan-covered and preferred medications as similarly efficacious to the requested Cosentyx, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, and recommend use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Cosentyx is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: left knee pain.
Treatment: Physical therapy
The insurer denied physical therapy. 
The health plan's determination is upheld. 

The patient is a male with left knee pain. The patient complains of left knee pain to palpation and worse with walking. At issue is the medical necessity of physical therapy services (current procedural terminology (CPT) 97140, 97110, 97032).

The physical therapy services in question are not medically necessary. As of the date in question, the patient could participate in a home exercise program to include strengthening and range of motion exercises. There was no documentation of significant improvement in strength, range of motion, pain levels, or function during the time frame in question.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Esophageal food impaction.
Treatment inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

According to the documentation submitted, this is a patient with a past medical history of obstructive sleep apnea. The patient presented to the emergency room with a complaint of food obstruction.

Esophageal food impaction is a common clinical problem. The most common type of food impaction is from meat. Causes include esophageal strictures, hiatal hernia, eosinophilic esophagitis, and esophageal carcinoma. [1, 2] Diagnosis is primarily based on history and physical examination, with patients presenting with chocking/gagging, vomiting, and dysphagia and/or odynophagia. Preferred imaging is a plain chest radiograph, although it is not always required. Management involves initial assessment of the airway. Medical management often has poor efficacy. Early endoscopy is recommended and is associated with improved outcomes. [3] Complications related to endoscopic removal of food impaction include aspiration, esophageal perforation, or the inability to retrieve the food endoscopically. [1, 2] 

Per clinical documentation, the patient presented, with an esophageal food bolus. The patient underwent an emergency esophagogastroduodenoscopy with removal of the food bolus. Anesthesia notes that the patient developed some wheezing and bronchospasm upon intubation. However, there were no further complications documented and the procedure continued. It was noted that he was "extubated smoothly." There is no clinical documentation demonstrating complications or abnormal vital signs after the procedure. There is no chest x-ray that demonstrated aspiration. Per Milliman Care Guidelines (MCG) criteria, inpatient admission for gastroenterology conditions are indicated for conditions, symptoms, or findings for which observation care has failed. [4] There are no indications that inpatient admission was medically necessary for this patient. Inpatient admission was not medically necessary. 

The health plan acted reasonably with sound medical judgment.

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

Diagnosis: Early delivery.
Treatment: Inpatient NICU (neonatal intensive care unit) admission.
The insurer denied the Inpatient NICU (neonatal intensive care unit) admission.
The denial is upheld.

This is an infant born prematurely via C-section with a birth weight of 2060 g (grams). The pregnancy was complicated by gestational diabetes, pre-eclampsia, and adequately treated GBS (Group B Streptococcus). His mother received labetalol and magnesium prior to delivery. Maternal labs were otherwise unremarkable. Apgar scores were 9, 9. Upon admission to the NICU (neonatal intensive care unit), he received glucose monitoring, routine newborn care, and no additional interventions. He was placed in an isolette.

The patient's glucose levels were normal. A CBC (complete blood count) was unremarkable. He received his Hepatitis B vaccine. His hearing screen was passed. He was weaned to an open crib. He was circumcised. A bilirubin level was 13.3. He was discharged home to follow-up the following day.

No, the Inpatient Hospital (NICU) Admission was not medically necessary.
The infant was admitted for prematurity and mildly low birth weight. At the time of admission, he was hemodynamically stable, euglycemic, and did not require respiratory support or sepsis evaluation. During his hospital stay, he required glucose monitoring and assistance with oral feeding but otherwise remained stable. The interventions provided, which included laboratory evaluation, temperature/weight monitoring, routine newborn care, and glucose monitoring did not require a NICU (neonatal intensive care unit) level of care. This care could have been safely provided at a routine newborn level of care. The requested NICU (neonatal intensive care unit) level of care for this hospitalization was not medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
The infant's condition could have safely been treated at a lower level of care. The plan appropriately denied the requested NICU (neonatal intensive care unit) level of care for this hospital stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory. 
Treatment: Inpatient Hospital. 
The insurer denied an inpatient admission. 
The denial is overturned.

The patient is a male with hyperlipidemia and prostate cancer who presented with chest pain.
In the emergency department (ED), temperature 97.5, blood pressure (BP) 115/76, heart rate (HR) 76, respiratory rate (RR) 20, peripheral capillary oxygen saturation (SpO2) 98% room air (RA). He was comfortable, breathing comfortably, clear lungs, alert and oriented. White blood cell (WBC) count was 8.9, sodium (Na) was 140, bicarb was 29, blood urea nitrogen (BUN) /creatinine (Cr) was 11/1.14, troponin (Tn) was undetectable.
Computed tomography pulmonary angiogram (CTPA) found bilateral pulmonary emboli (PEs) and possible right ventricular (RV) dysfunction, so a heparin drip was started. Subsequent transthoracic echocardiogram (TTE) found normal RV function and inferior vena cava (IVC). He was seen by hematology and oncology who recommended apixaban and a prostate cancer work-up.
BP remained stable. He felt well and was switched to apixaban. He had shortness of breath (SOB) and nausea, was hemodynamically stable and saturating well on room air (RA).
He felt well and was discharged on apixaban with outpatient follow-up.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

An inpatient admission was needed. While he was hemodynamically stable, his Hestia score and simplified pulmonary embolism severity index (sPESI) score both suggested an increased risk of adverse outcomes and that he was not a candidate for outpatient treatment. He met inpatient admission criteria with elevated sPESI score and hypoxemia.
The concern with elevated sPESI and Hestia is the risk of decompensated RV function and development of hemodynamic instability. His CTPA also found dilation of the RV, further raising concern for short term decompensation. All of these criteria require close monitoring to ensure there's no hemodynamic deterioration. Finally, he had persistent symptoms with SOB, also raising concern for persistently elevated PA pressures and RV strain.
Given elevated risk scores, possible RV dysfunction, and persistent symptoms, he was at high risk of adverse outcomes and needed close monitoring that cannot be provided at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acquired bilateral hip/foot deformities

Treatment: Dynamic seating back

The insurer is denied coverage for dynamic seating back.

