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

Diagnosis: Abscess
Treatment: D2751 White Glass With Metal Crown, Tooth 26
D3310 Nerve Treatment on Front Tooth, Tooth 26
The insurer denied the D2751 White Glass With Metal Crown, Tooth 26
D3310 Nerve Treatment on Front Tooth, Tooth 26
The denial is overturned, in part.

The patient is a female. The patient has an abscess at root apex of tooth #(number) 26. The tooth needs a root canal procedure. Denial was because the tooth was stated to have less than 50% (percent) bone support. The request is for root canal procedure and crown for tooth #26.

Yes, in part. The requested health service is medically necessary, in part.

Specifically, the requested root canal procedure is medically necessary, however, the requested crown for tooth after root canal is not medically necessary.

Tooth #26 has a periapical abscess at the end of the root from a dead/infected nerve. The root canal procedure is the only way to treat this problem, and it is medically necessary. The tooth has 75% bone support left, not the < (less than) 50% bone support as previously stated. There is definitely more bone holding this tooth in place than has been reported, and there is no need to remove this tooth once the root canal procedure has been performed.

The crown, however is not needed. This tooth has no decay or fractures, and the small access hole that will be created to do the root canal procedure can easily be filled with a small filling. The requested crown is not medically necessary.

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

Diagnosis: Adolescent idiopathic scoliosis
Treatment: Surgery (surgical procedure on the spine)
The insurer denied the Surgery (surgical procedure on the spine).
The denial is upheld.

The patient is a female. The patient has a diagnosis of adolescent idiopathic scoliosis. The patient presented  with complaints of worsening back pain and worsening deformity. The physical exam shows significant kyphosis of the thoracic spine and unable to straighten it out with postural adjustment. There is mild paraspinal tenderness with negative straight leg raise and normal strength and sensation. The patient was prescribed a brace. The patient has a diagnosis of Scheuermann's kyphosis of 72 degrees.

The patient had previous treatment with physical therapy. MRI (magnetic resonance imaging) of the thoracic spine showed some Schmorl's node and protrusions of the thoracic spine with mild anterior wedging of the vertebral bodies of T8 (eighth thoracic spine vertebra), T9 (ninth thoracic spine vertebra) and T10 (tenth thoracic spine vertebra). There was a normal spinal canal and normal spinal cord. Request is made for thoracolumbar fusion surgery.

No, the requested surgery is not medically necessary.
The guidelines indicate that treatment with surgery would be indicated if the patient has a curve greater than 75 degrees of kyphosis or greater than 60 degrees and has significant pain that has failed conservative measures. In this case, the patient has a curve greater than 60 degrees with pain, but there has not been a complete trial of conservative care. A trial of bracing would be appropriate prior to consideration for surgical intervention for this condition.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The indications for treatment for Scheuermann's kyphosis have been followed and are appropriate based upon the clinical information provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Postoperative Pain and Nausea.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with a history of dysmenorrhea, polycycstic ovarian syndrome (PCOS), premenstrual dysphoric disorder (PMDD), bipolar, migraines, and asthma.  She underwent robotic laparoscopic resection of endometriosis, ovarian wedge resection, appendectomy, dilatation and curettage, and hysteroscopy.  Postoperatively, the patient had some confusion.  She had stable vital signs.  She had some pain.  She was admitted for pain control.  She was kept with intravenous fluids, tylenol, intravenous toradol, oral gabapentin, and senna.  The Foley catheter was removed and she was voiding without issue.  She was tolerating ice chips and sips of fluids. The next day, the patient was voiding, ambulating, pain was controlled, and she was discharged home.

No, the Inpatient Hospital Admission was not medically necessary.
In review of the medical record, the patient was admitted post operatively after undergoing ambulatory surgery.  She was hemodynamically stable.  She did not have any comorbidities placing her at high risk for postoperative complications.  The procedure was also not complicated.  The post operative vitals, notes reveal stable vital signs, no vomiting, some pain controlled with medication, voiding, but no flatus. 

Discharge criteria following surgery vary depending on the surgical procedure performed.  In general the following are the standard recommendations that the patient must be meeting prior to discharge.
1)  adequate pain control
2)  stable vital signs
3)  return of bladder and bowel function
4)  adequate oral intake.

There is no indication that the patient required an inpatient hospital stay.  Although the patient did not have return of bowel function, she was meeting all the other criteria for discharge.  Therefore, the same care could have been provided at a lower level of care with the same outcome.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The inpatient stay does not meet medical necessity.  Therefore, the denial was made in sound judgement and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath and Cough
Treatment: Inpatient admission

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

The patient male with history of asthma. He presented to emergency room with wheezing and shortness of breath. The patient had been treated and discharged from ER (emergency room) the day prior with similar symptoms.

