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

Diagnosis: Possible atrial fibrillation.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld. 

This is an adult male with a history of osteomyelitis of bilateral feet, amputation of the right foot, schizoaffective disorder, diabetes with stage four kidney disease, and atrial fibrillation (AFib). The patient presented to Brookdale Emergency Department (ED) as a transfer from the psychiatry department.  On initial presentation, the patient was afebrile (temperature of 97.3 degrees Fahrenheit), blood pressure of 166/95, pulse of 75, respiration of 19, and oxygen saturation of 97 percent (%). On examination, the patient appeared in no distress, obese with right leg edema plus two (2+) and left leg edema plus one (1+) with volatile mood.

Laboratory studies were remarkable for hemoglobin 6.9, hematocrit 21.8, platelets 441, white blood cell count (WBC) 10.6, calcium 8.3, sodium 132, total bilirubin 0.2, ferritin 419.30. The patient's baseline hemoglobin is normally 7-8. An electrocardiogram (ECG), 4 days prior to transfer, demonstrated normal sinus rhythm. The treating physician's clinical impression was emergently concerned for symptomatic anemia needing intravenous (IV) iron therapy and Aranesp weekly. The patient was indicated as needing telemetry as he had a history of paroxysmal atrial fibrillation. 

The patient was stable, except for the exacerbation of his schizoaffective disorder. The patient's anemia was asymptomatic, intravenous (IV) iron and erythropoietin take weeks to work and can be done on an outpatient basis. The patient did not have the atrial fibrillation (AFib) on presentation, and AFib does not require telemetry. The patient's chronic kidney disease and diabetes can be managed on an outpatient basis.

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 an inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dysuria, Malaise and Fever.
Treatment: Inpatient Admission.

The insurer denied coverage for inpatient admission. The denial is upheld. 

This patient is an adult male with a past medical history of Benign Prostatic Hyperplasia (BPH), hypertension, hyperlipidemia, obstructive sleep apnea (OSA), and mitral valve (MV) repair who presented to the emergency department (ED) with dysuria, malaise, and fever. The patient was started on Ciprofloxacin (Cipro) 500 milligram (mg), tabs for presumed urinary tract infection symptoms the prior day. The patient presented with complaints of fever (101.7 degrees Fahrenheit) and fatigue. In the emergency room, the patient had a blood pressure of 90/59 and a white blood cell (WBC) count 26,900. Sepsis protocol was triggered. Creatinine 2.20, lactate level 2.5, and urinalysis showed pyuria hematuria. The patient was given intravenous fluid boluses and started on intravenous Rocephin. A computed tomography (CT) scan showed stranding adjacent to the prostate. A blood culture was obtained, and the patient was given an oral Levaquin 500 mg tab and placed in observation. 

The patient was admitted with a temperature of 100.8 degrees Fahrenheit the next day, with white blood cell counts 16,100. The patient improved gradually and was stable for discharge with two weeks of oral cefpodoxime. 

Per Milliman Care Guideline (MCG) Health (27th) Urinary Tract Infection, the patient fails to meet clinical indications for admission to inpatient care. The patient was mildly hypotensive in the emergency room but afebrile. Increased creatinine and lactate both responded to intravenous fluids. There were no positive blood cultures.

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably, with sound medical judgment, and in the patient's best interest. The medical necessity for full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Runny Nose, Nasal Congestion, Coughing and Shortness of Breath

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission. The denial is overturned.

This patient is a child with a history of a one-day illness with a runny nose, nasal congestion, coughing, and shortness of breath. The mother noted that the child was having difficulty breathing and administered the patient's brother's albuterol at home three times, with no improvement noted in the child's difficulty breathing. The patient's brother and father have a history of asthma. Because of the patient's persistent difficulty breathing, the patient's mother brought the child to the emergency room (ER) for additional treatment.