The denial is overturned. 

This male patient has a history of acquired bilateral foot deformities, growth hormone deficiency, osteopenia, hypothyroidism, Sturge-Weber syndrome with glaucoma, and eosinophilic esophagus.

This physician agrees with the patient's physical therapist, regarding the medical necessity of the requested dynamic back as a component of the requested wheelchair.  The patient has a diagnosis of Sturge-Weber syndrome with associated developmental deformities.  The patient currently has a dynamic back system that provides positional safely, absorbs vibrational rocking forces and extends the life of the wheelchair (less wheelchair frame wear and tear).   It should be replaced.  

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

The carrier's denial of coverage for dynamic seating back is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical Chest Pain.
Treatment hospital admission.
The insurer denied coverage for hospital admission.
The denial is upheld.

This patient with a history of gout presented to the hospital complaining of body aches and shortness of breath.  Upon arrival to the emergency department (ED), vital signs were stable with blood pressure (BP) 149/76 and pulse 114. Physical exam was significant for gouty tophi.  Twelve-lead electrocardiograms revealed no ST (interval on EKG [electrocardiogram]) or T (interval on EKG) wave abnormalities, serial serum troponin levels were not elevated times 3 (<0.01ng/ml [nanogram per milliliter]) and CT (computed tomography) angiogram revealed no evidence of pulmonary embolism.  A myocardial perfusion study was performed and revealed no ischemia and a left ventricular ejection fraction (LVEF) of 30% (percent).  The patient was admitted for depressed LVEF and treatment of systolic congestive heart failure.  Echocardiogram was performed and the patient was noted to have preserved left ventricle (LV) function with LVEF 65%.  The patient was discharged the following day without further cardiac work up.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with atypical chest pain and no significant past medical history. His pretest probability of coronary artery disease is low (Reference 1). Utilizing the HEART (history, EKG anomalies, 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 EKG 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. Although this patient had a perfusion study that noted a depressed LVEF, no findings on physical examination and no findings on CT chest were consistent with fluid overload or congestive heart failure.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, 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 hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Multaq. 
The denial is upheld.

The patient is a male with atrial fibrillation. Other than a medication list, no medical records were provided for review. It is unclear if the patient's atrial fibrillation is paroxysmal, persistent, or permanent. It is unclear which other Class I or Class III antiarrhythmic drugs, if any, he has tried. It is unclear whether or not he has a history of congestive heart failure, lung, liver, or kidney disease. The subject under review is the medical necessity for Multaq.

The health plan's determination is upheld.

This patient has been prescribed Multaq (dronedarone) for atrial fibrillation. Dronedarone is a Class III antiarrhythmic drug which may be appropriate for rhythm control in certain patients with paroxysmal atrial fibrillation. However, it must be used with caution, or is contraindicated, for patients with QT interval prolongation, patients with recently decompensated heart failure and depressed left ventricular systolic function, patients with New York Heart Association class III or IV heart failure, patients with permanent atrial fibrillation, and patients with significant liver disease. Given the clinical information provided it cannot be determined if this patient would be a good candidate for therapy with dronedarone.
The formulary alternatives are amiodarone and sotalol. Dronedarone is a structural analogue of amiodarone but lacks the iodine moieties of amiodarone. It is associated with a lower incidence of adverse events than amiodarone but is also less effective. Sotalol, like dronedarone and amiodarone, is a Class III antiarrhythmic drug. Like dronedarone, sotalol has been shown to be less effective than amiodarone in preventing atrial fibrillation recurrences but has fewer serious side effects. The decision as to whether amiodarone or sotalol might or might not be preferable to dronedarone for the management of atrial fibrillation for any given patient must be individualized and based upon a multitude of factors including patient age, number of prior antiarrhythmic drug trials, duration of atrial fibrillation, the presence or absence of heart failure or lung disease, liver and kidney function, underlying sinus and atrioventricular (AV) nodal function and the QT interval. Based on the information provided, medical necessity of Multaq for this patient is not supported.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Carious lesion
Treatment: Crown for Tooth #11
The insurer denied the Crown for Tooth #11.
The denial is overturned.

The patient is a male requesting a crown for tooth #11. Tooth #11 has had root canal therapy and has had a large carious lesion which has left a large area of tooth structure missing.

A crown was denied because the dental plan deemed multiple teeth in the upper arch as not worth restoring and they should be extracted and a partial denture made to replace them.

Yes, the proposed crown on tooth #11 is medically necessary.
Tooth #11 needs a crown to restore it. It has most of it's clinical crown gone due to caries (decay) and a filling is not strong enough to properly restore this tooth. A crown is medically necessary to restore tooth #11  to proper function. Extracting this tooth, a canine, is not a wise choice. The upper canine is a critical tooth to keep as it helps to guide the teeth to mesh properly during the chewing cycle.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.