Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Arm Weakness. 
Treatment:  MyPro (L8702) (power custom brace). 

The insurer denied the MyPro (L8702) (power custom brace). 
The denial is overturned. 

The patient is a male with history of lung cancer with brain metastases and associated with left hemiparesis. He has muscle strength of 2/5 in the Left upper extremity. He has failed physical and occupational therapy. 

The request by the treating physician is for a Myolectric orthotics (EWHO [elbow-wrist-hand orthosis]) to help with ADLs (activities of daily living). 

Yes, the health plan should cover the requested health service. 
The myoeletric elbow-wrist-hand-finger orthosis (EWHFO) device is medically appropriate as it was provided in accordance with and consistent with generally accepted standards of medical practice in the US (United States) for the treatment of hemiparesis status post stroke. 

The patient has tried and failed to progress with standard physical and occupational therapies and rehabilitation and plateaued, and this has affected his ADLs (activities of daily living). The use of the Myoelectric orthotics will improve his functionality/ADLs (activities of daily living). 

According to Willigenburg et al., "Repetitive Task-specific Practice (RTP) integrating myoelectric bracing may be more beneficial than RTP [repetitive task  practice] alone in improving self-reported function and perceptions of overall recovery." 

While Peters et al., concluded that, "utilization of a myoelectric elbow-wrist-hand orthosis significantly increased gross manual dexterity and performance of certain functional tasks." 

In this case, the Myoelectric Orthotics is FDA (United States Food and Drug Administration) approved and is the mainstream and standard treatment for hemiparesis secondary to cerebro-vascular accident (CVA) or brain injury as is the case with brain metastases in this patient who has failed main stream conservative measures including PT (physical therapy) and OT (occupational therapy) rehabilitation. The device is currently not in clinical trial or subject of review for a clinical trial and is not for the convenience of the patient. 

Yes, the Myoelectric EWHO (elbow-wrist-hand orthosis) is more beneficial than any standard treatment for the left arm weakness, as the myoelectric component enables stimulation of the muscles and enabling coordination of different muscles, which does not exist in other less used body-powered orthotics.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis Fever, nausea, vomiting
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.


The patient with a past medical history (PMH) of inflammatory Irritable bowel syndrome (IBS) and fibromyalgia who was admitted with complaints of (c/o) a fever associated with nausea, vomiting, and a headache. Vital signs were notable for a temperature (T) of 101 degrees Fahrenheit, pulse 110, and blood pressure (BP) 120/80. The physical exam was unremarkable. Lab work was notable for mild hyponatremia. A computed tomography (CT) scan of the head showed no acute intracranial abnormalities. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with sepsis and treated with intravenous fluids (IVF), intravenous (IV) antibiotics, anti-emetics, and cultures. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

No, the hospital stay was not medically necessary at an acute inpatient level of care.
This patient presented to the emergency department (ED) with c/o a fever associated with nausea, vomiting, and headache. The patient did not have associated high-risk features, such as acute renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability, bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable, did not have pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. The patient presented with nausea, vomiting, and a headache, was treated IV antibiotics, IVF, and radiological and biochemical work-up, and these interventions could have been safely and appropriately provided at a lower level of care.
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 previous medical history of hypertension, hyperthyroidism, and previous myocardial infarction who was admitted for a viral pneumonia due to (Coronavirus Disease) COVID-19 with symptoms of shortness of breath, diarrhea, abdominal pain and subjective fevers for a few days prior to admission. From admission, he was alert/awake/oriented, on treatment with Decadron, and Lovenox, did not require any interventions available only at an inpatient level of care. Although he was placed on supplemental oxygen in the emergency room for respiratory distress, the following day  his oxygen saturation was > (greater than) 90% (percent) on room air and he did not have any documentation of hypoxemia.