In the ER, the patient was in respiratory distress with nasal flaring and retractions. Upon physical examination, the patient had bilateral wheezing. The patient received three doses of DuoNeb, a bolus of intravenous (IV) normal saline, steroids, and magnesium sulfate. Blood gas was significant for respiratory acidosis with a potential hydrogen (pH) of 7.31 and an elevated carbon dioxide (pCO2) of 57. After treatment in the ER, the patient had a pulse oximetry reading of 93% (percent) and required ongoing frequent albuterol nebulizer treatments. Based on the respiratory acidosis and persistent wheezing, the decision was to admit the patient with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 3 hours.

The patient was treated appropriately in the emergency room (ER) for a cough, wheezing, and retractions. The patient was acutely sick with respiratory distress and continued to have increased work of breathing. This child with a family history of asthma with respiratory acidosis and elevated carbon dioxide (pCO2) required ongoing treatment with albuterol every 3 hours. This child could not have been safely discharged to their home since they required ongoing treatment with albuterol every 3 hours and continued monitoring for improvement in the respiratory acidosis.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the patient's best interest. The medical necessity for inpatient hospital stay is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pulmonary Embolism.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

This is a male patient with no past medical history (PMH), who was admitted on with complaints of (c/o) bilateral upper and lower extremity edema associated with chest pain. The vital signs were notable for peripheral capillary oxygen saturation (SpO2) of 100 percent (%). The physical exam was notable for no respiratory distress, non-toxic. Lab work was notable for negative troponin, brain (or B-type) natriuretic peptide (BNP) 27. Imaging studies, computed tomography angiography (CTA) of the chest showed acute segmental right lower lobe (RLL) pulmonary embolism (PE) without evidence of heart strain, extremity ultrasound (US) showed no deep vein thrombosis (DVT). The patient was diagnosed with an acute PE and treated with anticoagulation. 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 presented to the emergency department (ED) with complaints of (c/o) bilateral upper and lower extremity edema associated with chest pain and was found to have an acute RLL pulmonary embolism. The patient had no history of cancer, heart failure, or chronic lung disease, there was no hypotension, tachycardia, tachypnea, fever, altered mental status (AMS) or hypoxia. The pulmonary embolism severity index (PESI) score was consistent with class I, which is very low risk, with a 0-1.6% 30-day mortality. The simplified pulmonary embolism severity index (sPESI) was also indicative of low risk. In addition, there was no respiratory distress, hemodynamic instability, recent bleeding, or serious comorbid conditions, while the computed tomography (CT) scan showed no evidence of heart strain, the patient was hemodynamically stable, and troponin and BNP were unremarkable. Patients with a PESI score less than 65 are very low risk for 30-day mortality (0%), and patients in this category can be considered for outpatient management. This patient was monitored and received anticoagulation, which could have been provided safely at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Atrial Fibrillation.
Treatment:  Inpatient Hospital Stay.

The insurer denied Inpatient Hospital Stay.  The determination is upheld.

The patient is a female who presented to the emergency department (ED); she was brought by Emergency Medical Services (EMS) with chest pain and palpitations. Her chest pain was described as 7/10 and fatigue. The patient took Pepcid with no relief and called EMS. EMS recorded a rhythm strip, which revealed atrial fibrillation (afib) with rapid ventricular rate (RVR) 180 beats per minute (BPM). Intravenous (IV) normal saline (NS) was administered in route to the hospital.
The patient had a history of hypertension (HTN), diabetes mellitus (DM), gastroesophageal reflux disease (GERD), obesity, iron deficiency anemia and vitamin D deficiency.
An electrocardiogram (ECG) revealed atrial fibrillation with narrow QRS, ST depression. The plan was to administer procainamide, but the patient spontaneously converted to sinus rhythm. Her ECG while in sinus rhythm, revealed rate of 98 BPM, left axis deviation, prolonged QT, possible septal infarct, age undetermined.

The plan was to initiate beta blockers. The patient was admitted to the hospital. She was started on Eliquis.
The patient remained in normal sinus rhythm and her condition was stable. She was discharged home.
At issue is the medical necessity of an inpatient level of care.