The patient was noted to have asthma exacerbation. The patient received nebulizations and IV (intravenous) steroids. The patient was admitted to acute in hospital level of care. The patient was subsequently discharged the following day.

No, the Inpatient admission was not medically necessary.
The patient had mild asthma exacerbation that improved with emergency room care. The patient was not in any distress. The patient was able to speak in full sentences. The patient was tolerating oral diet. The patient did not require invasive drips.

Therefore, given the above, inpatient admission was not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Varicose Veins
Treatment: Sclerotherapy Echosclerotherapy (36466, 36465, 36471)
The insurer denied the Sclerotherapy Echosclerotherapy (36466, 36465, 36471)
The denial is upheld

This male patient presents with bilateral varicose veins. The provider has recommended bilateral sclerotherapy with ultrasound guidance. The patient has undergone multiple, bilateral axial ablation procedures in the past. 

The proposed Sclerotherapy Echosclerotherapy (36466, 36465, 36471) is not medically necessary.
The medical necessity of the proposed procedure (CPT 36471, sclerotherapy; CPT 76942, ultrasound guidance) is being evaluated. 

To answer, published, widely accepted standards [1-3], were considered under which sclerotherapy is appropriate when:
a- There has been a sufficient interval after axial ablation or stripping (applicable only for patients with axial reflux).
b- The patient has symptoms of venous insufficiency severe enough to interfere with normal function.
c- The patient's varicose veins are large enough to account for the symptoms.
d- The patient has failed a trial of medical grade compression stockings.

Requirement (a) has been satisfied. The patient underwent successful axial ablation in the past, more than six weeks ago.

Requirement (b) has not been met. The office note states that the patient has leg pain and an uncomfortable feeling, but the character of the symptoms is not described. The note states that the pain does not affect the patient's walking or sleep. The history is not sufficient to determine whether the symptoms are likely due to venous disease or whether they interfere with daily activity.

Requirement (c) has not been met. The patient's vein sizes have not been documented by physical examination or by ultrasound. The pattern of veins on the drawing suggest that the patient's veins are small and unlikely to cause significant symptoms.

Requirement (d) has been met, because the office note states that the patient has used 30-40 compression stockings for six months or more.

Therefore, the patient does not met published, well accepted criteria for performance of sclerotherapy. 

The appeal letter and the letter of medical necessity were reviewed. The first document contains inaccurate statements suggesting that the proposed treatment is necessary to reduce the patient's risk of venous ulceration. There are no published data to suggest that sclerotherapy will reduce risk of venous ulceration in a patient with no prior history of ulcers. Both documents refer to multiple leg symptoms, but these symptoms are not documented in primary source medical records. Moreover, the varicose veins depicted in the drawing are not likely to lead to the symptoms described by the provider.

The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: intractable back pain
Treatment: inpatient stay

The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

This case involves a man with hypertension and hyperlipidemia who presented to the hospital with complaints of low back pain. The symptoms started after the patient was lifting a heavy box. He experienced a new onset of severe low back pain, which he attempted to control at home by taking Advil. The symptoms were unrelieved. The pain was located on the left side of the lower back with radiation to the anterior left thigh. The pain is sharp, 6/10, worsening with movement, and minimally improved with rest and nonsteroidal anti-inflammatory medications. The patient's diagnosis is lumbar radiculopathy pain. 

The inpatient hospital admission was medically necessary. The patient had severe pain, requiring acute inpatient management. The documentation clearly states the medical team had to employ the services of a pain specialist as the patient's pain remained uncontrolled. The patient was still reporting 6 out of 10 pain, requiring frequent doses of oral opiate medications, as well as breakthrough doses of IV Dilaudid. A multimodal treatment regimen of pain medications was initiated to control the patient's symptoms. The duration of these adjustments exceeded the generally accepted observation care timeframe of 24 to 48 hours. Therefore, inpatient criteria are met.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ears/Nose/Throat. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is overturned.

The patient is a male who presented with a history of diabetes mellitus and left submandibular space abscess. White blood cell (WBC) count was elevated to 20.8. Previous treatment with oral antibiotics (Amoxicillin). Medical necessity required the patient to be transferred to another hospital for a higher level of care. The patient was transferred and was admitted as an inpatient and underwent extraction of a decayed tooth #18 with an incision and drainage and Penrose placement. Treatment of the infection included both intravenous (IV) Unasyn and Clindamycin. Wound culture reported no growth, but the gram stain showed gram negative bacilli.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

The inpatient stay was medically necessary. The patient had a significant odontogenic infection that caused an anterior/lateral neck mass. The pathology did cause pain with swallowing and dysphagia - sometimes spitting up secretions because he could not tolerate. In addition, the patient had already failed a course of oral antibiotics (Augmentin for 1 week) and required transfer to another hospital for a high level of care. The infection was not a cutaneous infection but a deep neck location - submandibular space. Submandibular space infections have a significant potential to create either an airway compromise or extend to one of the other potential spaces in the neck.
The patient's high-risk co-morbidity (diabetes mellitus), failure of previous oral antibiotics, location of deep neck space infection, and potential of the infection to extend to potential spaces in the neck make the inpatient admission medically necessary. Therefore, an inpatient admission for airway monitoring, post operative care following incision (I) and drainage (D), pain control, IV fluids, and IV antibiotics was medically indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uterine Fibroids.
Treatment: Inpatient Stay.
The insurer denied the inpatient stay.
The health plan's determination is overturned. 

