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

Diagnosis: Kidney Stone
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male with history of hypertension who presented to emergency department with left flank pain. A computed tomography (CT) scan obtained demonstrated a left ureteral stone, six millimeters. The patient was discharged to home on pain medication and tamsulosin for medical expulsive therapy. He developed severe flank pain refractory to pain medication and oral (PO) intolerance and represented to the emergency department the next day. On presentation, the patient was afebrile and hemodynamically stable; his initial blood pressure was elevated, and he was treated with Dilaudid with pain relief. Blood pressure improved in emergency department. Laboratory evaluation demonstrated a normal white blood cell count and creatinine of 1.54. Urinalysis had 9 white blood cells, 11 red blood cells, bacteria 19.0, negative leukocyte esterase, and negative nitrites. Urology was consulted and recommended admission, nothing by mouth (NPO), and intravenous fluids. The patient was taken to the operating room the next day for cystoscopy, retrograde study and stent placement. He received one intravenous dose of antibiotics. The urine culture grew 30,000 Escherichia coli (E. coli) from the emergency department; urine culture obtained for the left kidney intra-operatively had no growth. The patient was discharged to home later that day. Inpatient admission was denied as not medically necessary.

The proposed treatment was not medically necessary.

The patient is an adult male. He developed severe flank pain refractory to pain medication and oral (PO) intolerance and represented to the emergency department. However, this patient had no documented co-morbidities requiring inpatient hospitalization. He was hemodynamically stable, had a normal white blood cell count and mild elevation in his creatinine, and demonstrated no signs of sepsis. He could have been managed with a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Dental Issues
Dental/orthodontic

Diagnosis: anterior crossbite on tooth 7
Treatment: braces
The insurer denied braces. The health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on tooth 7. She presents with a skeletal Class III malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for Braces to address the crowding and crossbite.

Braces are medically necessary for this patient. This patient presents with an anterior crossbite on tooth 7, as well as moderate crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For this reason, braces are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Post-polio syndrome, multiple sclerosis
Treatment: Consumer Directed Personal Assistance Program (CDPAP): 9 hours per day - 7 days per week - for a total of 63 per week. 
The insurer denied Consumer Directed Personal Assistance Program (CDPAP): 9 hours per day - 7 days per week - for a total of 63 per week. 
The determination is overturned.

This is a male patient with a medical history notable for post-polio syndrome, multiple sclerosis, neuromuscular dysfunction of the bladder, diabetes, and arthritis. The patient is approved for 6 hours per day, 7 days per week (42 hours per week) of consumer directed personal assistance program. The patient and her care team requested an increase to 9 hours per day, 7 days per week (63 hours per week), and this request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The letter states that the patient is wheelchair bound due to chronic polio infection since the age of two. The physician states that the patient requires assistance with all activities to allow him to continue to live in his home safely without risk of injury.
The patient provided a letter of support on his own behalf for this appeal. It included a proposed care plan including the estimated number of hours of assistance required. 
A Uniform Assessment System (UAS) was available for review.  The patient lives alone in an apartment. He was alert and oriented but had periods of forgetfulness. Recall was two out of three at five minutes. His cognition was modified independence. At issue is the medical necessity of Consumer Directed Personal Assistance Program (CDPAP): 9 hours per day - 7 days per week - for a total of 63 per week. 

The requested health service CDPAP: 9 hours per day - 7 days per week - for a total of 63 per week is medically necessary for this patient.
The patient has multiple personal care needs secondary to his wheelchair bound status and neurogenic bladder / bowel with resulting incontinence. The task tool estimates that these needs can be met with 5.5 hours per day, and he is currently allocated 6 hours per day. The patient proposes that 12 hours per day is more appropriate, but this request is for 9 hours per day. 9 hours per day is a reasonable and medically necessary request for this patient. His personal care needs can be expected to be continuous and unscheduled throughout the day, as he requires assistance with toileting and transfers which cannot always be easily scheduled around his personal care hours as scheduled. This is especially so in light of his incontinence. Failure to address his personal care needs in a timely manner could result in falls, infections, and/or skin breakdown.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis; Palmoplantar Pustular Psoriasis. 
Treatment: Otezla 30 mg (milligrams). 
The health plan has denied the requested treatment, Otezla 30 mg, as not medically necessary. The health plan's determination is upheld. 

