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

Diagnosis: Shortness of breath
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult male. His past medical history is pertinent for known CAD (coronary artery disease) with prior STEMI (ST-elevation myocardial infarction), multi-vessel CAD (coronary artery disease), PCI (percutaneous coronary intervention) to the LAD (left anterior descending) 8 months ago, and COPD (chronic obstructive pulmonary disease). He complained of continuing shortness of breath. He had new regional wall motion abnormalities on his imaging, prompting another invasive strategy. The patient had an uncomplicated cardiac catheterization, showing continued medical therapy was appropriate and that no additional coronary interventions were needed. The requested coverage for Inpatient Hospital Admission was denied by the health plan as not medically necessary. The denial is being appealed.

The inpatient admission was not medically necessary.

Based on the peer-reviewed medical literature, there was not a medical need for the requested acute inpatient hospital stay. The severity of this patient's illness did not meet the intensity of 
service for inpatient hospital stay. In this particular case, the patient underwent planned LHC (left heart catheterization). The information provided does not support the medical necessity for 
admission after his successful procedures. LHC (left heart catheterization) is routinely performed in the ambulatory setting with overnight observation. There is no documentation of unstable medical conditions like ACS (acute coronary syndrome)/AMI (acute myocardial infarction), CVA (cerebrovascular accident), contrast nephropathy, acutely decompensated CHF (congestive heart failure), life-threatening cardiac arrhythmia, procedural complications like acute coronary perforation or vascular access complication requiring surgery, or other medical instability or acute care needs that would require acute inpatient management. The information provided does not support the medical necessity for admission, since this was a successful and uncomplicated LHC (left heart catheterization). The care he received like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Insertion of Braces and Adjustments of Braces
The insurer denied: Insertion of Braces and Adjustments of Braces
The denial is overturned.

The patient is a teenage female. The request is for orthodontic benefits. She has a Class 1 malocclusion with mild upper and lower jaw crowding. The health plan's prior denial of coverage was due to handicapping index score of 10. The denial is being appealed.

The Insertion of Braces and Adjustments of Braces are medically necessary.

The patient has a deep, impinging overbite with soft tissue damage to the palate. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem. The requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting. 
Treatment: Inpatient Hospital Stay. 
The insurer denied Inpatient Hospital Stay. 
The determination is upheld. 

The patient is a female with a past medical history of anxiety and depression remarkable who presented for vomiting for 3 days. The review of systems was negative for additional clinical symptoms. She was described as having a normal appearance. An electrocardiogram (EKG) showed normal sinus rhythm with a left anterior fascicular block. A computed tomography (CT) scan of the head was negative for intracranial etiology. A chest x-ray revealed no evidence of pneumonia or effusion. 
The patient was admitted for vomiting related to cannabinoid use versus gastritis. The patient was also noted to have chest pain. The patient was treated with an antacid, intravenous (IV) fluids and potassium chloride. It was thought that the patient's symptoms were related to cannabinoid hyperemesis. The patient was also treated for hypokalemia which improved. The patient eloped. 
An inpatient stay is under review for medical necessity. 
The requested health service/treatment of inpatient hospital admission was not medically necessary. The care could have been safely rendered at a lower level of care for IV hydration and supportive care. 
 
The patient was admitted for nausea, vomiting and epigastric pain related to cannabinoid hyperemesis. Supportive care was warranted including anti-emetics and IV fluids. Thereafter, there was no indication for transition of the patient to inpatient admission since there is documentation to support the following: 1) patient was tolerating liquids and had the diet advanced as tolerate, and 2) patient did not have any active or worsening of her symptoms to justify inpatient treatment. Based on the guidelines, the patient did not have any clinical indications for admission to inpatient care. There were no peritoneal signs, no hemodynamic instability, and no pathology was identified to require inpatient care. 
The management of cannabinoid hyperemesis is largely supportive. This includes lifestyle modification, antiemetics, hydration and cessation of the offending agent. In this case, the patient's vomiting was related to cannabis use. As such, a lower level of care would have been most appropriate for IV hydration, IV antiemetics and potassium administration. Aside from moderate hypokalemia, the patient did not have significant electrolyte derangements and showed clinical improvement in her oral intake.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I Occlusion. 
Treatment: braces. 
The insurer denied braces. 
The health plan's determination is overturned. 