The patient is a female who underwent an open abdominal supracervical hysterectomy. The procedure was done for multiple symptomatic fibroids and was reported to have been performed without complication. The patient was admitted to the hospital.

The inpatient hospital admission was medically necessary.
The reason for an open procedure is related to surgeon preference, as well as the size of the uterus. Recent restrictions on power morcellation have made laparoscopic supracervical hysterectomy, as well as some hysterectomies involving large fibroids, all but impossible. Open procedures are the only remaining option in these cases. In addition to pain issues in these open cases, nausea is also common. Nausea poses a significant threat to the ability to take medication, as well as need for hydration. Open procedures carry higher risks of wound complications, thrombotic events, postoperative bleeds, and cardiopulmonary events. All of these complications demand diligence, usually with q (every) 4-hour vital signs for 24-48 hours afterward. This observation of the patient cannot be conducted at home. Even simple facets of daily life like standing up straight can require a nurse to assist. Therefore, the inpatient care is the appropriate level recommended.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 

The insurer denied an inpatient stay. 
The denial is upheld.

This male presented to the emergency department (ED) complaining of several days of worsening dyspnea and orthopnea. His medical history was remarkable for nonischemic cardiomyopathy with a left ventricular ejection fraction of 10-20%, congestive heart failure, hypertension, hyperlipidemia, and chronic kidney disease. In the ED he reported having run out of his prescribed medications the week prior. His blood pressure was 168/111 millimeters of mercury (mmHg) with a heart rate of 91 beats/minute. His respiratory rate was 18/minute with a room air oxygen saturation of 99%. His physical exam was remarkable for pulmonary rhonchi. Chest x-ray showed a small right pleural effusion with basilar opacities. The patient's serum troponin I level was minimally elevated at .044 nanograms per milliliter (ng/ml). His N-terminal pro brain natriuretic peptide (BNP) level was 6640 picograms per milliliter (pg/ml). His serum creatinine level was 1.71 milligrams per deciliter (mg/dl). He was treated with intravenous furosemide and hydralazine and admitted to the hospital for management of decompensated heart failure. Daily intravenous furosemide along with his usual home medications were prescribed. The patient eloped from the hospital. Medical necessity for the inpatient stay is at issue.

The health plan's determination is upheld.

Based on the documentation provided an inpatient hospital stay was not medically necessary. This patient presented with dyspnea due to decompensated heart failure. He was hemodynamically stable. He did not have high risk features such as systolic blood pressure less than (<) 100 mmHg; cardiac Troponin I level greater than (>)0.3 ng/mL; serum creatinine level >3 mg/dL; or significant hyponatremia (< 135 milliequivalent per liter [mEq/L]). The records provided do not indicate that there were any acute electrocardiographic changes. Based on his Emergency Heart Failure Mortality Risk Grade score, his 7-day mortality risk was low. In stable heart failure patients, such as this patient, without high-risk features, studies have shown that lower-level care is safe and effective, with similar outcomes, including readmission, repeat emergency department visits and 30-day mortality, when compared to those treated as inpatients. Thus, in this instance, a lower level of care would have been sufficient; an inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain
Treatment; inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female with a medical history of Crohn's disease.  She presented to the emergency department with two days of abdominal pain, diarrhea (with bleeding), nausea, fever, and chills.  She was on Humira and mesalamine for Crohn's disease. Vital signs were notable for rapid heart rate of 103/minute.  Physical examination was notable for guarding, right lower quadrant tenderness, and costovertebral angle tenderness (right greater than left).  Labs showed elevated white blood cell count of 16.1 with 82% neutrophils, and an unremarkable comprehensive metabolic panel. A computed tomography (CT) scan of the abdomen and pelvis showed evidence of cecectomy and distal small bowel resection, new 2 centimeter inflammatory stricture of the small bowel in the region of the anastomosis with markedly dilated loops of upstream small bowel, localized fluid adjacent to the region of inflammation, and nonspecific fluid-filled distention of the remaining right colon and transverse colon. 