The patient is a male with moderate to severe psoriasis, for which Otezla is being prescribed. The patient is already being prescribed Stelara, 90 milligrams (mg) every eight weeks for his Crohn's disease. Humira has already been tried and failed. 

Health plan coverage of Otezla is under review for medical necessity. 
I uphold, in whole, the health plan's determination. 

The requested treatment of Otezla 30 mg is not medically necessary. 
The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate or other DMARD's (disease modifying anti-rheumatic drugs), which are more proven to be of benefit than Otezla for Crohn's Disease (and in consideration of the gastrointestinal (GI) side effects of Otezla). Particularly, for a patient with this particular history of systemic psoriasis therapy previously utilized, these preferred agents are as much or more appropriate for the treatment of this patient's clinical scenario as is the requested Otezla. For both psoriasis and Crohn's Disease, the use of Methotrexate or other disease modifying anti-rheumatic drugs (DMARDs) is more time-tested and literature-supported with respect to concurrent use with biologic therapies such as Stelara. Therefore, as per the patient's health plan policy language [1], and consistent with current medical literature [2-5] and associated standards of care, the requested Otezla is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems
Dental/Orthodontic Procedure

Diagnosis: Dental Disorder
Treatment: Cleaning inside roots of a back tooth (root canal) for tooth # 14, Cleaning inside roots of premolar tooth (root canal) for tooth #12, Post and hard materiel under cap for teeth #s 12 and 14 and tooth-colored with metal underneath (crown) teeth #s 12, 14 and 19.
The insurer denied Cleaning inside roots of a back tooth (root canal) for tooth # 14, Cleaning inside roots of premolar tooth (root canal) for tooth #12, Post and hard materiel under cap for teeth #s 12 and 14 and tooth-colored with metal underneath (crown) teeth #s 12, 14 and 19.
The determination is overturned.

This is a male patient who presented for the treatment of teeth number (#) 12, 14, and 19. Provided for review are letters of appeal and denial, a letter from his Medical Doctor (MD), radiographic images of the teeth in question, and health plan language. At issue is the medical necessity of the treatment of molar root canal treatment (3330) #14, porcelain fused to high noble metal crown (2750) #12,14,19, post and core (2952) #12,14, and endodontic therapy premolar (3320) #12.

The treatment of molar root canal treatment (3330) #14, porcelain fused to high noble metal crown (2750) #12,14,19, post and core (2952) #12,14, and endodontic therapy premolar (3320) #12 is all medically necessary for the patient. As there is infection affecting the pulp of #14 and # 12, there is a diagnosis of irreversible pulpitis. In any situation where the patient has the diagnosis of irreversible pulpits, as long as the tooth is restorable, there is the requirement to treat the pulpitis through removal of the infected nerve, artery, vein, as well as the canal tooth structure, irrigate with sodium hypochlorite, and fill with gutta percha medicament as this is the only therapy that will treat the diagnosed pathology. This is a root canal. If the therapy is not done, the pulpal infection can spread to the surrounding bone, which can lead to the presence of an abscess, with an array of sequential systemic sequela. Hence, based on the diagnosis of irreversible pulpits alone, the therapy of root canal therapy is indicated. As the teeth are restorable, and as there will be a significant amount of tooth structure removed in order to cleanup the infected pulp, core buildup and crowns are necessary as replacements of tooth structure. Therefore, the entire treatment of molar root canal treatment (3330) #14, porcelain fused to high noble metal crown (2750) #12,14,19, post and core (2952) #12,14, and endodontic therapy premolar (3320) #12 is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right-Sided Chest Pain and Shortness of Breath
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female with risk factors for CAD (coronary artery disease) including hypertension, diabetes, and history of CHF (congestive heart failure) due to non-ischemic cardiomyopathy. The patient presented with atypical right-sided chest pain and dyspnea. Cardiac enzymes were negative. EKG (electrocardiogram) showed sinus with old LBBB (left bundle branch block). Her pain improved. Nuclear stress test was non diagnostic. Echocardiogram showed wall motion abnormality. Cardiac catheterization showed normal, non-obstructive coronaries. The patient was discharged.

