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

Diagnosis: Impacted maxillary right canine
Treatment: D8080 Braces And D8670 Monthly Visit
The insurer denied the D8080 Braces And D8670 Monthly Visit.
The denial is overturned. 

The patient is a female.  The request is for dental benefit coverage for orthodontic treatment (braces). Clinical exam and x-rays indicate that the patient has an impacted maxillary right canine.

Yes, the treatment is medically necessary.

X-ray imaging reveals that this maxillary right canine does not have sufficient space to naturally erupt due to its position and the position of the adjacent teeth.  Under these circumstances, surgical exposure of this tooth coupled with orthodontic treatment is indicated as a corrective measure.

No, the health plan did not act in the best interest of the patient and with sound medical judgement because an untreated impacted canine can damage adjacent teeth and cause their eventual loss. Additionally, proper alignment and position of this tooth in the mouth is essential for chewing, functional guidance and aesthetics.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee pain.
Treatment: Acute inpatient admission.
The insurer denied coverage for the acute inpatient admission.
The denial is upheld. 

This is a female patient with a past medical history significant for partial right-sided paralysis due to a cervical spine injury, and depression who presented to the Emergency Department (ED) with complaints of knee pain and swelling following a fall. The patient's vital signs on presentation included: temperature 98.2, blood pressure 139/84, pulse 85, respiratory rate 18, and oxygen Saturation 93%. The patient's laboratory results included the following: WBC (white blood cell) count 11.66, hemoglobin 12.7, hematocrit 42.2, creatinine 0.69, glucose 103, and lactic acid 1.2. The patient was empirically started on intravenous (IV) antibiotics for possible cellulitis and acetaminophen for pain. The patient's lower extremities Doppler scan was negative for deep venous thrombosis (DVT). The patient's X-ray of the knee was negative for acute fracture or dislocation. The patient's blood cultures were negative. The patient remained afebrile, hemodynamically stable, and was discharged to continue outpatient management on oral antibiotics.

The patient presented with knee pain after tripping over a manhole cover. On presentation, the patient was afebrile and hemodynamically stable. The patient's laboratory results were only notable for a mildly elevated WBC count. The patient's X-ray of the knee and Doppler exams were unremarkable. The patient appeared to have a localized infection, not requiring surgical intervention. Based on the above clinical findings, the patient met criteria for observation level of management. As per literature review, inpatient admission was not medically necessary for this patient. 

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

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

Diagnosis: Alzheimer's disease, Hypertension, Hyperlipidemia and Cataracts. 
Treatment: Increase Personal Care Services Per 15 Mins Increase to 24 Hours Per Day (Live In). 

The insurer denied the Increase Personal Care Services Per 15 Mins Increase to 24 Hours Per Day (Live In).  The denial is overturned. 

The patient is a female with a history of Alzheimer's disease, hypertension, hyperlipidemia and cataracts.  Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).  An appeal review was requested for potential approval of 24 hours/day (live in) Personal Assistance Services to offer increased ADL (activities of daily living) support. 

Yes, the proposed treatment of 24 hours/day (live in) Personal Assistance Services is deemed medically necessary. 

This is a female with a history of Alzheimer's disease, hypertension, hyperlipidemia and cataracts.  Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).  Recent documentation from the patient's provider indicates that due to progressively worsening functional decline, decreased ability to perform ADLs (activities of daily living), decreased memory, worsening visual acuity and worsening gait ataxia, the patient has sustained numerous traumatic fall injuries and poses a serious safety risk if left unattended for any period of time.  Hence, the currently approved plan of 70 hours/week Personal Assistance Services is insufficient to meet the patient's current needs.  For these reasons, the proposed treatment 24 hours/day (live in) Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis.
Treatment: Dupixent (dupilumab).
The insurer denied coverage for Dupixent (dupilumab). The denial is overturned. 

This is a male patient with atopic dermatitis who has failed treatment on tacrolimus ointment and is now requesting treatment with Dupixent (dupilumab). Dupixent (dupilumab) is being prescribed for the patient's atopic dermatitis for what is described as covering 20% percent of his body surface area (BSA).  

