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

Diagnosis: Low back pain 
Treatment: Acute inpatient stay 

The insurer denied coverage for acute inpatient stay. The denial is upheld. 

This patient is a male who was with low back pain. The patient's computed tomography (CT) imaging indicated that the patient's symptoms were consistent with herniated nucleus pulposus at L4-L5 region of the patient's spinal cord. As per notes, the patient remained hemodynamically and neurologically stable. The patient's physical exam was unremarkable. There was no clinical documentation of infection or active bleeding noted, and the patient's pain was under control with medication. There was no urgent surgery needed. The patient had lumbar epidural steroid injection performed but this was considered an elective procedure. The patient was ambulating and tolerating oral intake. 

According to the MCG guidelines for low back pain (M-63), the clinical criteria for inpatient admission is acute neurologic deficit (i.e. cauda equina), confirmed etiology that requires inpatient treatment (e.g., aortic dissection, epidural abscess, spinal stability), and/or need of urgent inpatient surgery. Otherwise, the MCG guidelines recommend observation case admission if there is severe pain that cannot be managed on outpatient basis, suspected spinal infection (e.g., epidural abscess, vertebral osteomyelitis), and/or suspected cause that requires inpatient treatment (e.g., aortic dissection, spinal cord impingement). In this case, the patient did not require surgical intervention. The patient's back pain was not complicated by an infection or acute neurologic deficit, such as bowel dysfunction, bladder dysfunction, or saddle anesthesia. The patient was hemodynamically stable, and his inpatient stay was primarily pain management. The lumbar epidural steroid injection that the patient received was an ambulatory procedure that could have been received as outpatient. Thus, inpatient admission was not medically necessary to treat this patient's medical condition. 

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 acute inpatient stay is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Extracted tooth #3
Treatment: D6010 - Implant placement, tooth #3
D6060 - Abutment supported porcelain fused to metal crown (predominantly base metal), tooth #3

The proposed D6010 and D6060 are medically necessary. 

The patient had to have tooth #3 extracted. The recommended treatment after the extraction would be to place a single implant and have a crown attached to it. The procedure was medically necessary to treat this patient. A denture (or partial denture) is not indicated for this case since the patient is only missing one tooth (#3) in his upper arch. A partial denture for one tooth would not be appropriate since there would be a lot of material in the mouth just to hold up only one denture tooth. That is not a good treatment option.  Therefore, the D6010 - Implant placement, tooth #3 and D6060 - Abutment supported porcelain fused to metal crown (predominantly base metal), tooth #3 are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vision/poor vision 
Treatment: Inpatient hospital  
The insurer denied the inpatient hospital stay
The denial is upheld in whole

The patient with an unremarkable past medical history who presented to the emergency department with acute right-sided vision loss. Reportedly, two days before her presentation she started to experience blurred vision in the right eye. Over the course of two days,  symptoms became progressively worse, and this prompted the patient to come to the hospital.
The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at the lower level of care rather than admission to an inpatient level of care.
 This patient presented to the hospital with complaints of acute onset of vision loss. However, the results of the physical examination and diagnostic studies that were performed in the hospital did not reveal evidence of any serious problem that would require care at the acute inpatient level.
The review of medical records did not demonstrate any evidence that the patient had any diagnostic studies or treatment performed during this very short period of hospitalization that would require admission at the acute inpatient level of care.
 Some cases of vision loss related to eye pathology would require intervention at the acute inpatient level of care. There was no intervention including administration of medications, therapeutic procedures, or surgeries done in this clinical case. The patient's hospital stay was short, and the patient received no treatment that would justify medical necessity for admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