The Inpatient Hospital Admission was not medically necessary.

Determination of level of care is primarily dependent on the actual care a patient receives and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care.

In this case, the patient's symptoms were atypical and unlikely to be representative of acute coronary syndrome. The patient's exam and cardiac findings were unchanged with known NICM (nonischemic cardiomyopathy) and LBBB (left bundle branch block). Biomarkers and EKG (electrocardiogram) showed no evidence of acute ischemia. CXR (chest x-ray) was normal. Echocardiogram showed wall motion abnormality, but it was previously present. The physicians' treatment did not reflect any serious concern that the patient's cardiac condition represented ACS (acute coronary syndrome). Orders did not include medical therapy for ACS (acute coronary syndrome), such as IV (intravenous) heparin, dual anti-platelet inhibitors, high-dose beta blockers or IV (intravenous) NTG (nitroglycerin).

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The cardiac care that was provided was telemetry and uncomplicated heart catheterization, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD (coronary artery disease). In fact, all tests showed absence of ischemia. While there was always a potential for an adverse event (and in this case a low probability), one did not happen, and no actual treatment was added. There are no examples of care requiring inpatient level of care. 

Milliman criteria requirements for admission for unstable angina were not fulfilled, as there was never any evidence of ACS (acute coronary syndrome) present. Since all testing and therapy would be appropriate, safe and guidelines consistent in a lower level of care, inpatient level of care was not medically necessary. 

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain. 
Treatment: Inpatient admission. 
The health plan has denied the requested treatment, inpatient admission, as not medically necessary. 
The health plan's determination is upheld. 

The patient is a female with a past medical history (PMH) of hypertension (HTN), chronic kidney disease (CKD), and diabetes mellitus type 2 (DM2) who was admitted with complaints of right buttock and leg pain. The patient's vital signs were unremarkable. The patient's physical exam was notable for acute distress, mild tenderness to palpation (TTP) over the right piriformis, no TTP over the lumbar (L)-spine, and normal sphincter tone. Laboratory work was notable for a creatinine of 2.4 (discharge creatinine was 1.0) and a white blood cell count (WBC) of 16. Imaging studies included magnetic resonance imaging (MRI) of the L-spine which showed no acute compression fractures and an L5- sacral (S)1 disc bulge with extrusion causing moderate to severe spinal canal stenosis on the S1 nerve roots. The patient was diagnosed with spinal canal stenosis and an acute kidney injury (AKI) and was treated with gabapentin, physical therapy (PT), physical medicine rehabilitation (PMR), and intravenous fluids (IVF). The patient was discharged in stable condition.

At issue is the medical necessity of an inpatient admission. 
I uphold, in whole, the health plan's determination of medical necessity. 

The hospital stay was not medically necessary at an acute inpatient level of care. 
This patient presented to the emergency department (ED) with complaints of back pain without evidence of severely compromised neurological function. The patient received a thorough diagnostic and imaging work-up, which did not demonstrate any acute fractures or dislocations but did show disc bulge with spinal stenosis. The patient did not have an abdominal aortic aneurysm, aortic dissection, cauda equina syndrome, epidural abscess or hematoma, acute spinal fracture, meningitis, osteomyelitis, progressive neurologic deficits, fever, discitis, or tumor. The patient was evaluated by Neurology, did not require any acute surgical intervention, and there were no red flag symptoms presents with the back pain. The patient did have an acute kidney injury without significant electrolyte abnormalities, for which the patient was treated with IVF and responded well. For the back pain, the patient received pain control, gabapentin, a Neurology consultation, a radiologic work-up, and PT, all of which could have been safely provided at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.
 

This infant was brought to the emergency room for fever of 101 degrees F at home, loose stools today, and because she looked like she was in pain. She was admitted 2 weeks prior for urinary tract infection (UTI) for organism that was sensitive to ceftriaxone, for which she was treated. On examination in the emergency department (ED) the heart rate was initially 188, Respirations 28, temperature 98 degrees F. She was fussy, but was playful and interactive. 

