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

Diagnosis: Coronary Artery Disease. 

Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient has a history of coronary artery disease, congestive heart failure (CHF), hypertension, hyperlipidemia, and peptic ulcer disease. The patient presented to the emergency department for evaluation of chest pain which had been ongoing for 3 months. The patient had been having daily exertional chest pain for 2 weeks relieved by rest. The patient saw their private doctor who recommended the patient come to the emergency department (ED).  Physical examination was unremarkable. Electrocardiogram (ECG) did not show any ischemic changes. Initial troponin was normal. The patient was admitted. 

The patient underwent cardiac catheterization via right radial artery. It showed 80% stenosis of the left anterior descending (LAD) artery and first obtuse marginal. Drug-eluting stents were implanted in the LAD and first obtuse marginal successfully and without complication. The patient was observed uneventfully overnight and discharged. 

The patient had chronic angina of at least 3 months duration which may have been progressing. It was reasonable to bring the patient in for cardiac catheterization. In view of high-grade coronary stenosis, it was appropriate to intervene on these lesions with stenting. Further, prolonged observation was appropriate to assure no complications occurred in the immediate post-procedure period. However, the procedure and pre- and post-procedure management could have been performed either as an outpatient or on observation status assuming the period of observation would likely be 24 hours or less. A full hospitalization was not medically necessary. 

Considering the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations. 

As noted above, the patient's medical care could have been performed on observation status. An acute inpatient admission was not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crowding.
Treatment: Braces and Monthly Visit.
The insurer denied: Braces and Monthly Visit.
The denial is overturned.

The patient is an adolescent female. The request is for orthodontic benefits, including monthly visits. She has a Class III malocclusion with moderate upper and lower crowding. He health plan's prior denial was due to handicapping index scale score of 16. The denial is being appealed.

The requested braces and monthly visits are medically necessary.

The patient has two anterior upper teeth, 8 and 9, in crossbite (reverse bite), with clinical loss of attachment (gums) and recession of the gingival margins. These are both automatic qualifiers for treatment. This case has medical necessity, and orthodontic treatment is needed to correct these issues. The monthly visits are needed to make sure the treatment is progressing properly.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder.
Treatment:  Braces and monthly visits times 12.
The insurer denied Braces and monthly visits times 12. 
The determination is overturned.

This is a female patient with a Class I malocclusion, severe crowding, and an anterior crossbite of tooth number (#) 7. She is treatment planned for 30-36 months of orthodontics with extraction of four first premolars to correct her malocclusion. At issue is the medical necessity of braces and monthly visits times 12.
The services are medically necessary. This patient presented with an anterior crossbite and severe crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3) These problems are much more time consuming to correct than the patient's current orthodontic problem.
The patient has severe maxillary and mandibular crowding with # (number) 7 in crossbite. This tooth has a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time (4), which will make treating this occlusion at a later time more difficult. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures.
For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral Conductive Hearing Loss
Treatment: BAHA (Bone anchored hearing aid )(Med-el bone conduction hearing system 
implant) (Bonebridge)
The insurer denied: BAHA (Med-el bone conduction hearing system implant) (Bonebridge)
The denial is overturned.

The patient is an adult male with hearing loss and tinnitus. The patient has severe mixed hearing loss on the right and mild to moderate sensorineural hearing loss on the left. The patient 
has failed prior attempt at ossicular reconstruction. He has a 76 percent speech recognition score on the right.

The proposed treatment is medically necessary.

Medical necessity is established by the failure of conventional hearing aids to adequately address the patient's conductive hearing loss severity. The medical literature supports patients with this exact presentation of conductive hearing loss that cannot be corrected medically, surgically or with conventional hearing aids as ideal candidates for bone anchored hearing aid (BAHA). In addition, the prior determination is in opposition to the plan policy for coverage for this clinical scenario. The plan policy indicates bone anchored hearing aids are medical necessary for "hearing loss of sufficient severity that it would not be adequately remedied by a wearable hearing aid".
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy

Treatment: genetic testing (81243) x 1

The insurer denied coverage for genetic testing (81243) x 1

The denial is upheld 


This is an adult female with a first pregnancy with requested genetic testing for fragile X during the first trimester.

Current consensus guidelines from professional genetics organizations recommend carrier screening only for women with a family history of fragile X syndrome or undiagnosed intellectual disabilities, developmental delay, or autism or for those with ovarian insufficiency. 

The American College of Obstetricians and Gynecologists' (ACOG) Committee on Genetics recommends testing for fragile X syndrome as follows: 

Women with a family history of fragile X-related disorders, unexplained mental retardation or developmental delay, autism, or premature ovarian insufficiency are candidates for genetic counseling and fragile X premutation carrier screening. 
If a woman has ovarian insufficiency or failure or an elevated follicle-stimulating hormone level before age 40 years without a known cause, fragile X carrier screening should be considered to determine whether she has an FMR1 premutation. 
This patient does not have any of the above conditions. Testing for fragile X syndrome was not medically necessary.

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 genetic testing (81243) x 1 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus
Treatment: Inpatient admission
The insurer denied coverage for Inpatient admission.
The denial is Overturned.

