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

Diagnosis: Traumatic subarachnoid hemorrhage
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with ETOH (alcohol) abuse who presented to the ED (emergency department) with head trauma.

The patient had a head laceration. Her exam revealed that the patient was alert and oriented with slurred speech and agitation at times. CT (computed tomography) showed a small region of traumatic subarachnoid hemorrhage in the left frontal region on arrival.

The patient was monitored with q2h (every two hours) neurological checks. A repeat head CT (computed tomography) was ordered within eight to 10 hours.

The patient was admitted.

Yes, the Inpatient admission was medically necessary.

The patient presented with a traumatic subarachnoid hemorrhage, and she had a laceration and unclear history of injury. As such, it was appropriate to admit the patient overnight for repeat head CT (computed tomography) and close neurological monitoring. This type of bleeding has a risk for worsening, which can lead to long-term neurological injury and potentially death. This would not be appropriate to be treated in a lower level of care. Therefore the overnight admission is considered medically necessary for this patient.

The health plan should cover the hospitalization, as this patient had a traumatic subarachnoid hemorrhage and was at risk for further worsening of this bleeding. This is appropriate to be monitored in an acute level of care, as the patient needed a neurosurgery consultation as well as repeat head CT (computed tomography) and frequent neurological checks. This could not be performed at a lower level of care, and the inpatient admission therefore was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a male patient who was transferred from the inpatient psychiatry ward to the telemetry ward after developing chest pain for 45 minutes. The patient's past medical history was significant for hypertension, alcohol abuse and attempted suicide. Upon arrival to telemetry, the patient's electrocardiogram (EKG) revealed normal sinus rhythm. The patient's serial cardiac enzymes were not elevated. The patient was ultimately transferred back to the psychiatry unit.  

Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient. This patient developed acute onset of atypical chest pain while lying in bed. The patient was hospitalized in a psychiatry unit due to active suicidal ideation and required constant observation. The patient's pretest probability of coronary artery disease was low.1 Utilizing the history, electrocardiogram, age, risk factors, and initial troponin (HEART- History, Electrocardiogram, Age, Risk factors, Troponin) score, the patient was considered low risk.2 Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score, the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days.3 Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (2018). Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary for this patient. The patient could have been managed at a lower level of care such as an observation unit followed by transfer back to the psychiatry unit. 

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 hospital admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (gingival recession with sensitivity in the areas of tooth #3-5 and 12-13, maxillary gingiva).

Treatment: Periodontal treatment for soft tissue allograft for tooth #3, tooth #4, tooth #5, tooth #12 and tooth #13 (code D4275).

The insurer denied coverage for the periodontal treatment for soft tissue allograft for tooth #3, tooth #4, tooth #5, tooth #12 and tooth #13 (code D4275).

The denial is upheld. 

This is a female patient who presented for evaluation and management of gingival recession with sensitivity in the areas of tooth #3-5 and 12-13, maxillary gingiva. Based on the clinical and radiographic findings, the dentist recommended the aforementioned services of allograft to these sites for reduction of sensitivity and esthetics. The insurer has denied these codes stating that the documentation provided does not support the services as it is incomplete, and does not meet the insurer's clinical criteria. Therefore, the insurer deemed the procedure not medically/dentally necessary. The patient is appealing stating that she was told that these services are necessary and takes issue that her provider's office was requesting payment out of pocket.

Based on the clinical and radiographic information provided for review the alveolar bone height is acceptable. The full mouth series radiographs do indicate a level of alveolar bone loss commensurate with the patients' chief complaint and correlate with the periodontal chartings provided for review. However, it seems the main concern is esthetics and sensitivity reduction. Although grafting procedures are used for these purposes, in this case, there is no indication that non-surgical therapies were attempted in order to reduce the sensitivity. Further, the clinical criteria exclude esthetic concerns from coverage. At this point, the surgical services would be considered elective. If the patient elects to have these services provided, then these services would be considered an out-of-pocket expense as the remaining clinical criteria do not support surgical correction of this issue. 

