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

Diagnosis: Foot Pain.
Treatment: Custom Shoe Inserts (L3000x2), Pre-service.

The insurer denied the Custom Shoe Inserts (L3000x2), Pre-service.  The denial is overturned. 

The patient is a female with posterior tibial tendon dysfunction and subtalar joint pain.  UCBL (University of California Berkeley Laboratories Shoe Insert) devices were prescribed to control the hind foot.

Yes, the Custom Shoe Inserts (L3000 x 2) are medically necessary.

In growing children, custom molded inserts are often required. Their active growing feet often do not fit prefabricated inserts.  Randomized controlled high level clinical trials (1 ) have shown that these are often superior to prefabricated inserts. The Custom Shoe Inserts (L3000 x 2) are therefore medically necessary.

As stated above, in children, prefabricated inserts are often inferior to custom molded inserts.  In addition, alternatives such as surgical intervention at that age should be avoided (2).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ischemia. 
Treatment: Inpatient admission. 

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

The patient is a male admitted for scheduled catheterization and percutaneous coronary intervention (PCI). There was evidence of ischemia based on a "routine" stress test and positive perfusion study, and risk factors were present. The patient has history of coronary artery bypass grafting (CABG) and stenting as well as co-morbidities. Intervention was performed without complications. The patient was transferred to recovery for observation.  Left femoral access site was stable without hematoma or bleeding. Intravenous (IV) fluids and optimal medical therapy were prescribed. The patient has an uneventful recovery and was discharged. 

No, inpatient level of care was not medically necessary for safe treatment in this patient. 

Appropriateness of level of care is based on the actual care provided and a patient's stability. 

This was an elective, uncomplicated catheterization and percutaneous coronary intervention (PCI) that was scheduled after a positive nuclear test. The patient was always hemodynamically stable with normal vital signs, normal electrocardiogram (EKG), normal left ventricular (LV) function, and no significant ectopy. The only care given after the uncomplicated catheterization was monitoring, intravenous fluids (IVF), and routine medications. This meets the definition of outpatient care without any indication for a higher level. Many institution's protocols include a same day discharge.  Centers for Medicare and Medicaid Services (CMS), and guidelines, specify this as an outpatient procedure for an uncomplicated percutaneous coronary intervention (PCI). 

Best interest of patients is provided with care provided in most appropriate level of care. 

The appeal letter did not provide documentation that higher level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung cancer.
Treatment: Inpatient stay.

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

The patient is a woman with a history of lung cancer status post multiple rounds of chemotherapy and right lung resection who was readmitted for a staph aureus empyema in the setting of persistent bronchopleural fistula. She underwent bronchopleural fistula repair and underwent a re-operation due to adhesions which was complicated by shock leading to intensive care unit admission. She then underwent a redo right thoracotomy and patch repair of the bronchus intermedius with additional pericardial patch and insertion of rectus myocutaneous flap to the posterior mediastinum complicated by persistent air leak.

The inpatient hospital admission was not medically necessary. The patient had a stable wound care plan at this point and no plans for repeat surgical interventions, and no complications such as acute infection or hemodynamic instability or bleeding. The progress notes indicate that the patient was stable, and did not have uncontrolled pain. The care that the patient received during these dates could have safely and effectively been provided at a lower level of care. The patient went to the hospital for a thoracotomy, and the physician wanted to extend the stay, but an extended stay in the hospital is only considered medically necessary if more surgery is needed or there are complications such as bleeding, infection or severe pain.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congenitally missing teeth. 
Treatment: Braces. 

The insurer denied the braces. 
The denial is upheld. 

The patient is a male. The request is for dental benefits for Orthodontic treatment (Braces). 

Per the dental clinical summary, the patient presents with congenitally missing teeth #s 4, 13, 20, 28, 29. 

No, the proposed treatment of orthodontic therapy (Braces) is not medically necessary. 

The patient's adult teeth #s 4, 13, 20, 28, and 29 are congenitally missing, meaning that they never developed in the normal eruption process. The patient still has his baby teeth in these spaces and is not currently showing any visible spaces/gaps between his teeth. 

If the patient should lose any of these baby teeth in the future, then replacement options should be addressed at that time. 

The patient does not currently have any misaligned teeth; therefore, orthodontic treatment (Braces) is not warranted.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cleft lip. 
Treatment:  Braces, Pre-service. 

The insurer denied the  Braces, Pre-service. 
The denial is overturned. 

The patient is a female with history of two cleft lip surgeries.  The request is for orthodontic treatment. 