According to Tsianakas et al. (2017), dupilumab [Dupixent] "significantly improved clinical signs and symptoms in adults with moderate-to-severe atopic dermatitis in a randomized, double-blind, placebo-controlled, phase IIa trial." This is further supported by Han et al. (2017)'s meta-analysis of randomized clinical trials study on the efficacy and safety of dupilumab for the treatment of adult atopic dermatitis. As per Han et al. (2017)'s study, "Dupilumab was shown to be consistently more effective than placebo, with a trend of a dose-dependent effect, and had a placebo-like safety profile" and the "[c]ombination of dupilumab with topical glucocorticoids seemed to improve the effects." 

Based on the review of the patient's medical record, the patient's atopic dermatitis affects 20% of his BSA. The patient's severity and extent of disease is too much for use of topical treatment. The patient requires a systemic agent to control his active lesions.  Literature supports that the requested medication, Dupixent (dupilumab) is an effective and safe option for this patient's treatment. Thus, Dupixent (dupilumab) is considered medically necessary for this patient.

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 Dupixent (dupilumab) should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal Muscular Atrophy. 
Treatment: Evrysdi. 

The insurer denied the Evrysdi. 
The denial is overturned. 

The patient is a female with spinal muscular atrophy (SMA), type II. She has been treated with Spinraza. 

Yes, the requested treatment is medically necessary. 

Risdiplam is Food and Drug Administration (FDA) approved for this patient's condition and has been shown to be effective in adults with different forms of spinal muscular atrophy (SMA) (Mercuri et al.,). Therefore, use here is standard of care. 

In addition, the health plan denial reason states that this medication cannot be approved for persons who are worsening after gene therapy. This patient was treated with Spinraza, not gene therapy.  The denial goes on to say, "unless there has been stabilization or improvement with Evrysdi".  However, the patient has never been treated with Evrysdi.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p Motor Vehicle Accident With Traumatic Brain Injury
Treatment: Inpatient Acute Rehabilitation
The insurer denied the Inpatient Acute Rehabilitation. 
The denial is upheld. 

The patient is a female with history of Motorcycle accident in which she sustained severe Traumatic Brain Injury (TBI), Subarachnoid Hemorrhage (SAH), Subdural hematoma (SDH), Intracerebral Hemorrhage (ICH), Pulmonary contusion, acute respiratory failure, multiple Skull/facial bone fractures, multiple spine fractures, etc (et cetera).

The patient's current medical issues include dysphagia on PEG (percutaneous endoscopic gastrostomy)-Tube feeding, hypothyroidism, electrolyte imbalance, urinary retention/incontinence, Diabetes Mellitus, DVT (deep venous thrombosis) prophylaxis, 

Prior to admission, the patient was independent with ambulation and ADLs (activities of daily living), lived with her spouse in a single level house with four steps to enter. She retired from her job prior to the accident. The husband died a day after the accident.

The patient is Ranchos level 2, unresponsive, non-verbal, but arousable to pain also opens eyes, and unable to follow commands. She has tracheostomy, on O2 (oxygen) 5L (liters) through nasal cannula and feeding through PEG (percutaneous endoscopic gastrostomy)-tube. She continues to be dependent for feeding through PEG (percutaneous endoscopic gastrostomy) tube, required maximum assistance for dressing, bathing and non-ambulatory.

No, the proposed acute inpatient rehabilitation is not medically necessary.

The patient has not met all the criteria for acute rehabilitation care INTERQUAL Criteria 2020 for Acute Rehabilitation in a patient with CNS (central nervous system)/TBI (traumatic brain injury). She is Ranchos level 2, unresponsive, non-verbal, but arousable to pain also opens eyes, and unable to follow commands. She has tracheostomy, on O2 (oxygen) 5L (liters) through nasal cannula and feeding through PEG (percutaneous endoscopic gastrostomy)-tube. She continues to be dependent for feeding through PEG (percutaneous endoscopic gastrostomy) tube, required maximum assistance for dressing, bathing and non-ambulatory.

Based on not meeting the INTERQUAL requirements for acute inpatient rehabilitation, it is not medically necessary for patient to be admitted to the acute inpatient rehabilitation, as she is unarousable and unable to be alert and unable follow commands that will enable her participate effectively in every-three-hours daily rehabilitation.