The Inpatient Hospital Admission was not medically necessary for this patient. This patient with a previous medical history of hypertension, hyperthyroidism, previous myocardial infarction who was admitted for a viral pneumonia due to COVID-19 with symptoms of shortness of breath, diarrhea, abdominal pain and subjective fevers for a few days prior to admission. As per the clinical documentation in the emergency room, the patient was afebrile, hemodynamically stable, with a respiratory rate < (less than) 25 breaths per minute, was in no acute distress, his oxygen saturation was reported 94% - 95% on room air but on auscultation of the lungs he had decreased air movement/breath sounds bilaterally. While in the emergency room, he was started on oxygen supplementation up to 10 liters per minute due to respiratory distress. He was started on treatment with Decadron and Lovenox prophylaxis. During the remainder of the hospitalization, there was no indication that the patient's condition had worsened, he did not require invasive or non-invasive ventilatory support, did not have severe tachypnea/accessory muscle use/retractions, no documented airway obstruction, no dehydration or renal failure, no hypothermia and no documented cardiac arrythmias or coagulopathy. Although he was placed on supplemental oxygen in the emergency room, the following day, his oxygen saturation was > 90% on room air and he did not have any documentation of hypoxemia. In addition, the patient did not require isolation that could not be performed outside of the hospital. The patient had a clear diagnosis of COVID -19 virus infection and he was on appropriate treatment with good response and recovery with an observation level of care. Therefore, based on the available records, it was not medically necessary for this patient to be treated at the inpatient level of care, and the treatment and care could have been safely managed at an observation level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, appendicitis
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

This patient is a male who presented to the emergency department (ED) with the complaint of abdominal pain of one-day duration. Past medical history included asthma.  Examination revealed a right lower abdominal tenderness. Vital signs were normal at the time of presentation.  The white blood cell (WBC) count was normal at 17 thousand (K).  Surgical consultation was obtained. Computed tomography (CT) scan was completed showing findings of acute appendicitis.  The patient was started on intravenous (IV) antibiotics.  The patient underwent laparoscopy with appendectomy for the condition of appendicitis.  Surgical findings included acute nonperforated nongangrenous appendicitis.

Following surgery the patient was treated with intravenous (IV) fluid and analgesia.  Vital signs were consistently normal in the perioperative period.  He was transitioned to oral medications and diet.  He was discharged from the hospital following a period of recovery.  

The health plan rationale for denial is that the patient underwent uncomplicated appendectomy.  The denial letter states that there was no documentation of need for an inpatient level of care and the care rendered could have been provided without admission to the hospital.

No, the proposed treatment is not medically necessary.
Inpatient care was not medically necessary for this patient.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Acute inpatient hospitalization was not medically necessary for this patient.  The medical records support that this patient could have been reasonably and safely monitored without an inpatient stay.

This patient presented with abdominal pain.  The evaluation with examination, lab data, and computed tomography (CT) scan supported the diagnosis of acute appendicitis.  The patient underwent uncomplicated appendectomy.  He was admitted to an inpatient level of care and was discharged from the hospital on the first post-surgical day. 

There is no clinical documentation to support need for inpatient admission on these dates.  The patient remained hemodynamically stable throughout the perioperative period, there was no fever, or documented complication of surgery.  This patient's clinical needs could have been satisfied without an inpatient level of care.  This lower level of care would have provided for pre-surgical assessment, surgical treatment and post-surgical recovery including overnight observation (if required).  The records support that the care provided was clinically appropriate.  It is the level of care (inpatient versus outpatient / lower level of care) that is at issue in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Basal Cell Carcinoma of the forehead

Treatment: Levulan SOL (solution)

The insurer denied coverage for Levulan SOL

The denial is upheld.

The patient is a female with Basal Cell Carcinoma of the forehead that was biopsied. The patient was successfully treated with Mohs surgery for the basal cell carcinoma of the forehead with closure by advancement flap and clear margins by Mohs micrographic surgery. The requested medication was Levulan solution for photodynamic therapy.

Based on the submitted documentation Levulan is not medically necessary. The patient has a history of basal cell carcinoma which was treated with Mohs surgery and advancement flap closure. The basal cell carcinoma has been treated definitively and does not require further therapy based on the standard of care. It is noted that the patient has a prior history of actinic keratoses which were treated with liquid nitrogen. Documentation detailing the necessity for photodynamic therapy with Levulan solution is not provided. Based on the provided documentation, Levulan solution is not medically necessary for a basal cell carcinoma which has been successfully treated with Mohs micrographic surgery with clear margins. The decision is thus upheld based on the standard of care and the submitted medical documentation.  