Yes, the proposed braces are medically necessary. 

The health plans own verbiage states that if a person has had cleft lip surgery, than there is an approval for braces if they are needed. 

This patient has history and documentation of two cleft lip surgeries and multiple requests for orthodontic benefits. This patient has medical necessity for orthodontic treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope. 
Treatment: Inpatient admission. 

The insurer denied inpatient admission. 
The denial is upheld. 

The patient is a male with an extensive past medical history including postural orthostatic tachycardia syndrome, sick sinus syndrome status post dual chamber pacemaker and recurrent syncope.  The patient presented to the hospital with syncope after getting out of bed.  Additional past medical history includes familial hypokalemia and hypomagnesemia (Gitelman's syndrome), deep venous thrombosis (DVT), pulmonary embolism and asthma.  

Upon arrival, physical examination was normal with the exception of sinus tachycardia at 115 beats per minute (bpm).  Electrocardiogram (ECG) revealed no evidence of acute coronary event.  Pacemaker interrogation revealed a short episode of non sustained supraventricular tachycardia that did not correlate with the timing of the patient's loss of consciousness. Ultimately, the patient recieved potassium supplementation and was discharged home the following day. 

No, the proposed inpatient admission was not medically necessary. 

This patient has a long standing history of syncope and postural orthostatic tachycardia syndrome.  Evaluation revealed no abnormal physical examination findings and pacemaker interrogation revealed no malignant arrhythmia. 

This patient presented with postural orthostatic syncope, a benign process.  According to the European Society of Cardiology, this patient was a low risk patient for future morbidity and mortality. (Reference 1) In a study of individuals presenting to the emergency room, patients that were low risk or intermediate risk for cardiac events had an excellent progonosis and did not require admission to the hospital for further testing. (Reference 2).  In this case, the patient  falls into a low risk category and could be managed a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal and pelvic pain. 
Treatment: Inpatient admission. 

The insurer is denied coverage for inpatient admission. 

The denial is upheld. 

This female patient has a history of asthma and hyperthyroidism.  She presented to the Emergency Room (ER) with complaints of a 3 day history of 8 out of 10 lower abdominal pain and pelvic pain.  She recently had a positive home pregnancy test.  The patient reported having pelvic pain attacks 2-3 times a year. Pain was partially relieved by opioid analgesics given in the ER.  In the ER vital signs were stable and beta human chorionic gonadotropin (HCG) level was elevated.  A renal ultrasound (US) and magnetic resonance imaging (MRI) of the appendix was within normal limits (WNL).  No ectopic pregnancy was visualized.  The patient was evaluated by Gynecology and General Surgery.  The patient was kept on nothing by mouth (NPO) status. She was admitted with significant pain. Beta HCG levels increased appropriately indicating that there was a normal intrauterine pregnancy (IUP).  Endocrinology recommended stopping methimazole, checking thyroid stimulating immunoglobulin (TSI), and obtaining a thyroid US. The patient requested having the thyroid workup on an outpatient basis.  The thyroid US was WNL.  The patient was advised to follow up with endocrinology on an outpatient basis.  Pain Management was consulted for pelvic pain.  They recommended taking Tylenol and an outpatient referral to pain management. The patient was advised against the use of non-steroidal anti-inflammatory agents (NSAID) and opioids.  She was told to quit smoking.  The patient was discharged with instructions to follow up with her physicians on an outpatient basis.  

Pelvic and abdominal magnetic resonance imaging (MRI) were normal.  Pelvic ultrasound did not show any anomaly. She was evaluated by Surgery and Gynecology and both refused to admit the patient as there was no obvious pathology. She was admitted to Medicine for pain control. A repeat HCG showed adequate rise. She was discharged with the diagnosis of chronic pelvic pain. Pain during pregnancy is common, and its management is complex. Certain analgesics may increase the risk for adverse fetal and pregnancy outcomes, while poorly managed pain can result in adverse maternal outcomes. The first step is to rule out an ectopic pregnancy: The patient was stable, there was no evidence of bleeding, no evidence of blood loss. Admission of a stable patient to rule out an ectopic pregnancy is not medically necessary as those patients are usually followed with serial HCG as outpatients. Acute appendicitis is the most common general surgical problem encountered during pregnancy. However appendicitis was ruled out by a normal MRI, no abdominal pain that migrates to the right lower quadrant, no right lower quadrant tenderness, no nausea/vomiting, no fever, and no leukocytosis with left shift. 