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

This patient with a past medical history (PMH) of hypertension (HTN), hyperlipidemia (HLPD) and diabetes mellitus type 2 (DM2) was admitted  with complaints of (c/o) chest pain, which was relieved by nitroglycerin. Vital signs were remarkable for hypertension (HTN). The physical exam was unremarkable. Lab work was notable for negative troponins. A chest x-ray (CXR) showed no acute pathology. An electrocardiogram (EKG) showed dynamic ST depressions in the inferolateral leads in the setting of left ventricular hypertrophy (LVH), possible strain pattern. The patient was diagnosed with chest pain and treated with telemetry, a heparin drip, aspirin, and statin. Cardiology evaluated the patient and recommended a transthoracic echocardiogram (TTE) and stress test, which the patient refused. The patient left against medical advice (AMA). At issue is the medical necessity of an inpatient stay.
The hospital stay was medically necessary at an acute inpatient level of care. This patient with multiple cardiac risk factors, presented to the ED with c/o chest pain at rest and relieved with nitroglycerin, suspicious for cardiac disease, so much so that the patient was started on a heparin infusion and considered for left heart catheterization (LHC). She had dynamic changes on her EKG concerning for acute ischemia, had multiple coronary artery disease (CAD) risk factors, and her HEART (History, Electrocardiogram, Age, Risk Factors, Troponin) score was 7, indicating a high-risk major adverse cardiac events (MACE) of 50-65%. In addition, the patient's EDACS [Emergency Department Assessment of Chest Pain Score] was also not indicative of low risk. Due to this patient's high risk for mortality associated cardiac events, her chest pain, EKG abnormalities, and high risk clinically validated risk scores, the patient was treated as having unstable angina. Due to the patient's high risk for cardiac events, the need for urgent expert evaluation for possible intervention, a lower level of care would not have sufficed for her care and an inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation 
Treatment: Acute inpatient stay 

The insurer is denied coverage for the acute inpatient stay. The denial is upheld. 

This is a male patient with a history of hypertrophic cardiomyopathy and atrial fibrillation, benign prostatic hypertrophy (BPH), hyperlipidemia, anxiety, and gastroesophageal reflux disease (GERD). The patient presented to the Emergency Department (ED) with complaints of a  "strong heart beat" and was found to be in atrial fibrillation with rapid ventricular response. The patient's initial vital signs included blood pressure 116/98, heart rate 150, respiratory rate 22, temperature 97.9 F, and oxygen saturation 99% on room air. The patient's electrocardiogram (EKG) revealed atrial fibrillation with rapid ventricular response and ST segment depressions in V3-V6. The patient's chest x-ray was unremarkable. The patient's laboratory test results from included white blood cell (WBC) count 8.97, hemoglobin 12.3, creatinine 1.1, BNP 124, and troponin 0.06. The patient was treated with intravenous (IV) Cardizem and his rhythm converted to normal sinus rhythm, and then was discharged home on oral Cardizem. 

Based on the review of the medical record and literature, there is no evidence that this patient required an acute inpatient level of care to evaluate or to treat his paroxysmal atrial fibrillation with rapid ventricular response. The patient's evaluation and treatment could have been safely provided in the Emergency Department (ED) or at an observation level of care. Thus, inpatient admission was not medically necessary for this patient. 

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

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

Diagnosis: Central Nervous System / Neuromuscular Disorder
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

This is the case of a female with past medical history of psychiatric illness on Abilify, obesity, and smoking, who presented to the emergency department  with slurred speech, intermittent right lower extremity tingling, and bilateral lower extremity weakness with difficulty standing for the last day.
On presentation, she was afebrile with normotension, heart rate in the 90s and with normal oxygen saturation and respiratory rate. Exam otherwise noted intermittent 2/5 weakness of the bilateral lower extremities, and subjective paresthesias to the right lower extremity in the emergency department, with the admitting physician noting her exam significantly improved rapidly after presentation. Labs resulted with white blood cell (WBC) count of 8.3, hemoglobin (HGB) 12.1 platelets 317, sodium 141, potassium 4.8, blood urea nitrogen (BUN) 3.4 creatinine 0.84, liver function tests within normal limits, and troponin undetectable. Electrocardiogram (EKG) showed no evidence of acute ischemia or arrhythmia. Computed tomography (CT) of the head showed no acute process. Emergency department concern was for need for rule out stroke of transient ischemic attack with conversion disorder also on the differential. The patient was brought into the hospital with plans for neurology consultation, telemetry, echocardiogram, carotid ultrasound, consider magnetic resonance imaging (MRI) of the brain, and psychiatry consultation.
Neurology saw the patient with assessment that she had symptoms that rapidly improved after admission with recommendation for psychiatry consultation.
Psychiatry saw the patient with assessment that she had schizophrenia in partial remission with plans for outpatient psychiatry follow up.
Carotid ultrasound and echocardiogram showed no abnormalities.
Overnight and the next day the patient remained hemodynamically stable with 5/5 upper extremity strength and 4-5/5 lower extremity strength and was cleared for discharged. The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld in whole.

