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

Diagnosis: Crossbite. 
Treatment: D8080 Braces, D8670 Monthly Visit. 

The insurer denied: D8080 Braces, D8670 Monthly Visit. 
The denial is overturned. 

The patient is an adolescent female. The request is for dental benefits for orthodontic treatment (braces) and monthly visits. Per the provider's clinical dental summary, the patient evidences Class I skeletal growth pattern, left sided posterior crossbite, maxillary midline discrepancy relative to facial midline, deep overbite, maxillary and mandibular anterior crowding. 

The health plan denied coverage of the request because the patient did not score a 26, the score necessary for approval for orthodontic treatment on the Handicapping Labio-Lingual Deviation (HLD) Index Report. 

The appeal was requested based on the clinical diagnosis and the provider's score of 28 on the same HLD (Handicapping Labio-Lingual Deviation) Index Report. 

The requested braces and monthly visits are medically necessary. 

Based on the materials submitted, the patient exhibits a posterior crossbite involving teeth #s 13 and 14. 

The health plan denied coverage of the request because the patient did not score a 26 on the HLD (Handicapping Labio-Lingual Deviation) Index Report. The discrepancy comes from the score in regard to the posterior crossbite; meaning they scored "0" as opposed to "4." 
Because the photos support that the posterior crossbite involves teeth #13 and 14, with that scoring the HLD (Handicapping Labio-Lingual Deviation) Index would be a 28; a score that would indicate approval of orthodontic treatment. 

Therefore, given the above, the braces and monthly visits are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Type I Diabetes Mellitus.
Treatment:  E0784 External Ambulatory Infusion Pump Insulin (Tandem t:slim X2).
The insurer denied the E0784 External Ambulatory Infusion Pump Insulin (Tandem t:slim X2).
The denial is overturned.

This patient is an adult male with type I diabetes. Request for t:slim X2 insulin pump is under review. The prior request was denied because the patient has a pump in warranty. The provider is appealing this determination as the patient has tried and failed the Medtronic 770G insulin pump he has been using. His glycated hemoglobin (A1C) was 7.8%. He changed continuous glucose monitors to Dexcom because the Medtronic sensors were inaccurate, and the adhesive fell off his skin. The patient's average blood glucose on pump download was 226 milligrams per deciliter (mg/dL).

The proposed t:slim X2 insulin pump is medically necessary.

This request is for a t:slim X2 insulin pump for the management of type I diabetes. This patient has tried and failed the Medtronic 770G due to ongoing hyperglycemia with a glycated hemoglobin (A1C) of 7.8% and average blood glucose of 226 milligrams per deciliter (mg/dL). The use of the t:slim X2 pump is supported by the peer reviewed literature for the management of type I diabetes to reduce hyperglycemia and reduce hypoglycemia. In a randomized control trial of 168 patients with type I diabetes, the mean (standard deviation) percentage of time that the glucose level was within the target range (70 to 180 milligrams per deciliter [mg/dL]) improved in the group using the t:slim X2 pump with Control IQ from 6117% (percent) at baseline to 7112% during the six months and remained unchanged at 5914% in the control group (mean adjusted difference, 11 percentage points; 95% confidence interval [CI], nine to 14; P<0.001). Use of the t:slim X2 pump with Control IQ also reduced hypoglycemia with a mean difference in the percentage of time that the glucose level was less than 70 milligrams per deciliter (mg/dL) was 0.88 percentage points (95% CI, 1.19 to 0.57; P<0.001). Without the t:slim X2 pump, this patient will be at increased risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, the proposed Tandem t:slim X2 insulin pump is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

This patient is an adult female who presented to the emergency department at with a complaint of abdominal pain. Her examination revealed right lower abdominal tenderness. Vital signs were normal at the time of presentation. The white blood cell (WBC) count was normal at 12.5 thousand (K).  Surgical consultation was obtained. Computed tomography (CT) scan was completed showing findings of acute appendicitis. The patient was started on intravenous antibiotics. The patient underwent laparoscopy with appendectomy for the condition of appendicitis. Surgical findings included acute nonperforated appendicitis.

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

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

The proposed acute inpatient admission was not medically necessary.

Acute inpatient hospitalization was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely monitored with an observational status.  