The requested health service/treatment of inpatient admission was not medically necessary for this patient.
The patient presented with atrial fibrillation with rapid ventricular rate and elevated blood pressure. She was not in pulmonary edema, did not have signs of heart failure or acute coronary syndrome. Her BP was elevated, she was not in cardiogenic shock. The patient converted to sinus rhythm spontaneously, shortly after presentation. She did not require any intervention for rate or rhythm control. For the rest of the hospital stay the patient was stable. Her BP was elevated, but she was managed by oral medications. Based on the above information, the patient did not have indications for inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:	Malocclusion	
Treatment: Braces and monthly visit

The insurer denied braces and monthly visit.  The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images) orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings, including overjet, and overbite, and anterior crowding, and has recommended orthodontics. The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index, attaining 27 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary, as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 18 points by internal reviewers. The denial is being appealed on behalf of the patient.

Upon review of the submitted documentation it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system, if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 27 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 18 points on the HLD index (5 overjet, 6 overbite, 5 anterior crowding, 2 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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 D8080 braces and D8670 monthly visit services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lateral malleolar fracture
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This is an adult female who reported a fall. She was evaluated in the physician's office and diagnosed with a lateral malleolar fracture. He advised her to go to the hospital and be admitted for an open reduction internal fixation (ORIF). The patient was American Society of Anesthesiology (ASA) 3 with morbid obesity (body mass index [BMI] 37.74). The physician recommended admission to the hospital. She underwent open reduction internal fixation to the lateral malleolus and screw fixation to the syndesmosis. The surgeon also repaired the retinaculum of peroneal tendons.

The requested health service is not medically necessary.

The records show the condition was of low complexity with limited morbidity. There were no active medical conditions. Body mass index (BMI) was taken into consideration. The Milliman Care Guidelines (MCG) ambulatory exception note that it would be applicable for body mass index over 40. The patient's body mass index was 37.74. The surgery was not extensive with duration of less than one hour. The blood loss was less than 20 cubic centimeters (cc). The fixation exposed the lateral aspect of the ankle and reduced the fracture. The surgeon placed screws and plate. Lower screws were passed across the syndesmosis. He repaired the damaged structure he found in wound field. There was no drain. Vital signs were stable. There was no bleeding nor wound problems. The physical therapy records showed recommendation for home physical therapy. Pain was managed with oral medication. There was no need for additional consultations nor imaging. The discharge summary was completed on day number (#) 2. It reported the hospital course as uneventful. There were no extenuating circumstances to provide the service at the acute level. It could have been completed at a lower level of care. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Epigastric Pain.
Treatment:  Inpatient Hospital Stay.

The insurer denied inpatient hospital stay. The determination is upheld.

The patient is a female who presented with epigastric pain. The patient was scheduled to have her gallbladder removed in 2 days. She came in because the pain was too severe. She had a past medical history of hypertension, hypothyroidism, and chronic lymphocytic leukemia (CLL). The patient's vital signs were within normal limits. The patient had right upper quadrant and epigastric tenderness. General Surgery was consulted. The patient was hospitalized and was started on intravenous (IV) antibiotics. Magnetic resonance cholangiopancreatography (MRCP) was ordered. The patient's pain was 6/10 on palpation. The patient continued on antibiotics. The patient was set up for a laparoscopic cholecystectomy that afternoon. The patient underwent an uncomplicated laparoscopic cholecystectomy. The patient was monitored in the hospital overnight and discharged home the next morning. At issue is the medical necessity of an inpatient stay.