The patient in question is a male with a Class I, crowded occlusion and a deep bite where the mandibular incisors are occluding on his palate. He is treatment planned for 24-30 months of orthodontics (braces) to correct his malocclusion. 

Braces are medically necessary for this patient. A deep bite on its own is not a reason to treat with orthodontics. However, at the patient's age, he is already at significant risk of damaging the soft tissue of his palate, and teeth 7 and 8 are already compromised by having undergone root canal therapy. This deep bite will worsen with time if left untreated and can lead to periodontal problems in the future that will be more invasive and expensive to correct than the orthodontic problem he currently has.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: pneumonia
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

The patient is a male with an unremarkable past medical history who presented to the hospital with complaints of chest pain and shortness of breath. He described his chest pain as left-sided and noted that it was exacerbated by taking a deep breath. The patient was admitted to the hospital with a diagnosis of multifocal pneumonia and sepsis. Intravenous antibiotics were initiated, and cultures were sent for further evaluation. Additionally, a gold quantiferon test was administered to assess for tuberculosis.

The inpatient hospital admission was medically necessary. The patient presented to the hospital with signs of pneumonia and sepsis and required admission for the administration of intravenous antibiotics.
In order to decide if this patient possibly had sepsis, the systemic inflammatory response syndrome (SIRS) Criteria was applied. This is a risk stratification tool that defines the severity of sepsis and septic shock. Based on the calculations, the patient met sepsis criteria.
Specifically, the patient met the following criteria:
.	Heart rate > 90 beats per minute (bpm)
.	White blood cell count (WBC) > 12,000
In addition, there was clear evidence of infection based on the patient's symptoms and the computed tomography (CT) scan of the chest results.
Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. Sepsis represents a spectrum of diseases with mortality risk ranging from moderate to substantial (e.g. > 40%) depending on the various pathogens and host factors along with the timeliness of recognition and provision of appropriate treatment.
In general, the treatment of sepsis includes perfusion restoration with intravenous (IV) fluids and sometimes vasopressors, oxygen support, broad-spectrum antibiotics, source control, and sometimes other supportive measures. In order to provide treatment this patient with sepsis in the most efficient way in a timely manner, the inpatient hospital admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient was referred by their Primary Care Physician (PCP) for a hemoglobin of 5.2.  The patient reported headaches, dizziness, fatigue, shortness of breath on exertion and occasional palpitations. The patient also reported heavy periods lasting 8 days.  The patient denies chest pain, syncope. On admission there was no active bleeding.  The patient was transfused with 2 units packed red blood cells (PRBCs) and also received Ferrlecit 125 milligrams (mg) x 1 dose. 
The insurer has denied coverage for a hospital admission. In their Final Adverse Determination letter, they write that the patient went to the hospital for their low red blood cell count (anemia). The plan considers a full hospital admission for anemia medically necessary when there is active bleeding or another serious problem such as low blood pressure. The information they have does not show that the patient was having these or other severe problems. 

This patient has symptomatic anemia. The patient fulfills the transfusion guidelines for use of blood components as their hemoglobin was less than 8. Transfusion was necessary. 
It is obvious that in this day and age, transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home). The need for transfusion is not a reason for admission. The patient could have been transfused as an outpatient. Note that the patient was not actively bleeding. 
Milliman Care Guidelines (MCG) lists the clinical indication for inpatient care for patients with anemia. These include: active massive hemorrhage, active hemolysis, cognitive impairment, heart failure, chest pain, syncope. 
This patient was stable and did not have any of the above. 
Based on all of the above, the admission was not medically necessary. The patient could have been transfused with the 2 units PRBCs and discharged home ensuring that the patient was stable. 
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 inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath and chest pain
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

The patient is an adult male with a history of human immunodeficiency virus (HIV), asthma, pulmonary embolism, and pulmonary hypertension. He presented to the emergency room with shortness of breath and chest pain. In the emergency room, the patient was found to have tachycardia as well as metabolic acidosis. The computed tomography (CT) of the chest revealed small pulmonary embolism as well as pericardial effusion. The patient was admitted to the hospital for further workup. The patient left against medical advice the next day. The inpatient admission was denied coverage by the health plan due to lack of medical necessity. This denial is being appealed.