The patient is Ranchos level 2, unresponsive, non-verbal, but arousable to pain also opens eyes, and unable to follow commands. She has tracheostomy, on O2 (oxygen) 5L (liters) through nasal cannula and feeding through PEG (percutaneous endoscopic gastrostomy)-tube. She continues to be dependent for feeding through PEG (percutaneous endoscopic gastrostomy) tube, required maximum assistance for dressing, bathing and non-ambulatory.
She will be better in a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting And Inability To Drink Fluids
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male infant that was referred to the emergency department  with sudden onset vomiting several hours prior. He had six or seven episodes of non-projectile non-bilious vomiting, no fevers, and no diarrhea. The vomiting occurred after attempted feeding. His father was ill with vomiting and diarrhea. 

Vital signs included heart rate 167 and respiratory rate 18. Examination was unremarkable. Laboratory studies were unremarkable. An oral challenge was unsuccessful, so he was admitted to the pediatric floor for further care. Admission orders included nothing by mouth, intravenous (IV) fluids, and advance diet to Pedialyte as tolerated. He had one episode of vomiting overnight but was subsequently able to tolerate Pedialyte. After several hours and multiple feedings, he was successfully transitioned to formula. He was deemed stable for discharge with diagnosis of vomiting secondary to viral gastroenteritis.

No, the proposed inpatient admission was not medically necessary.

Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of five years. Most cases are caused by viruses, are self-limited, and require only supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications. Hospitalization may be necessary for those that do not respond to oral hydration and anti-emetic treatment, as well as those with severe dehydration.

This young male infant presented to the emergency department (ED) with multiple episodes of vomiting, unable to tolerate an oral challenge in the emergency department (ED). He had no clinical signs of significant dehydration but was at risk because of his age and inability to tolerate oral fluids. While it was reasonable to monitor him in the hospital for ability to drink sufficiently, he did not require acute inpatient admission. He was overall hemodynamically stable, with no evidence of impending sepsis, no evidence of severe dehydration, and no concerning underlying medical condition. He could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Inflammation Of The Gallbladder And/or Gallstones.
Treatment: Inpatient admission.

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

The patient is a woman. Her medical history included asthma and obesity. Twenty-weeks pregnant, the patient presented to her obstetrician with right-upper-quadrant abdominal pain. Her vitals were temperature 36.4, pulse 71, blood pressure 114/65, respirations 20. Physical examination demonstrated guarding and tenderness-to-palpation of the right-upper-quadrant of the abdomen. Serum laboratories demonstrated a normal white-blood-cell count of 9.75. Ultrasound demonstrated gallstones. Except for the presence of a Murphy's Sign, there was no other evidence of cholecystitis. 

The patient was admitted at an acute inpatient level-of-care with a diagnosis of gallstones. She was provided with bowel rest (clear liquid diet) and oral antibiotics. She tolerated these and reported resolution of her abdominal pain. 

Having returned to her baseline health and function, the patient was discharged home in good and stable condition with oral antibiotics, oral analgesics, and surgical and obstetric follow-up. 

No, the Inpatient Admission was not medically necessary.

The Tokyo Guidelines [TG18] constitute the international, gold-standard criteria for diagnoses of biliary diseases [Yokoe et al.]. According to TG18, for a diagnosis of acute cholecystitis, a patient requires: 1) a local sign of inflammation (most commonly, abdominal tenderness); 2) a systemic sign of inflammation (most commonly, fever or leukocytosis); and 3) radiologic evidence of cholecystitis (most commonly, by ultrasound). Insofar as the patient-in-question only met one of the three criteria (a local sign of inflammation -- abdominal tenderness/Murphy's Sign), she did not have acute cholecystitis; instead, she had symptomatic gallstones. Also, insofar as she was stable -- without any significant co-morbidities or physiologic derangements, she did not need admission at an acute inpatient level-of-care; she could have been treated at a lower level-of-care for gallstones. 

As the patient did not have acute cholecystitis by the Tokyo Guidelines, she did not need admission at an acute inpatient level-of-care. She could have been treated at a lower level-of-care for gallstones.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tremors - alcohol withdrawal.
Treatment: Inpatient admission.

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

The patient is a female with a history of alcoholism and alcohol withdrawal. She presented complaining of alcohol withdrawal after two days of alcohol abstinence.  She complains of tachycardia, nausea and vomiting.  