The patient's admission was not medically necessary at the inpatient level of care for the entire admission. The patient did not demonstrate signs of a systemic infection associated with cholecystitis; her white blood cell count (WBC) was elevated, but this was due to CLL. The patient also did not demonstrate significant concern for cholangitis. The patient did not show hemodynamic instability. The patient did not present severe or persistent pain that would require high-dose administration and monitoring. The patient did not demonstrate significant vomiting. The patient did not have signs of sepsis or bacteremia. The documentation does not suggest that the patient's care could not have been performed at a lower level of care. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity

Treatment: Wegovy 2.4 milligrams (mg) / 0.75 milliliter (ml) pen

The insurer denied coverage for Wegovy 2.4 milligrams (mg) / 0.75 milliliter (ml) pen

The denial is overturned

 
The patient has been on Wegovy for obesity. She has a history 
of dyslipidemia and hypertension. She has lost more than 5% of her body weight. 
She has been tolerating the maintenance dose. The medical record records a Body Mass Index (BMI) of 31.8. 

UpToDate has an article titled "Obesity in Adults: Drug Therapy." The article states that a number of medications are approved by the Food and Drug Administration (FDA) for the treatment of obesity in conjunction with healthy eating, physical activity, and behavior modification. Candidates for drug therapy include those with a BMI of 30 or over or a BMI over 27 with related comorbidities. Semaglutide is a glucagon-like peptide 1 (GLP-1) agonist that is approved for the treatment of obesity. It has demonstrated efficacy in weight reduction, as well as improvement in glycemia and lipids. It has also demonstrated cardiovascular benefits. 

An article in Journal of the American Medical Association (JAMA) 2021 ;325( 14 ): 1414-1425 is titled "Effect of Continued Weekly Subcutaneous Semaglutide vs Placebo on Weight Loss Maintenance in Adults With Overweight or Obesity." 803 participants in this study were randomized to either continue Semaglutide or to take a placebo.  After 20 weeks of semaglutide treatment, those who continued the treatment with semaglutide had ongoing weight loss, a better lipid profile, improved glucose metabolism, better blood pressure control, and physical functioning scores. The group who took the placebo regained their weight. The article states that the result of this study emphasizes the chronicity of obesity and the need for treatments that can maintain and maximize weight loss. 

This patient has been on Wegovy and has been successful in losing weight. The medical literature supports the continued use of Wegovy to maintain weight loss. Obesity is a chronic problem and likely to relapse if not being treated. The health care plan did not act with sound medical judgment or in the best interest of the patient. Wegovy is medically necessary. 
The denial is reversed.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Wegovy 2.4 milligrams (mg) / 0.75 milliliter (ml) pen is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: obesity
Treatment: sleeve gastrectomy
The insurer denied sleeve gastrectomy
The health plan's determination is upheld. 

This patient is a woman under consideration for bariatric surgery. She is 72 inches tall and weighs 231 lbs (pounds). This corresponds to a body mass index (BMI) of 31.7. She has comorbid health conditions of palpitations, gastroesophageal reflux disease (GERD), and sleep apnea. The patient sought evaluation for bariatric surgical consultation.

 Based on the submitted clinical documentation, the requested sleeve gastrectomy is not medically necessary for this patient at this time.

This patient has a current body mass index (BMI) of 31.7 without confirmed weight related comorbid health conditions. While she has completed a multidisciplinary bariatric evaluation with medical and mental health clearance, the nutritional assessment describes that she does not currently require continuous positive airway pressure (CPAP) for sleep apnea treatment and that she has made no prior weight loss attempts and does not exercise. The nutritional notes also describe a variety of maladaptive eating behaviors.

While the most recent guidelines for bariatric surgical patient selection have broadened, the submitted clinical data for this patient does not support that she satisfies the 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery criteria for the proposed bariatric operation. These most recent published guidelines for bariatric surgical patient selection support that bariatric surgery is proven effective therapy for appropriately selected patients with BMI of at least 35 with or without comorbid illness (as in this case) or a BMI of at least 30 with weight related illness.

The proposed sleeve gastrectomy procedure is a major and irreversible operative intervention with risk for adverse outcomes. The performance of this operation should only be performed for patients who definitively satisfy the ASMBS 2022 Guidelines.