The Inpatient admission was medically necessary.

The patient has multiple high risk medical problems including pulmonary hypertension and human immunodeficiency virus (HIV). He had worsening shortness of breath and was found to have pulmonary embolism as well as pericardial effusion. The patient would need to be closely monitored for worsening hemodynamics, including blood pressure, electrocardiogram (EKG) changes, and oxygenation levels. The monitoring required for pericardial effusion, pulmonary embolism, and pulmonary hypertension with worsening symptoms cannot be safely and 
effectively be at a lower level of care other than acute inpatient level of care. The acute hospitalization was medically necessary, as it is considered the current standard of clinical practice. Therefore, the Inpatient admission was 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 hospital with epigastric pain and vomiting. The patient reported her pain to be an 8-9/10 (eight to nine out of ten). The patient's temperature was reported to be 100, and her heart rate was 118 bpm (beats per minute). Upon admission, the patient was treated with IV (intravenous) fluids, IV Pepcid, IV Zosyn, IV Zofran, and Tylenol. 

A performed EKG (electrocardiogram) showed sinus tachycardia. The patient's lab results showed a WBC (white blood cell) count of 19.8, a Na (sodium) level of 132, a CK (creatine kinase) level of 185, an ALT (alanine transaminase) level of 47, and a lactate level of 2.63. A RUQ (right upper quadrant) US (ultrasound) resulted as normal. A performed TACT (thoracoabdominal computed tomography) showed no aortic dissection or pulmonary embolism. The patient was treated with IV (intravenous) Zosyn, IV Zofran, IV Pepcid, and IV Morphine. 

The patient continued to have epigastric abdominal pain. Her lactate level improved to 1.3, and her WBC (white blood cell) improved to 13. IV (intravenous) antibiotics were continued, and IV (intravenous) Protonix was started. Additionally, the patient was evaluated by gastroenterology, and the outcome diagnosis was that the patient had possible esophagitis. The plan was for an EGD (esophagogastroduodenoscopy), if the patient was unable to tolerate her diet. It is noted that the patient was reportedly able to tolerate her diet, and she was discharged home with prescribed medications Omeprazole and Carafate. Additionally, the patient was advised to follow up with a gastroenterology specialist. The request for the hospital admission is under review. 

The requested health service of an Inpatient Hospital Admission is not considered medically necessary. 

The patient did not have hemodynamic instability, severe pain requiring acute inpatient management, or peritoneal signs. The patient did not require identification of etiology or finding; or an evaluation requiring the patient to not eat or drink for an extended period (e.g., more than 24 hours). The patient did not have the inability to maintain oral hydration (e.g., intravenous fluid support was required) that persisted after observation care, and she did not have suspected toxic megacolon. Additionally, the patient did not have bacteremia, nor did she require a procedure that could not have been performed at an ambulatory basis or level of care. As such, the requested inpatient hospital admission would not be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain and Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This is an adult male with a history of alcohol, cannabis, and polysubstance abuse. He also had trauma and migraines. He was admitted with chest, head, back, and left upper extremity pain/numbness, as well as left lower extremity numbness and weakness. He had bradycardia with heart rate. Creatine phosphokinase (CPK) was 323. Electrocardiogram (ECG) was not acute. Blood pressure was normal. He was in no acute distress. There were no palpitations, dizziness, or syncope. He was walking with a steady gait and following commands. Cardiology was consulted for the bradycardia. The low heart rate 
improved with ambulation. Electrolytes were normal. A chest x-ray was unremarkable. The patient remained stable. An inpatient hospitalization is under review.

The requested health service is not medically necessary.