The periodontal treatment for soft tissue allograft for tooth #3, tooth #4, tooth #5, tooth #12 and tooth #13 (code D4275) is not considered medically necessary for this patient. 

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

The medical necessity for the periodontal treatment for soft tissue allograft for tooth #3, tooth #4, tooth #5, tooth #12 and tooth #13 (code D4275) is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Post-concussion syndrome.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a male patient who was seen in the Emergency Room (ER) for a seizure disorder and a fall.  The initial imaging was negative.  However, the patient returned to the ER with nausea and vomiting.  The patient's repeat computed tomography (CT) scan showed a temporal bone fracture.  The patient's vomitus contained streaks of blood.  The Ear Nose & Throat (ENT) consult did not advise any acute interventions.  The patient's abdominal exam was benign.  The patient's hemoglobin was 14.1.  The patient remained hemodynamically stable.  The patient's hematemesis resolved.  The seizure medication regimen was adjusted.  The patient was referred to a gastroenterologist for evaluation of a hiatus hernia and esophagitis.

Clinical indications for admission for Upper Gastrointestinal Bleeding (M-180) include ongoing bleeding, high risk endoscopic features, hemoglobin under 12, orthostatic hypotension, altered mental status, severe thrombocytopenia, and an inability to maintain oral hydration.  In this case, the patient did not have these conditions.

Clinical indications for admission for Traumatic Brain Injury, Non-Surgical Treatment (M-78) include hemodynamic instability, altered mental status, new focal neurological signs, an open skull fracture, an intracranial infection or recurrent seizures. In this case, the patient did not have these conditions.  The patient previously had seizures but they were controlled with medication.

The patient's neurological examination was non-focal and his CT scan findings did not warrant inpatient level of intervention or care.  According to the patient records, there is no clear evidence of acute change in the patient's neurological examination.  No acute motor, sensory or visual deficits that suggest an acute stroke was present. There was no instability, new focal neurological signs, acute stroke, hemodynamic or cardiovascular compromise or acute prolonged metabolic decompensation or seizure.  

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient was treated for a post-concussion syndrome with Zofran, Tylenol, and Toradol.  This treatment could have been given with observation status.  The patient's hematemesis was self-limited and did not meet MCG criteria for admission.  No surgical interventions were needed for the patient's temporal fracture.  

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 hospital admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Foreign Object.

Treatment: Inpatient admission.

 The insurer is denied coverage for the inpatient admission as not medically necessary. 

The denial is overturned. 

This is a male patient who was brought to the Emergency Department (ED) by his mother after swallowing a penny.  A single view of the chest was obtained and revealed a round foreign object within the proximal esophagus. The patient was admitted from the ED.  The patient was admitted for management and underwent esophagoscopy removal of the foreign object.  The procedure was uncomplicated and the patient was deemed stable for discharge. 

The inpatient admission is considered medically necessary for this patient.  The patient was brought to the ED.  The patient was admitted for Ear Nose & Throat (ENT) management. The patient had a hoarse voice upon waking per the ED nurse and his mother.  The patient was appropriate for admission due to the hoarse voice and to monitor him very closely for any change(s) in his condition due to his age and him swallowing a penny, which at any time could have caused difficulty breathing.  Direct laryngoscopy required general anesthesia.  In addition, due to the intervention that was performed, the patient would continue to be appropriate for inpatient admission until deemed stable due to the possibility of laryngeal swelling from the irritation caused by the penny and the direct laryngoscopy.

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

The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Erupted teeth.
Treatment: D7210 Surgical Extraction, Tooth 10,11,20,29, And 6.
The insurer denied the D7210 Surgical Extraction, Tooth 10,11,20,29, And 6.
The denial is upheld. 

The patient is a female. She who has been denied code D7210 for #6, #10, #11, #20 and #29. The reason for the denial is that these are not evidenced to be surgical extractions but routine extractions.

No, the D7210 Surgical Extraction, Tooth 10,11,20,29, and 6 are not medically necessary.