Troponin was only slightly above upper limit of normal. An electrocardiogram (EKG) revealed sinus tachycardia. The Cardiac consultation and interventions provided could have been done in the observation setting in the emergency department (ED). Cardiology saw her after admission and found hemodynamically stable and did not diagnose supraventricular tachycardia nor recommend a repeat troponin level. The discharge states the child was admitted for bacteremia. However, there was no leukocytosis, bandemia or Systemic inflammatory response syndrome (SIRS) criteria to suggest any clinical suspicion of bacteremia. Urinalysis was normal.

Only when sinus tachycardia is present with shock are hospitalization and other treatment measures indicated. Regarding bacteremia, "Completely immunized children with fever without a source may be followed as outpatients, but their caregivers should be instructed to promptly seek medical attention if the child becomes ill appearing, develops dehydration, has signs of a localized bacterial infection, or has a fever that persists for >48 hours."

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Inpatient hospital stay

Diagnosis: Orthopedic/Musculoskeletal-Bone Fracture/Break-Ankle fracture
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has upheld in whole the health plan's determination.

This case describes a female patient who sustained a right bi-malleolar ankle fracture as a result of a motor vehicle accident. The patient was advised by her orthopedic surgeon to present to the emergency department for admission to the hospital and for further care. The patient was admitted. She underwent open reduction and internal fixation (ORIF) of this right ankle fracture and was discharged the next day. At issue in this case is the medical necessity of inpatient hospital admission.

The requested health service/treatment of a hospital inpatient stay was not medically necessary for this patient. This decision is based upon the documentation in the provided medical records and the recommendations of the current, peer-reviewed orthopedic literature. First, the records document that this female patient was involved in a motor vehicle accident and sustained a bi-malleolar right ankle fracture. She was initially seen and discharged form an outside emergency room for outpatient follow up of this fracture. Her orthopedic provider recommended that she be seen in the emergency room at the hospital for admission and definitive care of this ankle fracture. This injury was a closed fracture with no neuro-vascular compromise. The justification of the inpatient hospital admission instead of ankle fixation surgery at a lower level of care is not clearly documented in the provided records. This patient is a healthy female with no medical history. 

Furthermore, the current, peer-reviewed orthopedic literature, including recent articles by Qin and colleagues in the Journal of Bone and Joint Surgery and by Malik and associates in the Journal of Foot and Ankle Surgery. These authors document the safety and efficacy of outpatient management for ankle fixation surgery. Qin and his co-authors concluded that "In patients with closed fractures and minimal comorbidities, outpatient ORIF was associated with reduced risk of select 30-day medical morbidity and no difference in surgical morbidity, reoperations, and readmissions relative to inpatient. Factors unaccounted for when creating matched cohorts may impact our results. Our findings lend reassurance to surgeons who defer admission for low-risk patients."
Therefore, based upon this peer-reviewed research, the inpatient hospital admission was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dental issues
Treatment: braces/monthly visits
The insurer denied braces/monthly visits. The health plan's determination is overturned. 

The patient in question is young female with a Class II malocclusion with severe maxillary and mandibular crowding. She has 5 millimeter (mm) overjet and 6 mm overbite as measured by the panoramic radiograph. She is treatment planned for Braces and Monthly Visits. 

Braces and monthly visits are medically necessary. Teeth #8 and #9 are protruding forward within the dental arch.
This makes them more prone to trauma. Additionally, there is a discrepancy between the overjet illustrated on the cephalometric radiograph and the photos. The photos show a significantly larger overjet than the radiograph. This would indicate that the patient shifted her jaw forward during the cephalometric radiograph making her malocclusion look less severe than it actually is. The cephalometric radiograph indicates a 5mm overjet (this overjet can be objectively measured due to the ruler included on the image), meaning her true overjet is at least 6mm.
In conclusion, this patient has a malocclusion that causes her incisors to be more prone to trauma, causes a reduced oral heath quality of life, and also meets criteria for medically necessary treatment. Therefore, the requested orthodontic treatment is medically necessary.