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

While the records support that the care provided was clinically appropriate, there is no clinical documentation to support the 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 with an observational level of care. This lower level of care would have provided for pre-surgical assessment, surgical treatment, and post-surgical recovery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Systemic Inflammatory Response Syndrome (SIRS) of unknown origin
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient is an adult male with past medical history significant for hypertension, diabetes, hemophilia A, pernicious anemia, and heart failure who presented to the emergency room with complaints of shivering. Vitals on presentation included the following: temperature max 100.2 Fahrenheit, blood pressure 179/86, pulse 106, respiratory rate 18, oxygen (O2) 96% (percent) on room air. Laboratory results showed: white blood cell count (WBC)10.1, hemoglobin (Hgb) 10.7, hematocrit (Hct) 35.5, creatinine 1.96, glucose 100, procalcitonin 0.22. Chest x-rays (CXR) revealed showed chronic elevation of the right hemi-diaphragm with mild atelectasis at the right lung base.
 
The patient was admitted for complaints of fever and shivering. He was empirically started on broad-spectrum antibiotics. CXR was negative. All cultures remained negative. The patient improved clinically, remained hemodynamically stable. He was discharged to continue outpatient management. 
 
According to medical records, the patient presented with low-grade fever, hypertension, and tachycardia. Laboratory results were notable for elevated creatinine (1.96). He had a normal procalcitonin level and negative CXR. Based on above findings, the patient met criteria for observation level of management. The patient did not fulfill criteria for acute hospital admission.  

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vitiligo

Treatment: Opzelura 1.5% (percent) ex (external) crea (cream)

The insurer denied coverage for Opzelura 1.5% ex crea.
 
The denial is overturned.

This is a patient with a diagnosis of vitiligo affecting 5-10% (percent) TBSA (total body surface area). The patient has failed therapy with triamcinolone, tacrolimus, and hydrocortisone. The patient's medical history is complicated by a diagnosis of Crohn's disease which appears to be well controlled with Infliximab therapy. The health plan has denied Opzelura for vitiligo as not medically necessary and not approved for use with infliximab.

Based on the standard of care and the documentation provided, Opzelura topical is medically necessary for the treatment of the patient's vitiligo. There is no known contraindication from using topical Opzelura for vitiligo while the patient receives treatment with Infliximab for Crohn's disease. Opzelura is the only approved FDA (Food and Drug Administration) treatment for patients 12 years of age and older treated for vitiligo. The patient has tried and failed standard therapies, including topical steroids and non-steroidal tacrolimus ointment. The use of Opzelura is medically necessary for the treatment of this patient's vitiligo.  

The insurer's denial of coverage for Opzelura 1.5% ex (external) crea (cream) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prostate Cancer
Treatment: Oncotype DX prostate
The insurer denied the Oncotype DX prostate.
The determination is overturned.

The patient has newly diagnosed prostate cancer. He had 2 of 12 cores in his biopsy with Gleason (3+3=6), grade group 1 adenocarcinoma. There was perineurial invasion in the right lateral apex. His prostate-specific antigen (PSA) was 4.3 nanograms per deciliter (ng/dL) and prostate-specific antigen (PSA) density is 0.14 nanograms per milliliter (ng/mL). The clinical stage is T1c. The Oncotype Dx prostate assay was obtained and is under review for medical necessity.

This patient has National Comprehensive Cancer Network (NCCN) very low risk prostate cancer based on having a tumor that is in histologic grade group 1 (Gleason score less than or equal to (<=) 6) on biopsy and a serum PSA less than (<) 10 ng/mL. The extent of disease within the prostate is limited (ie, fewer than three positive biopsy cores, with less than 50 percent involvement in any one core, and a PSA density less than 0.15 ng/mL/gram). The National Comprehensive Cancer Network (NCCN) considers molecular diagnostics to be reasonable for patients with at least 10 years life expectancy who have not received treatment for prostate cancer and are candidates for active surveillance or definitive therapy. This patient meets these criteria. The authors of UpToDate state "...The genomic prostate score (Oncotype Dx Genomic Prostate Score) and genomic classifier (Decipher) are multimarker tests that are specific to prostate cancer, are commercially available, and are recommended by expert groups for risk stratification in clinically localized disease. ..".
The 2019 American Society of Clinical Oncology (ASCO) clinical guidelines on molecular markers in localized prostate cancer concluded that the Oncotype Dx Genomic Prostate Score may be offered in situations in which the assay result, when considered as a whole with routine clinical factors, is likely to affect management; this patient is such an example.  The results of the test can influence the decision to observe a patient without intervention versus proceeding with radiotherapy or surgery; both of which carry risks the patient would not otherwise be exposed to. Given the support of the service in the peer-reviewed literature and in national guidelines, this assay meets criteria for medical necessity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain - delta troponin
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is: Overturned

