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

Diagnosis: Asthma with a possible viral pneumonia

Treatment: Inpatient admission

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

The patient was a female child with a family history of asthma. The patient had been sick for days with cough, nasal congestion and one day of fever. The patient was given albuterol 2 puffs four times a day at home, and when her symptoms did not improve, she was taken to the pediatrician on the day of admission for evaluation. The pediatrician noted fever and wheezing and administered 3 treatments of albuterol in the office. When there was no improvement the pediatrician referred the patient to the Emergency Room (ER) to rule out pneumonia. In the ER, the triage nurse noted that the patient was not in respiratory distress or having any evidence of retractions of the chest or abdomen. The patient's respiratory rate was 22 and the patient's pulse oximeter reading was normal. On physical exam, the patient had wheezing. The patient had a negative test for influenza, a normal chest x-ray and a normal complete blood count (CBC). The patient was treated with dexamethasone and 3 doses of DuoNeb. This was followed by one dose of albuterol. Following this treatment, the patient had clinical improvement in aeration but was still wheezing, and the decision was made to admit the patient with a diagnosis of asthma with a possible viral pneumonia.

Based on the review of the medical record and the literature, the patient was treated appropriately in the Emergency Room (ER) for a cough and wheezing. There was improvement in the patient's aeration of her lungs on physical exam following ER treatment with bronchodilators and steroids. The patient was not in respiratory distress during the period of time she was observed in the ER. The patient's physical exam, blood test and chest x-ray did not support a diagnosis of pneumonia.

Based on literature review, it is not uncommon for wheezing to persist in an acute episode of asthma following the administration of a bronchodilator in the ER. In the absence of physical findings of increased work of breathing, persistent wheezing is not an indication for admission to the hospital. The treatment with DuoNeb at approximately 1 hour intervals was not consistent with the recommended "back to back" treatment with 3 bronchodilator inhalation treatments for status asthmaticus. This patient who was not in respiratory distress with mild persistent wheezing could have been discharged with prednisone and albuterol to be administered at 4 hour intervals in the home with a follow up appointment with the pediatrician in 24 - 48 hours. Thus, inpatient admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient admissions should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic lung disease

Treatment: Pulmozyme

The insurer is denied coverage for Pulmozyme. The denial is upheld.  

The patient is a female who was born following a premature birth at over 30 weeks gestation.  The patient's history was significant for Pierre-Robin syndrome, seizures, developmental delay, scoliosis, dysphagia and chronic aspiration from sialorrhea. The patient had chronic lung disease and required Bilevel Positive Airway Pressure (BIPAP) when sleeping and had episodes of low oxygen saturations. The patient was treated with cough assist and Vest daily.  The patient had been treated with hypertonic saline, albuterol and Pulmozyme which the patient had been receiving twice a day for. The medical record indicates that this patient was at risk of prolonged hospitalizations prior to starting Pulmozyme and based on the impression of the patient's mother and the treating physician, the patient's respiratory condition improved on Pulmozyme.  The patient's mother indicated that the patient had clinically worsened since this patient's Pulmozyme was discontinued coverage by her insurance. The patient had been requiring additional chest physical therapy because of increased chest congestion and episodes of oxygen desaturation. The patient was seen and was not seen for a visit again until several months after.  The medical record notes that the patient had not required any Emergency Room (ER) visits or hospitalizations and she had only a few upper respiratory infection (URI) illnesses in the winter. The patient only required one course of antibiotics and treatment with 3 liters of oxygen on one occasion. 

Based on the review of the medical record and literature, Pulmozyme (dornase alfa) is not medically necessary. The patient had a complicated history of chronic lung disease and aspiration pneumonia and required airway clearance treatments on a daily basis.  There was no indication that the patient produced purulent sputum or had chronic bacterial lung infection.  There had not been a computed tomography (CT) scan or chest x-ray to document the presence of atelectasis or bronchiectasis.  The patient had not required a bronchoscopy.  In addition the medical record indicates that this patient had been stable over several months with no hospitalizations or Emergency Room (ER) visits.  The medical history does not support the need for ongoing daily therapy with Pulmozyme twice daily (BID) at home.  It is not the standard of care to prescribe Pulmozyme for lung disease related to chronic aspiration in the absence of persistent bacterial bronchitis, bronchiectasis and purulent sputum. 

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

The carrier's denial of coverage for Pulmozyme should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Procedure (Colonoscopy)
Treatment: Outpatient hospital-based facility 
The insurer is denied coverage for outpatient hospital-based facility.
The denial is upheld.