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

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

Diagnosis: subarachnoid hemorrhage

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned. 

This male patient has a history of alcohol abuse, depression, and hypertension who presented to the hospital as a transfer from another facility for subarachnoid hemorrhage (SAH). The patient reported that he may have hit his head when he put his head down on the bus the day prior to presentation. The patient also reported that he drinks daily. He endorsed a slight headache as well as lightheadedness. Computed Tomography Angiography (CTA) of the head was performed and was without evidence of aneurysm or other etiology to explain SAH. Laboratory testing revealed a platelet count of 76. One unit of platelets was ordered. Trauma and Emergency Surgery, and Neurosurgery were consulted. The patient was admitted to Inpatient, Medical Surgical level of care for SAH. During the hospital course, the patient's serial neuro checks were unremarkable. The patient was discharged home with Primary Care Provider and Traumatic Brain Injury (TBI) clinic follow-up.

According to current literature the requested hospital stay is warranted as a lower level of care is not the most appropriate in this scenario. This patient had imaging evidence of an intracranial bleed and needed close monitoring in the event of neurological decline. A lower level of care in this case would not have been safe and appropriate. The patient was discharged when stable and therefore, the requested inpatient admission was medically necessary.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Mellitus
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.


The patient has a past medical history (PMH) of gastroesophageal reflux disease (GERD) and asthma and was admitted with complaints of (c/o) polyuria, polydipsia, and polyphagia. The patient's outpatient blood work showed a blood glucose of 427 with an anion gap of 21 and he was sent to the emergency department (ED). Vital signs were unremarkable. The physical exam was unremarkable. Lab work was notable for carbon dioxide (CO2) of 12, creatinine 1.48, glucose of 427, potential of hydrogen (pH) of 7.352, beta-hydroxybutyrate (BHB) of 5.81. A chest x-ray (CXR) showed no active disease. The patient was diagnosed with new onset diabetes mellitus (DM) with diabetic ketoacidosis (DKA) and treated with intravenous (IV) fluids, an insulin drip, and intensive care unit (ICU) monitoring. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was medically necessary at an acute inpatient level of care.
This patient with no known history of diabetes presented to the ED with c/o polyuria, polydipsia, and polyphagia. He was found to have a significantly decreased bicarbonate of 12 associated with an elevated anion gap, elevated BHB level of 5.81 and hyperglycemia of 427. A serum Beta-Hydroxybutyrate (OHB) level above 3.0 millimoles per liter (mmol/L) can be used as the diagnostic threshold of DKA. OHB can serve as an index for assessing the severity of DKA. Due to the elevated anion gap and decreased bicarbonate, the patient was admitted and started on an insulin drip and IV fluids, requiring close monitoring. After initiating therapy, the patient improved enough to be safely discharged home and transitioned back to subcutaneous insulin. Overall, this patient could not have been safely treated at a lower level of care, given the severity and new-onset DKA complicated by acute kidney injury.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Supraventricular tachycardia 
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has hypertension, hyperlipidemia, type 2 diabetes and obesity and presented to the emergency room (ER) with right sided abdominal pain for 5 days. His blood pressure was 182/82 millimeters of mercury (mmHg) and pulse 97 beats per minute (bpm). His respiratory rate was 18 breaths/minute and he was afebrile. Laboratory studies and a non-contrast computed tomography (CT) scan of the abdomen were unremarkable. He was to be discharged when he suddenly felt dizzy and was noted to be in supraventricular tachycardia (SVT) with a heart rate of 160 bpm. He was given intravenous adenosine and his rhythm reverted back to sinus at 108 bpm.
He was admitted and seen by cardiology in consultation. It was felt that he likely had atrioventricular (AV) nodal reentry. A Holter monitor, stress test and echocardiogram (ECHO) were recommended as an outpatient. He was started on beta-blockers- metoprolol 50 milligrams (mg) twice daily. He was discharged. At issue is the medical necessity of an inpatient stay.
An inpatient admission was not medically necessary.
The patient could have been treated at a lower level of care for his SVT. He did not require inpatient admission for his abdominal symptoms, given the ER workup, including lab studies and CT findings. This patient had supraventricular tachycardia ( SVT) in the ER.
Based on Milliman Guidelines, criteria for admission for patients with SVT include:
. Hemodynamic instability,
. Persistent symptomatic Tachycardia (eg, chest pain, dizziness) despite observation care,
. Myocardial ischemia that persists despite observation care (eg, rate control), 
. Altered mental status that is severe or persistent, 
 Syncope, 
. Heart failure that persists despite observation care, 
. Medication toxicity causing arrhythmia,
. Underlying medical condition that necessitates inpatient care (eg, thyrotoxicosis),
. Initiation or adjustment of antiarrhythmic medication that requires cardiac monitoring, or
. Urgent electrical cardioversion that cannot be performed on outpatient basis or during observation care. [None of these conditions apply in this case.]
. Repeat cardioversion necessary (ie, reversion to supraventricular tachycardia after cardioversion performed in emergency department or observation care)
. Need for immediate inpatient anticoagulation (eg, IV heparin)
 