The patient is a male who presented to the emergency department complaining of pleuritic chest pain, abdominal pain, diarrhea and chills. His medical history was remarkable for abdominal aortic aneurysm repair, aortic valve replacement, small bowel obstruction, deep vein thrombosis, pulmonary embolism, hypertension, hyperlipidemia, multiple sclerosis, paraplegia, cigarette smoking and marijuana and alcohol use. In the emergency department (ED) his blood pressure was 92/63 millimeters of mercury (mmHg) with a heart rate of 81 beats/minute. His respiratory rate was 18/minute with a room air oxygen saturation of 98%. He was afebrile. An electrocardiogram showed sinus rhythm with nonspecific repolarization abnormalities and a prolonged QT interval. His D-dimer level was elevated. His high sensitivity troponin level was 1322 nanograms per liter (ng/L). His brain natriuretic peptide (BNP) level was 149.5 picograms per milliliter (pg/ml). His serum potassium level was 5.6 millimoles per liter (mMol/L). Chest X-ray showed hyperinflated lungs. Computed tomography (CT) scan of the chest, abdomen and pelvis showed no acute pathology. The patient was treated with aspirin and with calcium, insulin and dextrose for hyperkalemia. He was admitted to the hospital to rule out acute coronary syndrome. Repeat troponin levels were 1141 ng/L, 740 ng/L, 521 ng/L and 299 ng/L. The following day the patient left the hospital against medical advice. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

This patient presented with chest pain, marked serum troponin elevation and an abnormal electrocardiogram. Serial measurements showed a significant delta troponin. Thus, he met accepted criteria for a diagnosis of non-ST segment elevation myocardial infarction (NSTEMI). Patients with NSTEMI are at substantial risk for major adverse cardiac events including shock, heart failure and potentially lethal arrhythmias. Inpatient admission is therefore the standard of care in this situation and is endorsed by current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE)/American College of Chest Physicians (CHEST)/Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcoholism
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Overturned

The patient is a male with a history of alcoholism who presented to the hospital with a chief complaint of alcohol withdrawal. He complained of severe abdominal pain after drinking a bottle of rum for five days straight. His last drink was the day before the presentation, when the severe abdominal pain started, most prominent in the left upper quadrant with associated nausea and vomiting. Two weeks before this presentation, the patient was seen for identical symptoms at another hospital and signed out Against Medical Advice after a few days in the hospital.

The admitting diagnosis included alcohol intoxication with impending delirium tremens, elevated anion gap metabolic acidosis due to lactic acidosis, and prolonged QT interval. The patient was given clonidine and hydralazine; the Clinical Institute Withdrawal Assessment (CIWA) score was 17, for which he received 2 milligrams (mg) of intravenous (IV) Ativan. The medical team also started intravenous (IV) fluids and folic acid thiamine replacement. An Ativan taper was initiated based on the documentation by the medical team. Psychiatry reassessed the patient and deemed the patient to have the capacity now to make medical decisions. They recommended close outpatient follow-up. Later in the afternoon, the patient left Against Medical Advice again. The subject under review is the medical necessity for inpatient hospital admission.

The health plan's determination is overturned.

Based on the provided documentation, inpatient hospitalization is indicated for this patient. The patient presented to the hospital with severe alcohol withdrawal, documented CIWA Scale of 17, severe lactic acidosis with a lactate level of 6.3, and was deemed unable to make medical decisions. Based on medical necessity, this is an inpatient medical admission. Alcohol withdrawal, with delirium tremens, is a life-threatening condition with high morbidity and mortality and cannot be treated under observation level of care for such severe symptoms. The patient was experiencing severe alcohol withdrawal symptoms, lactic acidosis, and encephalopathy due to intoxication. The recovery course is unpredictable and can last days to weeks. There was a definite risk of further progression of this patient's condition to full delirium tremens with seizures. During the hospitalization, the patient required frequent monitoring of his symptoms, frequent administration of benzodiazepines, bedside sitter, frequent laboratory checkups, and aggressive IV fluids. This type of care cannot be provided under a lower level of care and requires inpatient hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis
Treatment is an inpatient admission
The insurer denied coverage for an inpatient admission
The denial is upheld.