This is a male patient who underwent a hospital-based colonoscopy as a follow-up screening test. The appeal documentation submitted stated that the patient had a cardiac arrhythmia and therefore a hospital-based setting was chosen since an outpatient setting was not considered safe according to the physician. It was reported that the patient's last colonoscopy was 10 years ago. This patient underwent the requested procedure, and had a 3 mm polyp removed. The patient was diagnosed with tubular adenoma. The patient was discharged after the procedure.

The procedure of colonoscopy for screening is clearly indicated according to national guidelines. However, the usual setting for this procedure is an outpatient ambulatory care.

In this case, the procedure was performed in a hospital-based ambulatory surgery facility. According to literature review, this procedure can be done either in a hospital or non-hospital based outpatient setting. There are no clear-cut national guidelines on choice except for when it cannot be done in a non-hospital setting, such as patients with a high ASA Physical Status classification. Typical contraindications for a non-hospital-based setting would be for patients with an ASA status of 3 or higher.

Based on the review of the medical record, this patient had a low ASA status and could have gotten his colonoscopy in an outpatient, non-hospital-based ambulatory setting. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the procedure (colonoscopy) performed at an outpatient hospital-based facility should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class Two Malocclusion

Treatment: D8080- Comprehensive Orthodontic Treatment

The insurer denied the D8080- comprehensive Orthodontic Treatment. The denial was upheld.   

This is a female patient who consulted an orthodontist for orthodontic treatment.  It was reported that the patient had a history of trauma of the anterior maxillary incisors, thumb sucking and tongue thrusting. A Handicapping Labio-Lingual Deviation (HLD) Index Report was completed and showed a score of 18, with an HLD score of 6 for overbite, and score of 12 for open bite. It was determined that the patient had a class two malocclusion with a retrognathic mandible with maxillary spacing and mandibular crowding, as well as an open bite and excessive overjet. 

Per Mayo Clinic, (2019), "Dental braces offer corrective treatment for:
1) Overcrowded or crooked teeth
2) Too much space between teeth
3) Upper front teeth that overlap the lower teeth too much either vertically (overbite) or horizontally (overjet)
4) Upper front teeth that bite behind the lower ones (underbite)
5) Other jaw misalignment problems that cause an uneven bite"

This patient has a malocclusion. To determine the severity of that malocclusion and the necessity for braces a Handicapping Labio-Lingual Deviation (HLD) index is utilized. 

To qualify for braces the patient must either meet the criteria for an automatic qualifier, or attain a score of 26 or more on the second section of the HLD.  

Automatic qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9mm or greater and underbite 3.5mm or greater.  This patient did not have an automatic qualifying condition. If a patient does not meet the auto qualifier criteria, a scoring of her dentition according to the second part of the HLD occurs. A score of at least 26 is required to prove medical necessity.

The insurer's HLD appears to be off in that the overbite of this patient is more like minus five, not three. That changes the HLD to 23. This number is below what is needed to support medical necessity.

Based on the above, the medical necessity for D8080- comprehensive orthodontic treatment of adolescent dentition is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Brain Injury.
Treatment:  Acute Rehab. 
The insurer denied the inpatient acute rehab admission.  The health plan's determination is overturned. 

The patient is a female with history of alcohol abuse and questionable anoxic brain injury who presented with fall down stairs with loss of consciousness.  Imaging noted subdural hemorrhage, subarachnoid hemorrhage and intracerebral hemorrhage.  She was evaluated by neurosurgery who decided on nonsurgical management.  She required Intensive Care Unit (ICU) admission for respiratory failure with intubation followed by a tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement. Her hospital course was complicated by aspiration pneumonia and rhabdomyolysis. Under review is the admission to acute rehabilitation.

The admission to acute inpatient rehabilitation was medically necessary as the patient required close physician oversight and benefited from speech therapy, physical therapy and occupational therapy.  When she arrived at acute inpatient rehabilitation, she was still requiring a tracheotomy and tube feedings.  She was dependent with assistance of 2 for all activities of daily living (ADL) and MAXA for bed mobility.  Upon reviewing all documentation, the patient required multiple medication adjustments since admission.  Given the extent of her traumatic brain injury and need for strict physician oversight, admission to acute inpatient rehabilitation was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorder
Inpatient stay  The insurer denied the inpatient stay.
The determination is upheld.


The patient was admitted due to fighting with siblings and parents, depression and suicidal ideation with a plan. For the dates under review, the patient was improving. He was diagnosed with major depressive disorder (MDD), recurrent, severe without psychotic features, disruptive mood dysregulation disorder (DMDD). Het had no active suicidal ideation with a plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. He was not catatonic. He had no significant medical instabilities. The patient had no required emergency medications, restraints or seclusions. At issue is the medical necessity of an inpatient behavioral health stay.