The patient's VS (vital signs) were as follows:  Temperature 98.9, heart rate, 128, respiration rate 18, blood pressure 139/83. The patient's exam was unremarkable. Her CBC (complete blood count) and BMP (basic metabolic panel) were normal.  Her EtOH (ethanol) was 377.  

The patient was admitted with alcohol withdrawal.  The patient's VS were as follows:  Temperature 97.5, heart rate, 117, respiration rate 20, blood pressure 145/78.  She complains of shaking, palpitation, and anxiety. Her exam was remarkable for hand tremors. Her EKG (electrocardiogram) revealed sinus tachycardia. Her CXR (chest x-ray) revealed NAD (no active disease).  Her plan of care included telemetry, IVF (intravenous fluids), CIWA (clinical institute withdrawal assessment) protocol and IV (intravenous) BDZ (benzodiazepine) prn (as needed). 

The following day, the patient's VS were as follows:  temperature 97.8, heart rate 100, respiration rate 18, blood pressure 136/86. There were no new complaints. Plan was to continue CIWA (clinical institute withdrawal assessment) protocol.  

Two days after admission, the patient's vital signs were stable.  The plan was to continue current management.  

The patient's vital signs were stable. She felt better. The plan was for discharge.  

No, the Inpatient Admission was not medically necessary.

This patient was admitted for alcohol withdrawal.  The patient did not have active comorbid conditions.  The patient was hemodynamically stable and afebrile.  She had tachycardia but no arrhythmia.  She did not have persistent vomiting, delirium, seizures, or gross tremor.  Labs were unremarkable.  The patient was admitted with plan for IVF (intravenous fluids) and CIWA (clinical institute withdrawal assessment) protocol.  During admission, she had findings of hand tremors.  No CIWAs (clinical institute withdrawal assessments) were recorded.  The patient was clinically stable and did not have findings of severe alcohol withdrawal.  She did not have symptoms that required an acute inpatient level of care.  She had not failed management in a lesser level of care.  The requested inpatient admission was not medically necessary.  Withholding the treatment would not reasonably be expected to affect the patient's health adversely.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia, Diabetes Mellitus,
Hypothyroidism and Breast Cancer
Treatment: Personal Care Services, 24 hours per day, 7 days a week (Split Shift) for a total of 168 hours per week
The insurer denied the Personal Care Services, 24 hours per day, 7 days a week (Split Shift) for a total of 168 hours per week. 
The denial is overturned. 

The patient is a female with a history of Schizophrenia, Diabetes Mellitus, Hypothyroidism and Breast Cancer. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 168 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the Personal Care Services, 24 hours per day, 7 days a week (Split Shift) for a total of 168 hours per week is deemed medically necessary. 

This is a female with a history of Schizophrenia, Diabetes Mellitus, Hypothyroidism and Breast Cancer. Recent documentation from the patient's provider indicates that due to progressively worsening mental status, gait ataxia, respiratory distress/dyspnea requiring 24/7 supplemental oxygen, the currently approved plan of 56 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 168 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-displaced left parietal calvaria fracture
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld. 

This patient is a female child with no past medical history. The patient's mother was sitting in a wooden chair feeding her.  The patient threw her head back and hit her head on the wooden arm rest. There was no fall. The patient acted normally and continued to breast-feed without issues.  The mother denied the patient had a loss of consciousness or vomiting. The following day the mother felt a swelling on the back of the patient's head. The mother took the patient to the primary medical doctor and was sent to the hospital for evaluation. 

The patient had been acting at baseline per her parents, smiling, playful, and had normal oral intake. The physical examination was normal with the exception of the hematoma.  Pediatric Neurosurgery and the social worker were to see the infant. Neurosurgery indicated that the patient was to be admitted overnight for observation and undergo a rapid brain Magnetic Resonance Imaging (MRI). The MRI of the brain revealed a non-displaced left parietal calvaria fracture. The adjacent extracranial cephalohematoma was grossly stable. There was no gross evidence for intracranial hemorrhage within the limitations of the MRI screening technique. The skeletal survey on day 2 of admission was normal and the patient was subsequently discharged.

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

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

The carrier's denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.