The inpatient stay was not medically necessary. This patient presented with transient slurred speech and possible bilateral lower extremity weakness and word-finding difficulties. She improved rapidly without worsening or recurrence of her presenting symptoms, new neurologic deficits, hemodynamic instability, concomitant cardiac ischemia, or other acute medical issue requiring acute hospital care.
With rapid improvement in her symptoms and particularly with her young age and conversion disorder on the initial differential diagnosis (both making stroke diagnosis less likely), she could have been safely cared for at a lower level of care status. Inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Issue: Medical necessity of Taltz
The health plan's determination is upheld in whole

This patient has a history of chronic psoriasis and psoriatic arthritis with axial involvement. The patient has been treated in the past with methotrexate (MTX), Enbrel, Humira and cosentyx. The preferred agents are : Otezla, Stelara, inflectra and renflexis.  The issue in this case is the medical necessity of Taltz.

The requested health service/treatment of taltz is not medically necessary for this patient. 

The patient's provider stated that inflectra and renflexis require co-administration with MTX for the treatment of psoriatic arthritis and that MTX is 'contraindicated in this patient due to concerns of liver toxicity with prior use'. However, for psoriatic arthritis (PsA), inflectra or renflexis may be given with or without MTX so there is no medical reason why Inflectra or Renflexis are not options for this patient.  Otezla does not have a role in axial disease so would not be appropriate in this case. Likewise, there is recent data stating that Stelara is not very effective in axial disease either. Therefore, neither Otezla nor Stelara would be options for this particular patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems
Treatment: Dental /Orthodontic Procedure
The insurer denied: braces
The denial is: Overturned in whole

The patient is a male with #9 in anterior crossbite. The patient was treatment planned for 24-30 months comprehensive orthodontics, but the plan was denied due to lack of medical necessity.

The health plan's determination is overturned in whole.

Braces are medically necessary for this patient. Treatment for the patient's anterior crossbite in the mixed dentition is medically necessary. It is a generally accepted practice guideline in orthodontics to treat anterior crossbites as soon as feasible because of the damage that can occur to the patient's dentition if left untreated. 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 and difficult to correct than the patient's existing orthodontic problem.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System.
Inpatient hospital.

Diagnosis: shortness of breath.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is overturned.

This case represents a female with a medical history of obesity, hypertension and asthma who presented to the emergency department (ED) with complaints of increased shortness of breath, cough, chest pain, wheezing and low grade fevers. She had symptoms for several days prior to being seen in the ED on the day of admission and was evaluated in both an urgent care and an ED for evaluation before. She was treated with steroids, breathing treatments and initially felt better, but this did not last, and she came back to the ED with complaints of shortness of breath for a repeat evaluation. 

The inpatient level of care is medically necessary for this patient. This female who presented to the hospital ED with complaints of dyspnea. This is not a new complaint. Approximately 3 days before, she was seen in an Urgent Care and the ED where she was subsequently treated with steroids and inhalers. While she had some initial improvement with an outpatient regimen of therapy, she did not improve significantly and had return of her shortness of breath which is what prompted her return to the hospital for medical management. She has a history of asthma and findings concerning for acute decompensation that is manifested by her pH being 7.43 and a pCO2 that is approaching normal. Given the previous attempt at management via an outpatient level of care and progressive symptoms, an inpatient level of care is warranted based on clinical grounds.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tracheomalacia.

Treatment: Chest computerized tomography.

The insurer is denied coverage for chest computerized tomography. The denial is overturned. 

The patient is a female who was being seen by pulmonologist for evaluation of symptoms of allergic rhinitis, chronic cough and gastroesophageal reflux disease (GERD). The patient complained of shortness of breath. The patient had history of bronchitis/pharyngitis for which she had been treated with Augmentin. As per visit notes, the patient complained of chronic cough. The patient's physical exam was unremarkable other than for mild expiratory wheeze. The patient's provider was considering the possible diagnosis of tracheomalacia given the patient's chronic symptoms, and ordered a dynamic computed tomography (CT) scan of the chest to establish this diagnosis. The patient underwent a CT scan of the chest which revealed a 90 % bowing of posterior membrane of trachea on expiration scan, which was consistent with the diagnosis of tracheomalacia.

