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

Diagnosis: Cholecystitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a woman. Her medical history included metastatic pancreatic adenocarcinoma for which she was undergoing chemotherapy; and cholecystitis for which she underwent cholecystostomy.

She presented to an emergency room with a one-day history of fevers (to 100.4) and right-upper-quadrant abdominal pain. Her vitals were temperature 36.7, pulse 89, blood pressure 147/85, respirations 18, and oxygenation 99% on room air. Physical examination demonstrated "C-tube in place with minimal surrounding erythema, no fluctuance or drainage. Draining to bag." Serum laboratories demonstrated a normal white-blood-cell count of 5.7. Computed tomography demonstrated: "Interval placement of cholecystostomy tube with collapsed gallbladder... No collections or acute findings in the abdomen and pelvis otherwise."

The patient was admitted at an acute inpatient level-of-care with a diagnosis of cholecystitis. She was made nil-per-os [NPO]; and provided with intravenous fluids, antibiotics, analgesics, and anti-emetics.

The patient underwent laparoscopic cholecystectomy and cholecystostomy removal. Surgery and recovery were uncomplicated.

Having returned to her baseline health and function, the patient was discharged home in good and stable condition with outpatient surgical follow-up.

No, the Inpatient admission was not medically necessary.
According to guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons [SAGES], "Patients undergoing uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged home on the day of surgery". Therefore, in the absence of unstable vital signs; significant anatomic or physiologic derangements; or complications, the patient could have been treated at a lower level-of-care.

In accordance guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons [SAGES], in the absence of unstable vital signs; significant anatomic or physiologic derangements; or complications, the patient could have undergone evaluation and treatment for cholecystitis at a lower level-of-care.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Myocardial Infarction
Treatment: Air Ambulance Transport by Helicopter 
The insurer denied the Air Ambulance Transport by Helicopter. The health plan's determination is upheld. 

This man was evaluated in his cardiologist's office after having been seen in the emergency department a few days prior for chest pain. In the office, an electrocardiogram showed an acute ST segment elevation myocardial infarction. The nearest hospital did not have the capability for acute coronary intervention. The Ambulance was notified and they notified an air transport service to transport the patient the appropriate Hospital. 

Air Ambulance Transport by Helicopter was not medically necessary for this patient. This patient presented with an acute ST segment elevation myocardial infarction (STEMI). In patients with STEMI, the duration of time between presentation to a medical facility and inflation of the angioplasty balloon (door-to-balloon time) is closely correlated to survival. Shorter times are associated with lower in-hospital and 6-month mortality. In this particular case, while the air transport time of 13 minutes was significantly shorter than the estimated ground transport time of 41 minutes, the total elapsed time from the time when the ground ambulance service notified the air transport service of the need for transport and the time when the air transport service arrived at the receiving facility was 38 minutes, a difference of only three minutes.
Thus, based on the information provided, if the ground ambulance had departed with the patient and driven directly to the receiving hospital, it appears as if they would have arrived at almost the same time as the air transport did. There would have been no significant difference in door-to-balloon time. Therefore, air transport would not have been medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mild elevation in troponin levels in the setting of supraventricular tachycardia.
Treatment: Inpatient stay.
The insurer denied coverage for the inpatient stay. 
The denial is upheld. 

This is a male patient who presented to the Emergency Department (ED) following a bicycle accident with subsequent syncope after standing up. His past medical history was significant for supraventricular tachycardia (SVT). Upon arrival in the ED he was noted to be asymptomatic and normotensive. Electrocardiogram (ECG) revealed short RP interval tachycardia (SVT) with a rate of 180 beats per minute (bpm). ST interval (the line on the electrocardiogram that begins with the end of the QRS complex and ends at the beginning of the T wave) depressions were noted in the inferior leads while in SVT. Tachycardia resolved and ECG while in sinus rhythm demonstrated normal sinus rhythm without ST or T wave abnormalities. Physical exam was largely unremarkable. Serum troponin levels were mildly elevated. Echocardiogram was performed and revealed normal wall motion and left ventricular ejection fraction (LVEF) of 55%. The patient was discharged the following day on metoprolol.
 
According to the European Society of Cardiology, this patient was a low risk patient for future morbidity and mortality.(1) The etiology of syncope in this case was most likely neural reflex syncope.  In a study of individuals presenting to the Emergency Room, patients that were low risk or intermediate risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing.(2) In regard to mild elevation in troponin levels in the setting of supraventricular tachycardia, this patient had a low risk of future cardiac events and no attempt to risk stratify the patient was made while hospitalized.(3) In this case, the patient  falls into a low risk category and could be managed a lower level of care. In conclusion, the inpatient admission was not medically necessary.

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

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

Diagnosis: Alcohol Withdrawal. 
Treatment: Emergent Hospital Admission. 

The insurer denied coverage for emergent hospital admission. 

The denial is upheld. 