The panorex radiograph shows that the involved teeth are erupted. The documentation evidences these to be simple extractions. However, even if the crown of the tooth has been fractured, and the removal of the exposed root is elevated and/or removed with forceps, even if a periosteal flap is completed, the appropriate ADA (American Dental Association) code is not D7210. If, in addition to the flap, bone is removed, or the roots are sectioned in order to remove the roots, then the surgical extraction code is D7210. D7210 would only be justified with an operative report showing that bone removal was required. Therefore, the D7210 Surgical Extraction, Tooth 10,11,20,29, and 6 are not medically necessary.

Code D7210 would require an operative report showing that bone removal was required. Standard of care for a patient such as this would involve code D7140, extraction, erupted tooth or exposed root (elevation and forceps removal).
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with CAD (coronary artery disease), HTN (hypertension), HIV (human immunodeficiency virus) was sent to the emergency room after having had an abnormal radiology evaluation. The emergency evaluation revealed pleural effusion and pulmonary edema/pneumonia. The patient was admitted to acute in hospital level of care for IV (intravenous) antibiotics.

No, the Inpatient admission was not medically necessary.

The patient's CURB-65 (confusion, blood urea nitrogen, respiration rate, blood pressure, Age 65+) score was 1. This score is a low-risk group for adverse outcomes, and can be safely treated as an outpatient. The patient was hemodynamically stable. The patient was able to ambulate and tolerate oral diet. The patient did not require supplemental oxygen. The acute inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted teeth
Treatment: Braces (D8080) And Monthly Visit (D8670), Pre-service
The insurer denied the Braces (D8080) And Monthly Visit (D8670), Pre-service.
The denial is overturned. 

The Patient is a male. The requesting is for dental benefits for Orthodontic therapy and monthly visits. Per the dental clinical exam summary, the Patient has a Class I on the left, Class II on the right side.

The patient has impacted third molars, tooth #31-(lower right 2nd molar) is horizontally impacted. The patient complains of pain in this area.

Yes, the proposed treatment of orthodontic therapy and monthly visits are medically necessary.

The proper alignment and position of tooth #31 (lower right 2nd molar) is essential for proper chewing function on the patient's right side. This horizontal impaction of tooth #31 and its positioning against the distal root of the adjacent tooth (#30- lower first molar) is a severe deviation from the normal eruption position. This tooth should be vertical with the clinical crown present against the opposing tooth for normal chewing function to occur. This impaction does not only compromise tooth  #31 itself, but also potentially compromises tooth #30 and therefore has the potential of rendering both molars on the patient's lower right side unavailable for chewing.

The consequence of leaving this condition untreated can severely impact the patient's ability to chew on the right side of his mouth and leaves the potential for the opposing tooth--(tooth #2--upper right 2nd molar) to super erupt and grow into the space of the lower tooth--#31.

The complications from this condition has the potential to affect a total of three molars on the right side of the patient's mouth.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dislodged percutaneous endoscopic gastrostomy (PEG) tube.

Treatment: Acute Inpatient Hospitalization.

The insurer denied coverage for the Acute Inpatient Hospitalization.

The denial is upheld. 

This is a female patient whose medical history includes deep vein thrombosis, pulmonary embolism, and hypertension. She presented to the Emergency Room (ER) with a dislodged percutaneous endoscopic gastrostomy (PEG) tube. She was also noted to be more sleepy than usual. She was afebrile and the vital signs were stable. The old PEG tube was removed and a new feeding tube was placed. A head computerized axial tomography (CAT) scan was negative for acute disease. The Infectious Disease (ID) consult advised that there was no sign of infection and that antibiotics were not needed. The organism found in a culture bottle was considered a contaminant. Intravenous hydration was given. Her mental status improved.

Clinical Indications for admission for Dehydration according to Milliman Care Guidelines (MCG) include hemodynamic instability bowel obstruction, severe vomiting, and persistent abnormal mental status after appropriate treatment, severe electrolyte abnormalities, and an inability to provide oral nutrition after observation care. The patient did not have these conditions. The PEG change did not require an inpatient hospitalization. Intravenous hydration could have been given with observation status. Her mental status improved after the intravenous hydration was given and the feedings were restarted. 