This patient presented with bradycardia and remained stable. There was no recurrent syncope, respiratory distress, myocardial infarction (MI)/acute coronary syndrome, hemodynamic instability, syncope-related serious injury, severe electrolyte abnormalities, need for prolonged intravenous medications, introduction of high-risk medications requiring in-hospital monitoring, dehydration, need for a temporary pacemaker, need for invasive monitoring, severe mental status changes, need for emergent cardioversion, or an unstable neurologic syndrome (i.e., cerebrovascular accident [CVA]). In this setting, an acute inpatient level hospitalization, compared to for example observation, has not been established as standard of care toward 
improved cardiac outcomes. Therefore, it is considered not medically necessary in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lung Cancer
Treatment: Prophylactic Cranial Irradiation (PCI) Intensity Modulated Radiation Therapy (IMRT)
The insurer denied Prophylactic Cranial Irradiation (PCI) Intensity Modulated Radiation Therapy (IMRT).
The determination is overturned.

This is a female patient with a history of limited stage small cell lung cancer status post (s/p) definitive chemoradiation with good response. Repeat staging MRI (Magnetic resonance imaging) of the brain shows no evidence for metastatic disease. She has been recommended to proceed with prophylactic cranial irradiation. At issue is whether Prophylactic Cranial Irradiation (PCI) Intensity Modulated Radiation Therapy (IMRT) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Yes, the proposed PCI employing IMRT is likely to be more beneficial than any standard treatment (i.e. 3 dimensional (D) conformal radiation therapy (CRT)) for the insured's limited stage small cell lung cancer. PCI is proven to maximize the patient's chances for improved long-term survival by preventing development of brain metastases which is associated with deterioration in quality of life and death. Hippocampal sparing IMRT is supported by numerous high quality prospective randomized clinical trials as it has been shown to minimize the incidence of neurocognitive decline. IMRT allows for optimal coverage of the brain tissue target volume while employing narrow margins and steep dose gradients to minimize hippocampal exposure, the area of the brain that is associated with memory.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lung Cancer
Treatment: Prophylactic Cranial Irradiation (PCI) Intensity Modulated Radiation Therapy (IMRT)
The insurer denied Prophylactic Cranial Irradiation (PCI) Intensity Modulated Radiation Therapy (IMRT).
The determination is overturned.

This is a female patient who presented with limited stage small cell lung cancer. The patient was treated with chemotherapy- radiation therapy (RT) with good response. She is being evaluated for Prophylactic Cranial Irradiation (PCI) using intensity modulated radiation therapy (IMRT) and this is under review.  
The proposed health service or treatment Prophylactic Cranial Irradiation (PCI) Intensity Modulated Radiation Therapy (IMRT) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease This treatment avoids decline in cognitive function.
This is a young patient who has had good response to a primary tumor in the lung and is being evaluated for hippocampal avoidance (HA) IMRT for PCI. There are a few randomized trials published to support this treatment. NRG CC001 results: HA during whole brain radiation therapy (WBRT) + memantine for brain metastases leads to sustained preservation of cognitive function and continued prevention of patient-reported neurologic symptoms, symptom interference, and cognitive symptoms with no difference in survival or toxicity.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lung Cancer
Treatment: Prophylactic Cranial Irradiation (PCI) Intensity Modulated Radiation Therapy (IMRT)
The insurer denied Prophylactic Cranial Irradiation (PCI) Intensity Modulated Radiation Therapy (IMRT).
The determination is overturned.

This is a female patient with a limited stage small cell lung carcinoma post chemotherapy and radiation therapy with good response on reimaging.  Magnetic resonance imaging (MRI) ot the brain showed no evidence of metastases. Prophylactic radiation therapy to the whole brain with hippocampus sparing is recommended and intensity modulated radiation therapy (IMRT) is requested to deliver 10 treatments. At issue is whether Prophylactic Cranial Irradiation (PCI) Intensity Modulated Radiation Therapy (IMRT) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The proposed treatment of prophylactic cranial radiation therapy with IMRT is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening disease. The recommended whole brain radiation therapy for prophylactic treatment with hippocampus sparing with intensity modulated radiation therapy (IMRT) is considered a standard treatment option for patients in this clinical scenario. There are excellent phase III clinical trials published in peer reviewed journals supporting the benefits and safety of this approach of treatment. National Comprehensive Cancer Network (NCCN) Guidelines has category 2A support for the use of IMRT for hippocampus sparing whole brain prophylactic radiation therapy.