This is the case of a male with a history of alcoholic cirrhosis who presented with vomiting of coffee grounds and melena. He was continuing to drink alcohol regularly. A year earlier he underwent an extensive gastrointestinal (GI) workup and was treated for Helicobacter pylori (H. pylori) gastritis. Upon presentations in the Emergency Room (ER) he had a tachycardia and a Clinical Institute Withdrawal Assessment (CIWA) score of 12. There was no abdominal rebound and guarding. The hemoglobin was 12.1. The tachycardia resolved after he was treated with Valium. An endoscopy revealed a Mallory-Weiss tear but no active bleeding. He was discharged on proton pump inhibitor (PPI) therapy. 

Clinical indication for admission for Upper GI bleeding (M-180) include hemodynamic instability, ongoing active bleeding, high risk endoscopic features, variceal bleeding, severe coagulopathy, severe anemia, bowel obstruction and peritoneal signs. The patient did not have these conditions. 

This patient had an upper GI bleed. He required an urgent endoscopy but it could have been done with observation status. He was not having variceal bleeding and there was no active bleeding on the endoscopy. His hemoglobin remained stable. The initial tachycardia was due to alcohol withdrawal and not the bleeding. He could have been treated for the withdrawal with observation status. He did not meet MCG Criteria for admission for Upper GI Bleeding. 

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient. An inpatient admission was not medically necessary. 

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

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

This patient is a previously healthy, male who presented to the emergency department (ED) with the complaint of abdominal pain of one-day duration. Examination revealed right lower abdominal tenderness. Vital signs were normal at the time of presentation.  The white blood cell (WBC) count was normal at 9.3 thousand (K).  Surgical consultation was obtained. Computed tomography (CT) scan was completed showing findings of acute appendicitis.  The patient was started on intravenous (IV) antibiotics.  The patient underwent laparoscopy with appendectomy for the condition of appendicitis.

Following surgery, the patient was treated with intravenous (IV) fluids and analgesia.  Vital signs were consistently normal in the perioperative period.  He was transitioned to oral medications and diet.  He was discharged from the hospital.  

The health plan rationale for denial is that the patient underwent uncomplicated appendectomy.  This procedure is usually performed with an outpatient level of care.  The denial letter is and references Milliman Care Guidelines (MCG).   Per this letter there is no documentation of need for an inpatient level of care.

Acute inpatient hospitalization was not medically necessary for this patient.  The medical records support that this patient could have been reasonably and safely monitored with a lower level of care.

This patient presented with abdominal pain.  His evaluation with examination, lab data, and computed tomography (CT) scan supported the diagnosis of acute appendicitis.  He underwent uncomplicated appendectomy.  He was admitted to an inpatient level of care and was discharged from the hospital. 

There is no clinical documentation to support need for inpatient admission on these dates.  The patient remained hemodynamically stable throughout the perioperative period, there was no fever, or documented complication of surgery.  This patient's clinical needs could have been satisfied with a lower level of care.  A lower level of care can provide for pre-surgical assessment, surgical treatment and post-surgical recovery including monitoring.  The records support that the care provided was clinically appropriate.  It is the level of care that is at issue in this case.

Alternative care would include a lower level of care rather than acute inpatient care.  A lower level of care would have provided for pre-surgical assessment, surgical treatment and post-surgical recovery including monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Achalasia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is a male with a history of achalasia and had previous dilatation and a Heller myotomy.  A Perioral endoscopic myotomy was done and was reported to be uncomplicated.  After the procedure, the patient was feeling well.  The patient's esophagram did not show a leak.  The patient was able to tolerate a diet.

As per the MCG Guideline ACG-A-0204, the clinical indications for a myotomy of the lower esophageal sphincter include having achalasia with dysphagia.  However, this procedure is listed under Ambulatory care.  It does not require an acute care inpatient hospitalization.  No complications were reported.  This patient was able to tolerate a diet and was feeling well after the procedure. Thus, while the patient required a myotomy of the lower esophageal sphincter, this patient did not require an inpatient hospitalization. 

Inpatient level of care was not medically necessary for this patient. The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient level of care is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Violent Behavior, COVID 19.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient with a past medical history (PMH) of bipolar disorder and autism who was admitted with complaints of (c/o) violent behavior. His vital signs were unremarkable. His physical exam was unremarkable. Lab work was notable for mild transaminitis. An electrocardiogram (EKG) showed sinus tachycardia. The patient was diagnosed with violent behavior secondary to autism and treated with 1:1 constant observation and a psychiatry consultation. Of note, the patient developed coronovirus disease (COVID-19) during the hospital stay and he developed mild symptoms of a cough and fever. At issue is whether the inpatient level of care was medically necessary.
The hospital stay was not medically necessary at an acute inpatient level of care.
This patient presented to the ED after demonstrating violent behavior to his parents. Psychiatry was consulted and they made medication adjustments to which the patient responded well. The patient did develop COVID-19 during his stay, but it was documented to be an uncomplicated course. Otherwise, the patient did not have any hemodynamically instability, there was no hypoxia, respiratory failure or distress, apnea, intentional overdose/exposure, other acute co-existing illness, fever, significant trauma, or unstable vital signs. The patient is documented to be clinically stable and awaiting group home placement, with physician notation demonstrating the difficult placement.
Overall, the patient was clinically stable and the care could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental issue
Treatment: White Glass with Gold Crown, Tooth 3 
The insurer denied a White Glass with Gold Crown, Tooth 3. The health plan's determination is upheld 

The patient is a male who presents for evaluation and treatment of tooth #3. Provided for review are previous letters of appeal and denial, full mouth radiographic images, multiple pages of American Dental Association (ADA) claim forms, and a narrative from the treating provider.
In question is the medical necessity of white glass with gold crown, tooth 3.