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

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

Diagnosis: cough/difficulty breathing.
Treatment; Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a female infant who presented to the emergency department (ED) with two-day history of cough and difficulty breathing. The cough began two days prior, with eventual development of difficulty breathing including subcostal retractions, decreased oral intake, and decreased urine output. Vital signs included temperature 36.3, heart rate 158, respiratory rate 44, and saturation 97%. Examination was significant for being fussy but consolable, moist oral mucosa, grunting, subcostal retractions, no wheezing or rhonchi, benign abdomen, slightly prolonged capillary refill 3 seconds, and non-focal neurologic exam. She was treated with albuterol and supplemental oxygen due to desaturations to high 80s while awake and vomiting.

The requested acute inpatient admission was not medically necessary for this young female patient admitted for management of enterovirus/rhinovirus bronchiolitis. She could have been safely and appropriately managed at lower level of care. This child presented to the ED with signs and symptoms consistent with bronchiolitis and tested positive for rhinovirus/enterovirus. While she had evidence of respiratory distress and an initial oxygen requirement, she was overall hemodynamically stable with no concern for impending respiratory failure, and no severe distress. She was able to wean from supplemental oxygen rapidly. She did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ectopic pregnancy. 
Treatment: Inpatient hospital. 

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

The patient is a pregnant female who presented to the emergency room with abdominal pain and concern for ectopic pregnancy. Imaging showed what appeared to be an ectopic pregnancy in the right adnexa. Her last meal was at 14:30 and she was assessed as hemodynamically stable, so she did not go right to the operating room. The patient was placed on the floor to await surgery the following day. She underwent an uncomplicated laparoscopic right salpingectomy, and was discharged shortly after the surgery. 

The inpatient hospital admission was not medically necessary. An inpatient level of care for this patient was not medically necessary. The laparoscopic procedure was performed the day after admission and reported to have been performed as planned without intraoperative complication. This procedure is generally considered an outpatient procedure. There were no unexpected events, and she was discharged about 5 hours after the surgery ended. She required no serial testing or observation, and her vital signs were never unstable (American College of Obstetricians and Gynecologists (ACOG) criteria reports vital signs within 20% of baseline to be stable for discharge). There is no report of hemorrhage after the surgery. There are no notes from the resident or attending physician suggesting there was a plan to escalate care, continue observation, monitor the patient further, or keep her in the hospital another night. She was treated only with oral pain medication after leaving the recovery room (Percocet) and discharged after only one night in the hospital. Her vital signs were within normal limits for her entire stay (other than occasional outliers that were likely not accurate). The customary definition of inpatient care is that which cannot be provided as an outpatient safely. This patient was just waiting for surgery, which could have been done at a lower level of care. There was nothing in the notes to suggest an inpatient level of care was needed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: Ultraviolet Light System.
The insurer denied the Ultraviolet Light System.
The denial is overturned.

The patient is a male with psoriasis to over 70% (percent) BSA (body surface area) with remarkable improvement to phototherapy. The patient has a single panel home unit, with which it is difficult to control exposure. The provider is requesting home UVB (ultraviolet B) light box.

Yes, the requested Ultraviolet Light System is medically necessary.
Comparative studies of home-based phototherapy and office-based phototherapy have been conducted in psoriasis and atopic dermatitis primarily. A multicenter, single-blind, randomized clinical trial of 196 patients from the Netherlands demonstrated that home NB-UVB (narrowband ultraviolet B) is just as effective as outpatient-administered NB-UVB (narrowband ultraviolet B). The findings from the study demonstrated that home ultraviolet B phototherapy for psoriasis is not more burdensome than phototherapy in an outpatient setting and proved to be effective. As both treatments are at least equally effective and patients express a preference for home treatment, the authors concluded that home phototherapy should be the primary treatment option for patients who are eligible for phototherapy with ultraviolet B light.

A review of home phototherapy concluded that home phototherapy is a safe, effective, less burdensome, and patient friendly therapeutic option. The advantages of home phototherapy include improved quality of life, greater convenience, and less time lost from work and social activities. Increased physician awareness of the benefits of home phototherapy is necessary in order for the implementation of its use in appropriate patients. A review which compared effectiveness of biologics and phototherapy concluded that despite the fact that biologic drugs were more effective, home-phototherapy was a more efficient treatment for the treatment of moderate to severe psoriasis. Home phototherapy resulted in an effective alternative for psoriatic patients with potential applications in the sanitary health system. Phototherapy can often be used in conjunction with other treatments (including topicals and systemic medications), and can be used intermittently to maintain or establish improved disease control.