As per UpToDate, tracheomalacia (TM) may be suspected on the basis of a patient's symptoms and signs. The major symptoms and signs of TM in adults are dyspnea, cough, and sputum retention. Consistent with this patient's case, wheezing may also exist. Once TM is suspected, literature supports that the patient should undergo both dynamic CT and bronchoscopy with forced exhalation maneuvers to evaluate the degree of TM and bronchomalacia (BM). Both tests are necessary because either test alone may underestimate the degree of TM. CT and bronchoscopy have unique advantages. CT is better able to show the distal extent of the TM when it extends into the segmental and subsegmental bronchi. This has implications for treatment, since neither stenting nor surgical options can correct the distal disease. CT can also provide objective measurements of anterior - posterior and lateral dimensions as well as cross-sectional area. Bronchoscopy provides information about the ease of navigation into and within
the airways, which is useful for planning future interventions. Thus, CT chest was an appropriate diagnostic modality for this patient's diagnosis of tracheomalacia (TM). Thus, the chest computerized tomography (CT) is considered medically necessary.

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

Based on the above, the medical necessity for chest computerized tomography (CT) is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System.
Treatment: Inpatient Hospital.
Issue: Medical necessity
The health plan's determination is upheld in whole.

Patient has a past medical history (PMH) of hypertension (HTN), hyperlipidemia (HLPD) and tobacco use and was admitted  with complaints of  a two-day history of fevers, chills, body aches and productive cough. Vital signs were unremarkable. Physical exam notable for not appearing ill, no respiratory distress, and positive for wheezing. Lab work notable for positive influenza. Imaging studies, chest x-ray (CXR) showed right upper lobe (RUL) infiltrate concerning for pneumonia (PNA). An electrocardiogram (EKG) showed 1st degree AV block without acute ST changes. The patient was diagnosed with community acquired PNA and treated with intravenous (IV) antibiotics, Tamiflu, DuoNeb's, anti-tussive, prednisone and IV fluids. The patient was discharged in stable condition.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with c/o fevers, chills, body aches and productive cough. The patient was found to have viral PNA and treated with anti-virals. The patient was hemodynamically stable, did not require intubation, non-invasive positive pressure intubation, did not have any severe respiratory distress, tachypnea, use of accessory muscles in neck, severe intercostal retractions, cyanosis, new AMS, significant hypoxia, and the CURB-65 score was 0, indicating a low-risk patient. The pneumonia severity index was risk class I, indicating that outpatient therapy was reasonable. The patient was diagnosed with viral pneumonia and treated with IV fluids, anti-virals, DuoNeb's, prednisone, and anti-tussive, all of which could have been safely and appropriately provided at a lower level of care, and this would have been within the accepted standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Wheezing, shortness of breath, chest discomfort.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

No, the Inpatient Admission was not medically necessary.

The patient is a male with history of asthma with worsening shortness of breath, chest discomfort and palpitations. He was admitted to acute in hospital level of care for possible asthma exacerbation, as well as telemetry monitoring for tachycardia. 

The patient was not in any distress. The patient had tachycardia ranging from 100-130s. The patient was treated with IV steroids, IV antibiotics and nebulization treatment, as well as telemetry monitoring.

The patient likely had bronchitis leading to mild asthma exacerbation. Due to chest tightness and tachycardia, the patient was admitted to inpatient hospital. However, the patient was overall hemodynamically stable. His tachycardia had improved significantly. His electrolytes and hemoglobin were within normal limits (WNL). The patient was ambulating and tolerating oral diet. The acute hospitalization is not medically necessary. The observation level of care would have been safe and effective.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain.
Treatment:  Inpatient admission.

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

This is a male patient with a history of pulmonary sarcoidosis, substance abuse, hypertension, coronary artery disease (CAD), myocardial infarction (MI), tobacco use and obesity.  He presented to the Emergency Department (ED) with complaints of chest pain and a worsening cough.  His presenting vital signs were: temperature 97.9, blood pressure 113/75, heart rate 85, respiratory rate 20, and oxygen saturation of 98% on room air.  The patient's cardiovascular exam was also unremarkable.  The patient's electrocardiogram (EKG) showed T- wave inversions.  The patient's troponin was negative.  The patient's urine toxicology was positive for cannabinoid.  The patient was admitted to the hospital.  His medical treatment included intravenous (IV) fluids, IV famotidine and nitroglycerine sublingual.  The patient ruled out myocardial infarction (MI).  The patient was cleared for discharge home.

Based on the review of the medical record and clinical guidelines, inpatient admission was not medically necessary for this patient.  The patient presented with chest pain.  The patient's initial evaluation in the Emergency Department (ED) was unremarkable, including a non-diagnostic electrocardiogram (EKG) and negative cardiac biomarkers.  The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing.  Further evaluation was warranted; however, inpatient admission criteria was not met.  There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. 

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 admission is not substantiated.  The insurer's denial should be upheld.