The inpatient stay was not medically necessary. . At the time of admission the patient was medicated with Zoloft, Adderall extended release (XR), and Adderall.  The patient had previously tried and failed Prozac and Lexapro.  The patient had no other previous hospitalizations.  He had a history of using tetrahydrocannabinol (THC).  He was diagnosed with MDD, recurrent, severe without psychotic features, DMDD. He had adequate sleep, appetite and activities of daily living (ADLs).  He had some anxiety.  He was medicated with Olanzapine Zydis, Sertraline, Adderall XR and Clonidine was added.  There were no side effects to medications. He had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. He was not physically aggressive, acutely manic or sexually inappropriate. The patient was not catatonic. The patient had no significant medical instabilities. He had no required emergency medications, restraints or seclusions.  There was no indication that inpatient level of care was medically necessary. Treatment could have been addressed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genitourinary/Kidney Disorder 
Treatment: Inpatient Hospital 

The insurer denied: Inpatient Stay 
The denial is: Overturned in whole 

The patient is a male with past medical history of tobacco abuse and obesity who re-presented to the emergency department (ED) with severely symptomatic left proximal ureteral calculus with obstructive changes per computed tomography (CT) A/P that required hospitalization. His pain was not able to be managed with oral pain meds that were given initially as outpatient treatment, and intravenous (IV) Toradol and IV Morphine were required. IV hydration along with IV Zofran were also necessary. Of note, the patient had presented the day prior for the same pain and found to have a 4 millimeter (mm) stone in the left ureter and was discharged on pain medication. 
White blood cell (WBC) count on admission was 14.58, urinalysis (UA) with red blood cells (RBCs), ketones and bacteria. Vitals were stable on admission. The following day, patient's WBC increased to 15.82 and patient's pain was still present while on IV meds.
He underwent cystoscopy, left retrograde pyelogram and left stent placement. Operative findings revealed of obstructed system and hydronephrotic drip. The patient was kept as inpatient for further medical care due to increasing WBC. On the date of discharge the patient's WBC was 19.18 without signs of infection and patient's pain was resolved and was sent home in stable condition. 

The subject under review is the medical necessity of the inpatient stay. 

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

Given the patient's health status, diagnosis, and condition, an acute inpatient level of care is medically necessary. As outlined by the American Urological Association (AUA) guidelines, the patient does meet criteria for inpatient level of care from for the dates of service in question, due to his requiring definite surgical intervention for stone management and signs of complications post-operatively. Although the patient's pain was eventually controlled with IV pain medications Morphine and Toradol, he met an inpatient level of service throughout his hospital admission due to worsening condition requiring further stabilization in the hospital setting as seen by increasing leukocytosis. This patient's management was appropriate for inpatient level of care. 

In addition, there is a sufficient level of documentation of the patient's previous history and comorbidities that required this procedure to be done at an inpatient level of care, including postoperative concern for infection, which require an acute level of care for monitoring. Based upon these factors the patient also meets InterQual criteria for the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems - Hypertension/High Blood Pressure 
Treatment: Inpatient Hospital 

The insurer denied the inpatient hospital stay.  The denial was upheld. 

The patient is a woman with a history of asthma, bipolar disorder, polysubstance abuse (alcohol, tobacco, heroin, cocaine), and hypertension.  She presented to the emergency room with high blood pressure.  There was some mention of an earlier headache, but this was not further defined and she had no other complaints.  She was in no acute distress.  The initial blood pressure was 179/124.  The exam was otherwise normal.  The electrocardiogram (EKG) showed left ventricular hypertrophy and repolarization abnormality.  The chest x-ray showed mild cardiomegaly and changes consistent with chronic obstructive pulmonary disease (COPD), but no infiltrates.  The urine drug screen was negative.  Labs were otherwise non-contributory; there was a trivially elevated troponin.  A computed tomography (CT) scan of the head was negative.  Medications were administered in the emergency room.  Subsequent blood pressures were 169/89 and then 159/101. 

Upon admission to a monitored bed, the patient was treated with oral medications.  The following day her blood pressure was 165/95.  The hospital course was clinically uneventful, and she was discharged four days later to a substance abuse rehab facility. 

At issue is the medical necessity of the inpatient stay.  The health plan's determination is upheld. 