The review by Jacob et al again concluded that "Home phototherapy is associated with significant cost savings treatment and increased adherence."

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

Diagnosis: Allergic reaction.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient has a past medical history (PMH) of asthma and was admitted with complaints of (c/o) a possible allergic reaction to peanut oil and tongue and lip swelling. Vital signs were notable for peripheral capillary oxygen saturation (SpO2) of 99%. The physical exam was notable for no acute distress, angioedema of the tongue, no pulmonary retractions, labored breathing, or expiratory stridor, and able to speak in full sentences without difficulty and able to handle secretions. Lab work was unremarkable. The patient was diagnosed with anaphylaxis and treated with intravenous (IV) fluid, antihistamines, IV steroids, intramuscular (IM) epinephrine times (x) 2, and a nebulizer. Of note, the patient's symptoms improved upon arrival to the emergency department (ED), and improved after initial treatment in the ED. 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. This patient with a recent history of an urticarial rash presented to the ED with c/o possible allergic reaction to peanut oil and tongue and lip swelling. There was no actual or impending airway compromise, unstable vital signs, hypoxia, respiratory distress or respiratory failure, progression of allergic reaction/angioedema while undergoing treatment, hypotension, acute coronary syndrome (ACS), hoarseness or need for IV vasopressors. Overall, this stable patient was treated with IV steroids, IM epinephrine, and antihistamines, and responded to the treatment in the ED, and these interventions could have been safely provided at a lower level of care than inpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD (chronic obstructive pulmonary disease) exacerbation. 
Treatment: Inpatient admission. 

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

The patient is a male with a history of hypertension, cirrhosis, heart failure, and chronic obstructive pulmonary disease on home oxygen who presented to the emergency department with shortness of breath.  Vital Signs: Temperature = (equal) 36.7, Pulse = 83, Respiratory Rate = 20,  Blood Pressure = 121/76,  Pulse oxygenation 95% (percent). The exam was unremarkable.  Labs:  White blood cells (WBC) = 9.3,  Hemoglobin/Hematocrit (H/H) = 15/47.9, Platelet (Plt) = 285, Sodium (Na) = 142,  Potassium (K) = 3.4,  Blood urea nitrogen/Creatinine (BUN/Cr) = 14/1.32,  Glucose = 88,  Troponin .05,  Venous blood gas - 7.29/65.6/33/31, Chest x-ray - no acute disease,  EKG - no acute changes. 
The patient was admitted to the hospital with a diagnosis of COPD (chronic obstructive pulmonary disease) exacerbation. The plan of care included duonebs, IV (intravenous) steroids, Symbicort, and Tiotropium. The patient was instructed to continue cardiac medications. 
The patient was noted to be improving, the plan of care included holding antibiotics, and to transition to oral steroids over a 24 hour period. The patient was cleared for discharge. 

No, the proposed treatment, Inpatient Hospital Admission is not medically necessary. 

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

Hospitalization of patients with exacerbations of Chronic Obstructive Pulmonary Disease (COPD) includes high-risk comorbidities, such as pneumonia, arrhythmia, and congestive heart failure. The inadequate response of symptoms to outpatient management marked an increase in dyspnea, inability to eat or sleep due to symptoms, worsening hypoxemia or hypercapnia, and altered mental status.  This patient presented to the ER (emergency room) complaining of SOB (shortness of breath). However, the patient's clinical presentation does not meet the criteria for inpatient admission. The patient did not have tachypnea, hypoxia, or AMS (altered mental status). Diagnostic did not show pneumonia or evidence of congestive heart failure (CHF), nor did the patient's EKG (electrocardiogram) show ischemic changes. The patient did not have an exacerbation of CHF (congestive heart failure) or other high-risk comorbidities that required treatment at an inpatient level of care. Inpatient admission was not medically necessary for this patient. The patient had not failed a lesser level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems/Other/Class I Occlusion. 
Treatment: Dental/Orthodontic Procedure. 

The health plan denied the requested dental braces as not medically necessary. 
The health plan's determination is upheld. 

The patient is a female with a Class I occlusion, with moderate mandibular crowding and mild maxillary spacing, moderate overjet and moderate overbite. 
At issue is the medical necessity for braces. 

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

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score an 18 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9mm (millimeters) or greater and underbite 3.5mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, braces are not medically necessary for this case.