The inpatient level of care is not medically necessary. The patient presented with symptoms (abdominal pain, diarrhea, nausea, fever, chills) and imaging suggestive of Crohn's disease flare. However, there was no complication such as intra-abdominal abscess, bowel perforation, toxic megacolon, peritonitis, fistula, or sepsis, which would require the inpatient level of care. Her symptoms quickly improved with conservative management, analgesics, and antiemetics, and her diet was gradually advanced. The interventions performed, including labs, monitoring, imaging, and medical therapy could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hearing Loss
Treatment: Hyperbaric Oxygen Treatment (G0277)

The insurer denied the Hyperbaric Oxygen Treatment (G0277).
The denial is overturned.

The patient is a female with a history of bilateral SNHL (sensorineural hearing loss), worse on the left, which has been fluctuating. Menieres disease was diagnosed. She was treated with HBOT (hyperbaric oxygen therapy) after oral and intratympanic steroids had not been successful. Addition of the HBOT (hyperbaric oxygen therapy) significantly improved the patient's hearing. The HBOT (hyperbaric oxygen therapy) treatment was denied previously and the provider is appealing the denial.

Yes, the requested health service is medically necessary.
All records were reviewed. The patient had a history of sudden SNHL (sensorineural hearing loss) documented on audiogram. It is reported that the patient's hearing did not respond to oral and intratympanic steroids. HBOT (hyperbaric oxygen therapy) was used and the patient's hearing improved significantly, with word recognition improving from 5 to 100%.

There is support in the scientific literature for the efficacy of HBOT (hyperbaric oxygen therapy), up to 20 sessions per event, in treating patients with sudden SNHL (sensorineural hearing loss) who have not responded to oral and or intratympanic steroids. This treatment is also supported by the 2 major specialty societies whose members treat the majority of patients with this condition, the AAO HNS (American Academy of Otolaryngology-Head and Neck Surgery) and Undersea and Hyperbaric Medical Society. Therefore, based on the above, the medical necessity of the HBOT (hyperbaric oxygen therapy) in question would be confirmed.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
As the HBOT (hyperbaric oxygen therapy) was not approved by the health plan as medically necessary, it cannot be confirmed that the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Congestion
Treatment: Hospital admission

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

The patient has a history of (H/O) congestive heart failure (CHF) - ejection fraction (EF) 20-25 % (percent), hypertension (HTN), hyperlipidemia (HLD). H/O polysubstance abuse. The patient presented to the hospital with complaint of (C/O) Nausea and Vomiting. The patient had used Cocaine the previous night. The patient has H/O crack/Cocaine/Marijuana use the patient also had some cough and shortness of breath (SOB). Denied Fever. No chest pain (CP).  Vital signs (V/S) at presentation: Temperature 98.3, Respiratory Rate 19, Heart Rate 100, Blood Pressure 132/98 mm Hg (millimeters of mercury), and oxygen (O2) saturations 95% on Room Air. The patient was in no acute distress (NAD), Lungs were clear and cardiovascular system (CVS) was normal.  Creatine phosphokinase (CPK) 214, B-type natriuretic peptide (BNP) 3173 (close to baseline) Chest x-rays revealed (CXR) Pulmonary congestion.

The patient was admitted to Telemetry to rule out (R/O) ACS (acute coronary syndrome).
The patient was treated with intravenous (IV) lasix, and serial cardiac enzymes were done. O2 saturations were 92-94% on room air so placed on 2 liters nasal cannula.  
The patient refused high flow nasal cannula (HFNC) or bilevel positive airway pressure (BIPAP). 

The patient responded to treatment in emergency department (ED). A few hours later, the patient was in no acute distress (NAD) and improving; Temperature 98.3, Heart Rate 78, Respiratory Rate (RR) 22, Blood Pressure (BP) 110/78. Lungs were clear and cardiovascular symptoms were normal. There was no edema. Troponin X (times) 3 were negative. Myocardial infarction (MI) was ruled out and BNP was at baseline.
Deep vein thrombosis (DVT) study was Negative.

The patient remained stable after admission. He was treated with diuretics and other maintenance medications. The patient signed out against medical advice (AMA).  This patient did not need acute inpatient hospitalization. He could have been placed in Observation status while diagnostic testing and treatment were initiated.  Observation could be for up to 48 hours. The patient could have had MI ruled out and diuresis done while in observation. He was close to his baseline.

This patient did not need further acute inpatient hospital stay. He could have been discharged home on oral (PO) diuretics and other maintenance medications with close follow up (FU) in outpatient setting once MI was R/O and initial diuresis done. The patient was afebrile and hemodynamically (HD) stable. Lungs were clear.  No edema of LE (lower extremities) noted. The patient was able to tolerate PO.

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

The insurer's denial of coverage for the hospital admission is upheld. Medical Necessity is not substantiated.