The healthcare plan acted reasonably and with sound medical judgement. An inpatient hospitalization was not medically necessary. 

The medical necessity for the Acute Inpatient Hospitalization is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tonsillar Hypertrophy.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient had sleep apnea and her exam revealed tonsillar hypertrophy. She had no other significant medical or surgical history. She underwent a tonsillectomy and adenoidectomy. There were no intraoperative complications. The patient was admitted to the hospital overnight. There were no peri-operative complications noted. She was discharged home the next day.
The inpatient stay was not medically necessary.
The patient had sleep disordered breathing. She had no underlying medical problems. She underwent an uncomplicated tonsillectomy and adenoidectomy. There were no intraoperative or peri-operative complications. There was no documentation that supported an inpatient level of stay for this patient. She could have been managed at a lower level of care which allows for an overnight stay. The current standard of care based on the American Academy of Otolaryngology Head and Neck Surgery recommends overnight stay for children under the age of 3 who undergo a tonsillectomy. An inpatient admission was not necessary, however, as the child had no significant medical comorbidities or documented complications from the procedure. An inpatient stay would not be expected to provide better outcomes than a lower level of care in a child who underwent an uncomplicated tonsillectomy and adenoidectomy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Immunologic Disorders/Arthritis
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested prescription drug, Xeljanz. The health plan's determination is upheld.

The patient is a female with psoriatic arthritis (PsA). The issue in this case is that Xeljanz XR is being denied by the health plan, reason cited is that it is not medically necessary as she has not failed or had an intolerance to two of the preferred products, including Cimzia, Humira, Simponi, Stelara or Tremfya. The reason cited is 'severe needle phobia' stated in a letter from her physician. Prior treatment: nonsteroidal anti-inflammatory drugs (NSAIDs) , Rheumate, Tizanidine, Prednisone and MTX.
At issue is the medical necessity of the requested prescription medication, Xeljanz.

I uphold, in whole, the health plan's determination of medical necessity. 

No, the requested health service/treatment of Xeljanz XR is not medically necessary for this patient. She does not have a contraindication to one of the preferred agents, Cimzia, Humira, Simponi, Stelara or Tremfya. These medications are all indicated for psoriatic arthritis and are consistent with the standard of care. They are not inferior to the non-formulary drug, Xeljanz XR. Needle phobia is not a contraindication or intolerance to the preferred drugs covered by the health plan, including Cimzia, Humira, Simponi, Stelara or Tremfya. As stated, the patient does not have a contraindication to one of the preferred agents. A study published in Expert Review in Clinical Immunology concluded that 'CZP (Cimzia) demonstrated positive results in several domains of psoriatic disease, also in patients previously exposed to other tumor necrosis factor (TNF-a) inhibitors and in patients receiving re-treatment after treatment interruption'.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Deep Vein Thrombosis.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient hospital stay due to the lack of medical necessity. 
The health plan's determination is upheld.

The patient is a  female who was admitted to the hospital  for left leg swelling. She has a history of asthma and deep vein thrombosis (DVT). On presentation, her electrocardiogram (EKG) was normal. A chest x-ray noted mild atelectasis. A computed tomography (CT) angiogram of the chest noted a pulmonary embolism. An ultrasound of the leg also noted a DVT. The patient had severe dyspnea. Vitals were stable. Lab-work was unremarkable. She was started on full dose Lovenox. An echocardiogram was unremarkable. Brain (or B-type) natriuretic peptide (BNP) and troponin were normal.
The question is whether the patient met medical necessity for the acute inpatient level of care.

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

The patient in question does not meet medical necessity for the acute inpatient level of care per current literature and standard of care. According to Konstantinides et al., (2019), Kearon et al., 2016), and Ortel et al., (2020), the patient had a low-risk pulmonary embolism according to the pulmonary embolism severity index. The patient had no high-risk features such a right heart strain, abnormal EKG, elevated troponin, or elevated BNP. The patient would have been appropriate for the observation level of care.