Standard of care, based on current American College of Cardiology (ACC) / American Heart Association (AHA) guidelines and literature, is to treat an acute episode of SVT with AV node blocking medication or vagal maneuvers. Following this, treatment can be accomplished on an outpatient basis, with either chronic medical therapy or catheter ablation.
Inpatient treatment following acute termination of an SVT episode is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Cardiac/Circulatory Problems/Congestive Heart Failure/CHF
Treatment: Home Health Care
The health plan denied the requested increase in personal care assistant hours as not medically necessary. 
The health plan's determination is overturned.

This is the case of the chronic care of a male who lives alone with congestive heart failure (CHF), emphysema, is oxygen dependent and steroid dependent, has edema, dyspnea, hypertension, urine incontinence, imbalance, walker/wheelchair dependent, with multiple needs including bathing, meal preparation and toileting. He presently has personal care assistance (PCA) for 12 hours per day. The request for 24-hour care has been denied by the insurance plan. The family is seeking 24-hour care.
At issue is the medical necessity of the requested increase in personal care assistant hours.

The health plan's determination of medical necessity is overturned, in whole.

It is this reviewers' opinion that the patient needs full time help to treat his multiple co-morbidities as listed, and his complex polypharmacy including chronic nasal oxygen and immunosuppressive doses of steroids, which cause progressive muscle weakness. His gait is unsteady, and his balance is poor. He needs total assistance for toileting and transferring. He fell and could not get up. He needs continuous PCA services to maintain his health and safety in his home. The standard of care requires 24-hour care as a reasonable treatment in the best interest of the patient. The requested 24 hour per day, split shift PCA service is medically necessary.
After review of the Uniform Assessment System-New York (UAS) that was performed, the patient requires maximum assistance needed for toilet, locomotion and extensive assistance for bed mobility. He is incontinent and his self-sufficiency has declined. Expect further deterioration.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic short stature (ISS) and pituitary hypoplasia. 

Treatment: Norditropin FlexPro.

The insurer denied coverage for Norditropin FlexPro.

The denial is upheld. 

This patient is a male child diagnosed with idiopathic short stature (ISS) and pituitary hypoplasia. This request is for Norditropin. The patient has central precocious puberty (CPP). His magnetic resonance imaging (MRI) of the brain showed a small hypoplastic pituitary gland consistent with anterior pituitary hypoplasia. His growth hormone (GH) stimulation test with arginine and clonidine peaked at 12. His height velocity is reported to be 8.1 centimeters (cm)/year. His insulin-like growth factor 1 (IGF-1) was 368. His mid-parental height is 172.72 cm [-0.58 standard deviations (SD)].

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient as the request is not medically necessary as described below. The peer reviewed literature including consensus clinical guidelines and randomized controlled trials are summarized below:

Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society, the Lawson Wilkins Pediatric Endocrinology Society, and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 SD below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 year more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 year in children above a certain age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 year or more than 1.5 SD sustained over 2 years. The biochemical criteria include low IGF1 or insulin-like growth factor binding protein 3 (IGFBP3) or GH stimulation testing with a peak GH less than 10 nanograms per milliliter (ng/ml).

The patient did not meet biochemical criteria. GH stimulation testing peaked at greater than 10. The patient has a normal height and a normal height velocity and a normal IGF-1. The patient does not meet accepted criteria for the diagnosis of GH deficiency. This diagnosis cannot be made based on the pituitary MRI.

Growth hormone in the treatment of ISS is supported by randomized controlled trials and consensus guidelines. The patient does not have a pretreatment height less than or equal to -2.25 SD. The patient therefore does not meet ISS criteria. The patient has normal stature, and a normal height velocity.

The request does not meet any nationally accepted criteria for use of growth hormone. 

The insurer's denial of coverage for Norditropin FlexPro is upheld. The medical necessity is not substantiated.