This is a child with a history of a previous hospitalization for wheezing. The patient was coughing and having chest congestion with a sore throat and episodes of vomiting. The cough was noted to be worse at nighttime. When the patient's mother noted difficulty breathing and retractions of the area on the neck, she brought the patient to the emergency room (ER) for evaluation.

In the ER the patient was noted to be in respiratory distress with suprasternal, and subcostal retractions with bilateral wheezing right greater than left (R>L) upon auscultation of the lungs. The patient was treated with 3 doses of Combivent and Prednisone and administered a bolus of normal saline by intravenous (IV). On physical examination the patient continued to have increased work of breathing (WOB) and wheezing. A respiratory viral panel was positive for rhino/entero virus. The patient was then treated with additional nebulizer treatments with Albuterol in the ER and when reevaluated, the work of breathing and bilateral wheezing were not improved and the decision was made to admit the child to the hospital with a diagnosis of status asthmaticus for continued treatment with Albuterol every 2 hours.

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.

Denial OVERTURNED.

This patient was treated appropriately in the Emergency Room (ER) for an acute episode of wheezing and difficulty breathing. The child has a history of a previous hospitalization for wheezing with a respiratory illness. When the child did not respond to treatment in the ER and was noted to have retractions and persistent wheezing on physical examination, it was appropriate and consistent with the standard of care to admit the child to the hospital with a diagnosis of status asthmaticus for ongoing treatment with albuterol every two hours. The child was not stable enough to be safely discharged.

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

Diagnosis: Type I Diabetes

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient is an adolescent newly diagnosed with diabetes, most likely type I, who was seen in the provider's office complaining of polyuria and decreased appetite and weight loss and listlessness. Examination showed the patient was moderately dehydrated with altered mentation. Urinalysis showed 2,000 milligrams (mg)/deciliter (dl) of glucose and moderate ketones. Serum glucose was at 500 (max for the glucometer the provider had). The patient was sent to the emergency room (ER).

In ER, labs revealed: serum glucose 924 with evidence of diabetic ketoacidosis (DKA), venous PH 7.28, and sodium 124.  The patient's vitals were: oxygen saturation 98% (percent), heart rate 83, blood pressure (BP) 107/61, urine ketones 40, urine PH 6, and urine proteins 30.

The following day, labs revealed: bilirubin 1.9, alkaline phosphatase 252, blood glucose greater than 200, beta-hydroxybutyrate 17.2, sodium 139, potassium 3.7, bicarbonate (HCO3) 23, and anion gap 9.  The patient's hemoglobin A1C was 12.6 with a high probability of type I diabetes. The patient was also diagnosed with microcytic anemia likely due to iron deficiency anemia. The patient required management and diabetic education. 

Hospitalization for DKA is universally medically necessary(1-9). Patients with diabetes and diabetic ketoacidosis (DKA) initially generally require intensive care unit (ICU) level care(1),(3),(4),(5) until they are converted to subcutaneous insulin and have closed their anion gaps and have no other conditions requiring ICU level care (10),(11).  Most hospitals admit patients with DKA to the ICU due to rules regarding level of service with every 1 hour blood draws and nursing care. 

Diabetes education consists of several components, nutritional counseling, self-monitoring of blood glucose and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components (1,2). 

The patient was admitted for treatment of diabetic ketoacidosis. The patient met all criteria for diabetic ketoacidosis as the patient had type 1 diabetes, hyperglycemia, ketosis, acidosis.  The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.  Furthermore, the patient needed diabetes education.  The admission was medically necessary.

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

The medical necessity for full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who presented to the emergency department (ED) via Emergency Medical Services (EMS) complaining of chest pain. He received aspirin and sublingual nitroglycerin en route to the ED without relief. His medical history was remarkable for diabetes, hypertension, hyperlipidemia and carotid arterial disease. Per the report, his electrocardiogram showed sinus rhythm with nonspecific repolarization changes and an inferior infarction. The age of the infarction was not mentioned. His serum troponin level was normal. A chest x-ray showed no acute pathology. A repeat electrocardiogram was interpreted as showing an acute ST segment elevation myocardial infarction. The patient was treated with heparin and ticagrelor and was taken directly from the ED to the cardiac catheterization laboratory. Coronary angiography showed minimal nonobstructive disease. Left ventriculography showed a left ventricular ejection fraction of 55 percent (%). The procedure was uncomplicated. The patient's troponin level remained normal. He was discharged. The medical necessity of an inpatient admission is at issue.
Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient presented with chest pain. His electrocardiogram was interpreted as showing an acute ST segment elevation myocardial infarction (STEMI). Accordingly, he was taken directly from the emergency department to the cardiac catheterization laboratory when coronary angiography and left ventriculography showed no evidence of significant coronary artery disease or of a STEMI. The patient was in sinus rhythm, hemodynamically stable, with normal cardiac biomarkers and no evidence of congestive heart failure. The procedure was uncomplicated. The medical record does not indicate that coronary artery spasm was thought to be likely. Based on the records provided there was no indication for an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a medical history notable for autism and seizure disorder. The patient had four episodes of seizure-like activity at home and was brought to the hospital for further care. The family described the episodes as the patient becoming unresponsive to questioning; there were no convulsions noted. The patient received lorazepam and a loading dose of Keppra in the emergency department. He was noted to be post-ictal, but otherwise had no acute neurologic findings. Vital signs were stable. His white blood cell count was elevated to 20.0. A computed tomography (CT) scan of the head did not show any acute findings. He was admitted to the hospital for the diagnosis of breakthrough seizures.

The Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented to the hospital after four episodes of possible seizure-like activity at home. He was reportedly taking his seizure medications In the emergency department he was given intravenous lorazepam. He was noted to be in a post ictal state at the time of admission, but had also received lorazepam. The hospital cites his altered mental status as justification for inpatient admission, but this is not unusual in the setting of a patient who is post-ictal and who received benzodiazepine medication. The patient did not have any witnessed seizure activity in the hospital and had no new neurologic findings. He required one night of observation in the hospital and was discharged home for outpatient care. The patient could have been safely treated at a lower level of care. There is no evidence of severe neurologic abnormality which would warrant inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, Vomiting and Abdominal Pain. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult female with past medical history of marijuana use and depression. She presented at the hospital with abdominal pain with radiation and nausea. The patient had fluid hydration and a computed tomography (CT) scan. It was noted she had elevated creatinine for which Nephrology was consulted. Intravenous (IV) antibiotics were converted to oral route and the patient was subsequently discharged to home. There was a subsequent denial of inpatient level of care as not meeting InterQual criteria. The physician is appealing the determination. 

The proposed treatment is not medically necessary. 

The request level of care was not medically necessary as it was provided primarily for the convenience of the patient/practitioner; it was not the least intensive and/or most appropriate level of care among alternatives available. The proposed treatment was not medically necessary. Inpatient level of care was not medically necessary as there was no documentation of hemodynamic instability, vomiting that was severe or persistent, altered mental status that was severe or persistent, or persistence or worsening of clinical findings despite a lower level of care. There was no documentation that parenteral antibiotics were needed beyond observation care or that any other condition, treatment, or monitoring required inpatient admission. The patient could 
have safely and effectively been managed at a lower level of care. Therefore, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pelvic inflammatory disease and possible a tubo-ovarian abscess. 
Treatment: Air Ambulance (A0435 and A03430). 

The insurer denied: Air Ambulance (A0435 and A03430). 
The denial is overturned. 

The patient is an adult female with a past medical history of ovarian cysts. While on vacation on a cruise ship, she became ill. She sought medical attention from the ship physician for low abdominal pain. Records of that evaluation show that the patient was tachycardic, but otherwise had normal vital signs. She was tender to palpation in both lower quadrants of the abdomen. A pelvic examination revealed yellow vaginal discharge and cervical motion tenderness. Blood work was remarkable only for an elevated CRP (C-reactive protein) level. The physician diagnosed pelvic inflammatory disease and possible a tubo-ovarian abscess. IV (intravenous) and oral antibiotics were given. Morphine was given for pain. The decision was made to transfer the patient from the Bahamas to the United States for further testing and treatment. An air ambulance was called to transport the patient to the United States. Flight notes from the air 
ambulance crew indicate that the patient required additional pain medicine during transport. The patient's health plan has denied coverage for air ambulance transport on the grounds that it was not medically necessary. The denial is being appealed.

The air medical transport was medically necessary. 

The American College of Emergency Physicians has published a Policy Statement on the appropriate and safe utilization of an air medical services (reference below). This Policy states that clinical benefit from such services may be provided when:  
1. Such services meaningfully shorten the time to delivery of definitive care to patients with time sensitive medical conditions or 
2. Services provide necessary specialized medical expertise or equipment to patients before and/or during transport or 
3. Services provide transport to patients otherwise inaccessible by other means of transport. 

These criteria were met on the date of transport. The patient presented with signs and symptoms of pelvic inflammatory disease. There was a concern for an ovarian abscess. The patient needed urgent imaging to exclude an abscess. She needed an evaluation by a gynecologist. None of this was possible on the cruise ship she was travelling on. The patient had a time-sensitive medical condition. If she were to have had an abscess, she would have needed surgical intervention quickly to treat it and prevent further spread of infection. There was no less intensive service other than air ambulance to transport this patient to a facility that could provide the services she required.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth decay
Treatment: Root canals for teeth numbers 2 and 15
The insurer denied: Root canals for teeth numbers 2 and 15
The denial is overturned.

The patient is an adult female requesting benefits for root canal therapy on teeth numbers 2 and 15. Both teeth have severe decay, and the patient is in severe pain on both sides of her mouth. The prior denial was because the patient has more than 8 teeth that touch together during biting, and therefore these two teeth should be extracted.

The proposed treatment is medically necessary.

Both of these teeth are functioning teeth, meaning they bite against another tooth. The treatment needed, root canal therapy, will stop the patient's pain and allow her to keep these teeth. There is no reason to have these teeth removed as they have good bone support and just need the proposed treatment. Removing these teeth could possibly cause shifting of other teeth which would cause bite alignment issues. There is medical necessity to treat these teeth with root canals.