Based on the provided documentation, the white glass with gold crown for tooth #3 is not medically necessary for the patient. From the documentation provided, there is not any evidence of decay under the crown of tooth #3 nor any decay associated with tooth #3. As there is no decay, the current restoration does not require replacement. The tooth margins are without defect and replacement of the current restoration is not supported as medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis. 
Treatment Dupixent 300 mg/2 mL. 
 
The insurer denied the Dupixent 300 mg/2 mL. 
The determination is upheld. 

The patient has severe and chronic atopic dermatitis. Prior to using Dupixent weekly, and when the patient was on a dosage of Dupixent used every two weeks, the patient had an involved body surface area score of 15%, an Eczema Area and Severity Index (EASI) score of 16, and an Investigator's Global Assessment (IGA) score of 2. Using Dupixent on weekly dosing, the patient had an involved body surface area score of 3%, an EASI score of 3, and an IGA score of 1. The patient has been using weekly-dosed Dupixent. Prior to using Dupixent, the patient tried and failed topical triamcinolone, clobetasol, fluocinonide gel, and 0.1% Protopic. When the patient previously used Dupixent every two weeks, her response stopped days before her next dose, and the patient is now virtually clear on weekly Dupixent (3% body surface area involvement and IGA 3). The medical necessity of weekly-dosed Dupixent is under review. 
The Dupixent as requested is not medically necessary. The patient has no documented treatment failure with, or true medical contraindication to, standard Dupixent dosed at every two weeks, and treated concurrently with either supplemental phototherapy, or standard, first-line oral medications. Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies, and for severe cases of atopic dermatitis, the use of concurrent and synergistic treatments is standard of care to avoid potential safety issues and to enhance efficacy. Preference is not the same as true medical necessity. Therefore, consistent with the current medical literature [1-4], the requested Dupixent is not medically necessary. 

Atopic dermatitis (AD) is a common chronic inflammatory skin disease that predominantly affects children. However, it can persist in adulthood and/or start at older ages. Due to its chronic nature and frequently occurring relapses, AD has a substantial effect on patients' quality of life, often requiring long-term systemic treatment, especially in adult patients, who are more frequently refractory to adequate topical treatment with mid- to high-potent corticosteroids and/or calcineurin inhibitors. Therefore, treatment with systemic therapies is often needed to take control of the disease, prevent exacerbations and improve quality of life. However, data regarding systemic treatment effectiveness and long-term safety in adult patients with AD are insufficient. Indeed, standardized international guidelines are lacking, and the treatment approach widely differs among diverse countries. This review focuses on the use of systemic treatments in adult AD patients analyzing published literature. (2)
Many AD patients respond satisfactorily to topical or systemic treatments, but for those patients who do not respond or have contraindications, new biologic agents appear to be promising therapies. (4)
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer.
Treatment: OncotypeDX Prostate Test (0047U).
The insurer denied the OncotypeDX Prostate Test (0047U).
The denial is upheld. 

The patient is a male with prostate cancer. He had the Oncotype DX Prostate Cancer Assay performed. The original biopsy was positive and demonstrated a Gleason 3+3=6 adenocarcinoma in 1 of 20 cores. The clinical stage was T1c (nonpalpable prostate cancer diagnosed by needle biopsy). The PSA (prostate-specific antigen) was <10.

No, the OncotypeDX Prostate Test (0047U) was not medically necessary.

The patient has a low-risk prostate cancer.

Per AUA Guidelines, "14. Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. (Expert Opinion)"[ref #2]

Guideline Statement 32[ref #2]
Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up. (Expert Opinion)[ref #2]

Therefore, given the above, the OncotypeDX Prostate Test (0047U) was not medically necessary. The health plan's denial was consistent with generally accepted guidelines and practice.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skeletal class II-retruded mandible, normal vertical growth pattern, permanent dentition, mild maxillary crowding, mild mandibular crowding, slightly excessive overjet, and deep impinging overbite with severe soft tissue damage. 
Treatment: D8080 braces and D8670 monthly visit x 12. 

The insurer denied coverage for orthodontic treatment. 

The denial is upheld. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal class II, excessive overjet, maxillary and mandibular crowding, and deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. 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 10 points on review by internal reviewers. The orthodontist is appealing the decision on behalf of the patient. 

Upon review of the submitted documentation, (study models were not provided for review), 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, an HLD 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 claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage, and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet the insurer and the plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer, attaining 10 points (i.e., 2 points overjet, 6 points overbite, and 2 points labiolingual spread). 

The coverage for D8080 braces and D8670 monthly visit x 12 is not considered medically necessary for this patient. 

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visit x 12 should be upheld. The medical necessity is not substantiated.