According to the documentation submitted, this is a patient with past medical history of ovarian cysts who presented to the Emergency Department. As per the ED (emergency department) triage note she was afebrile. As per the ED provider note she was a female with past medical history of ovarian cyst who presented to the ED with complaints of abdominal pain. The pain progressed throughout the day. She endorsed a temperature of 101 and vomited and had diarrhea x 2. The pain was in the front and radiated to the back. The pain was the same as when she had an ovarian cyst but without vomiting. On exam she had right and left suprapubic tenderness. Her white blood count was 13.13. CT (computed tomography) of the abdomen revealed appendix containing several appendicoliths and was otherwise within normal limits.

The patient was admitted, and the History and Physical reported this was a female with complaints of abdominal pain located in the RLQ (right lower quadrant) and mid lower abdomen. The pain progressed throughout the entire day. The assessment was a female with a history of ovarian cyst presenting with complaints of abdominal pain located in the RLQ associated with nausea. The provider noted appendix with appendicolithiasis with no surrounding inflammatory changes. The plan was to admit the patient for observation versus early acute appendicitis. The patient was kept NPO (nothing by mouth), IV (intravenous) antibiotics and IV fluids.

Furthermore, according to MCG (Milliman Care Guidelines) health Inpatient and surgical care 26th edition Ambulatory Surgery Discharge and complications: common complications and conditions CCC:CCC- 044 (ISC) Surgery or procedure performed on ambulatory basis may require inpatient stay for 1 or more of the following: Inpatient care needed for clinically significant preoperative disease or condition; Complex surgical approach or situation anticipated; Procedure is not low risk and patient at high anesthetic risk; Presence of drug-related risk; Inadequate outpatient care situation; Postoperative event, condition, or finding that warrants inpatient stay. She did not require an acute care admission only observation as she did not have an acute medical condition preoperatively or post operatively that required an inpatient status. She had appendicitis and should have been easily managed within a 23-hour observation status.

To summarize, the inpatient admission was not medically necessary at the acute inpatient level and denial for a hospital admission should be upheld. The patient was admitted and underwent an uneventful lap (laparoscopic) appendectomy - all of which should have been done in an observation status.
Finally, the medical necessity of the acute admission was not justified, as observation status was sufficient.

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

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

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

The patient is a female with a past medical history significant for Bell's palsy who presented to the emergency department with complaints of headache, numbness, and weakness in the right upper extremity.
The patient stated that she was under severe stress recently. She described a right occipital headache that occurred the evening before her presentation. 

The inpatient hospital stay was not medically necessary. This patient did not need admission at the acute inpatient level of care. The patient presented with symptoms that were suspicious for cerebrovascular accident (CVA) versus cervical radiculopathy. The imaging studies ruled out CVA. The cervical radiculopathy was really mild and the patient did not need any surgical intervention for this.
There was no evidence that the patient had significant or progressive weakness in the extremities that was severe enough to cause functional disability and justify admission at the acute inpatient level of care. There was no evidence of paralysis, spasticity, or dystonia. Taking into consideration all these facts, neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
Treatment: Inpatient day
The insurer denied coverage for inpatient day
The denial is upheld.

This elderly woman presented to the hospital for elective cardiac catheterization due to worsening of dyspnea on exertion. Past medical history was significant for hypertension and diabetes mellitus. She was noted to have a positive stress test. Cardiac catheterization was performed and revealed a left anterior descending artery stenosis. A drug eluting stent was successfully deployed. There were no perioperative complications, and the patient was discharged the following day. 

This patient presented for elective percutaneous revascularization. She underwent an uncomplicated procedure, and a drug eluting stent was placed in the left anterior descending (LAD) artery. She was discharged the following day. Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (Reference 1-4). Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care (Reference 4). In conclusion, inpatient admission was not medically necessary. The patient could have been managed 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 inpatient day is upheld. Medical Necessity is not substantiated.