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary.  Upon presentation, there was no ongoing objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints.  There was no credible evidence of end organ damage.  There were no neurologic signs or evidence of heart failure.  The EKG did not show acute ischemia, and the minimally elevated troponin was not repeated and could easily be explained by ventricular strain.  The CT scan findings were not convincing of acute serious abnormalities.  The blood pressure came down quickly while in the emergency room, suggesting a high likelihood that her elevated blood pressure was at least partially attributed to poor medication compliance.  It also appears that perhaps there was some difficulty with discharge planning due to the Christmas holiday and the need to have a new intake performed for admission to substance abuse rehab.  Ruling out an acute coronary syndrome could have been completed at a lower level of care.  The services provided - oral medication and blood pressure monitoring- were not at the acute inpatient level of intensity and could have been safely and efficiently provided at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient hospital

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

The patient is a male with medical history of pancreatitis and former alcohol use. He presented to the emergency department with one month of productive cough, chronic steatorrhea, 6 months of intermittent left-sided abdominal pain, and chronic diarrhea. He noted an unintentional weight loss of 50 pounds over the past 6 months. Vital signs showed tachycardia with pulse rate of 103/minute. Physical examination was notable for lower abdominal tenderness (right more than left), cachexia, and temporal wasting. 

The inpatient hospital admission was not medically necessary. The patient had an elevated blood glucose but did not have a diagnosis of diabetic ketoacidosis or hyperosmolar hyperglycemic state. Although imaging was consistent with chronic pancreatitis, as well as sequelae of acute pancreatitis such as pseudocyst, there was no diagnosis of acute pancreatitis. The day after presentation, he had improvement in abdominal pain and was tolerating oral intake. Imaging was suspicious for malignancy of the pancreas and chronic pancreatitis, which required evaluation (and transfer), but did not warrant the acute inpatient level of care. For these reasons, the inpatient level of care is not supported by the provided documentation.
Appeal type: Medical necessity
Decision: Overturned

Trauma/injuries 
Inpatient hospital 

Diagnosis: Fall/trauma 
Treatment: Inpatient stay. The insurer denied the inpatient stay. The health plan's determination is overturned. 

This is the case of a female with a history of asthma who presented to the emergency department (ED) after falling out of a bunk bed. The patient complained of pain of the left forearm, as well as swelling around the left eye. 

The inpatient hospital stay is medically necessary for this patient. This patient presented to the ED with trauma status/post fall from a bunk bed. Although a buckle fracture of the distal radius and ulna is considered typical for a fall of this type, the degree of facial trauma (including eye swelling and facial abrasions) is unusual. Thus, the necessity for ophthalmology and social work consultations to verify the history given and rule out the possibility of abusive trauma.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems 
Dental/Orthodontic Procedure 

Diagnosis: Dental Issue 
Treatment: porcelain crown for #18 (D2740), and buildup for #18 (D2950).
The insurer denied the porcelain crown for #18 (D2740), and buildup for #18 (D2950). The health plan's determination is upheld. 

The patient is a male who presents for evaluation and treatment of tooth # (number) 18. Provided for review are previous letters of appeal and denial, radiographic images, three narratives from the provider, one page of American Dental Association (ADA) claim forms, and clinical images of tooth #18. In question is the medical necessity of the treatment of porcelain crown for #18 (D2740), and buildup for #18 (D2950). 

A Porcelain Crown and Core Buildup for Tooth Number 18 is not medically necessary for this patient. From the provided documentation, the clinical images, and radiographic images, there is not support for the procedures performed, no support for the presence of decay, no cuspal involvement of any type, nor any fractures of the tooth. Neither a crown nor a buildup are supported treatments for tooth #18 based on the provided documentation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive uropathy
Treatment: HHA (home health aide)12 hours per day-7 days per week; 12 hours per day-7 days per week (split shift) for a total of 168 hours per week

Summary:
This is a male with a history of obstructive uropathy requiring placement of bilateral nephrostomy tubes and rheumatoid arthritis. For these reasons, he requires assistance for completion of the majority of his activities of daily living (ADLs). Recent documentation from one of the Interventional Radiologists involved with the patient's nephrostomy tube placements/exchanges; indicates that due to the patient's advanced age, rheumatoid arthritis and associated decrease in manual dexterity and overall mobility; he is unable to properly perform daily nephrostomy tube flushes, maintain appropriate tube positioning to prevent blockage and proper routine emptying of urinary collection bags. For these reasons, the currently approved plan of PCA services 5 hours per day, 7 days a week for a total of 35 hours per week is insufficient to meet the patient's current needs. Hence, the proposed treatment of HHA 12 hours per day-7 days per week; 12 hours per day-7 days per week (split shift) for a total of 168 hours per week is deemed medically necessary for increased assistance with completion of ADLs.