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

Diagnosis: Right distal ureteral stone with right hydronephrosis.
Treatment: Inpatient admission.
The insurer denied coverage for Inpatient admission.
The denial is Upheld.

This is an adult patient with a past medical history of renal stones, who presented with right flank pain. The patient was hemodynamically stable in the Emergency Room (ER) with a white blood cell count (WBC) of 13,000. Computed tomography (CT) scan showed a right distal ureteral stone with right hydronephrosis. The patient was admitted, and taken for cystoscopy, right ureteroscopy (URS), and laser lithotripsy with stent placement. The patient tolerated the procedure well and improved post-operatively. The patient was stable for discharge to the home with outpatient follow-up. 

The patient was an adult with no serious medical co-morbidities that would constitute ASA (American Society of Anesthesiology) class III or IV physical status classification of the patient's condition, including severe systemic disease such as cardiac, chronic obstructive pulmonary disease (COPD), diabetes, ascites, immunocompromised status, morbidity obesity. 

The patient fails to meet InterQual criteria for admission to inpatient care. In addition, per Millian Care Guidelines (MCG) Health Renal Colic and Kidney Stones, the patient fails to meet guidelines for admission to inpatient care. The patient underwent an uncomplicated procedure.

The patient was symptomatic with a large right distal ureteral stone with outpatient services indicated.

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 inpatient services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gunshot wound
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a previously healthy, intoxicated male patient who presented to the emergency department (ED). He had been shot in the right thigh and punched in the face with a resultant lip laceration.
At the time of presentation to the ED, he was awake and alert. The Glasgow coma score was 15/15 at the time of presentation. Computed tomography (CT) scans and x-rays did not identify bone or vascular injury. The lip laceration was repaired by the Oral and Maxillofacial Surgery service while he was in the ED.
The patient was admitted to the hospital. He was started on a diet and he was able to walk in his room and was receiving oral pain medications. He was considered to be stable for discharge from the hospital. At issue is the medical necessity of an inpatient admission.
Inpatient admission was not medically necessary for this patient based on the submitted clinical documentation and the standards of medical care. A lower level of care would have been clinically appropriate in this case and would have been consistent with medical standards.
There is no documentation of an adverse change in clinical status, intensity of services or new condition supporting need of an inpatient level of care. In this case the patient was clinically stable at the time of presentation to the ED. Evaluation that included physical exam, labs and diagnostic imaging. He was without traumatic injury that required inpatient admission. He was able to resume a diet and tolerate oral medications. He remained stable throughout the period of monitoring. A lower level of care would have permitted the short term monitoring that would not have been expected to be longer than 48 hours and would have permitted acute treatment and reassessment, monitoring of his response to therapy, and diagnostic evaluation to establish a treatment plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied Braces.
The determination is upheld.


This is a female patient with a Class I malocclusion, severe maxillary crowding and mild mandibular crowding, mild overjet, mild overbite with an ectopically erupting tooth number (#) 6 and tooth #11 and missing a lower incisor. At issue is whether the requested health service/treatment of braces are medically necessary.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 19 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, deep impinging overbite with severe soft tissue damage, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, the requested health service/treatment for braces are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins
Treatment: Sclerotherapy or Echosclerotherapy (including 
ultrasound guided foam sclerotherapy) (Code 36471)
The insurer denied: Sclerotherapy or Echosclerotherapy (including ultrasound guided foam sclerotherapy) (Code 36471)
The denial is overturned.

The patient is an adult female. She presents with varicose veins and venous insufficiency of the right leg. The patient has already undergone right greater saphenous vein (GSV) ablation 3 months ago. The follow-up office note 3 months ago states that the patient has residual calf symptoms for which the provider has recommended phlebectomy and sclerotherapy. Coverage for sclerotherapy has been denied on the basis of existing medical guidelines.

The requested health service is medically necessary.

In order to determine the medical necessity of the procedures, widely accepted criteria will be applied. Under widely accepted criteria (1, 2), phlebectomy and/or sclerotherapy of varicose vein clusters is medically necessary when: 
1. The patient has venous insufficiency symptoms severe enough to affect normal function. 
2. The patient has failed a trial of prescription compression stockings. 
3. The patient does not have axial reflux in the affected leg, or such axial reflux is to be treated before or at the same time as phlebectomy/sclerotherapy. 
4. The patient has varicose veins large enough to account for the symptoms.
Requirement # (number)1 has been met. The patient has residual symptoms after successful ablation of the right greater saphenous vein. According to both the office notes and the patient's appeal letter, her symptoms adversely affect her job as a teacher. 
Requirement #2 has been met. Office notes and the patient's letter show that the patient tried and failed compression stockings prior to the greater saphenous vein ablation. 
Requirement #3 has been met, because the axial reflux has already been treated. 
Requirement #4 has been met. The submitted photos depict very large varicose veins suitable for phlebectomy. The same photos depict smaller branch varicose veins suitable for sclerotherapy. In view of these considerations, sclerotherapy is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure disorder
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult male with a history of seizure disorder who presented to the emergency ward after two reported seizures. He had another seizure after presentation in the emergency ward. He reported non-compliance with his anticonvulsant regimen. He was loaded with parenteral levetiracetam in the emergency ward. He was admitted for further evaluation and management. Admission note at presentation documented normal mental status.

The Inpatient admission was not medically necessary.

The patient had a known seizure disorder, and the reason for breakthrough seizure was identified at presentation as noncompliance with anticonvulsant regimen. Appropriate treatment was established in the emergency ward (1), and he returned to his baseline neurological status prior to admission. The treatment, monitoring, and diagnostic studies could have been safely and effectively provided at a lower level of care (2).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: iron deficiency anemia

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


This is an adult female with a history of an immune deficiency disease and post-traumatic stress disorder (PTSD). The patient was sent to the emergency room (ER) by her primary care provider (PCP) for dyspnea and a hemoglobin (Hgb) of 5.7. The patient was admitted to the hospital and transfused. The plan was for esophagogastroduodenoscopy (EGD) and a colonoscopy despite not having active bleeding but the patient left against medical advice. (AMA). 

The patient presented with iron deficiency anemia, and while symptomatic they did not have objective bleeding. The patient was transfused in the emergency room (ER) and improved. There was no reason provided to delay esophagogastroduodenoscopy (EGD) for two days.  As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate.

"Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L (grams per liter), with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB (upper gastrointestinal bleeding) undergo endoscopy within 24 hours of presentation. "(Barkun AN., et al 2019)

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is an adult male with a past medical history of hypertension diabetes mellitus and coronary artery disease who presented to the hospital with chest pain on deep inspiration.  He had presented to a neighboring emergency department (ED) one day prior with similar symptoms.  On arrival to the hospital, vital signs were stable (Blood Pressure 132/96, Pulse 82).  Physical examination revealed reproducible chest pain with palpation of the anterior chest wall.  12 lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST (interval on ECG) or T (interval on ECG) wave abnormalities. Serum troponin levels were not elevated (<0.01 ng/ml). The patient was admitted to the hospital for treatment.  Nuclear perfusion testing demonstrated no ischemia.  The patient was treated with antihypertensive medication and discharged home.

This patient presented with atypical chest pain and a past medical history of coronary artery disease, hypertension and diabetes mellitus. His pretest probability of coronary artery disease was high. Utilizing the HEART (score to assess cardiac event risk) score he was considered low risk.  Utilizing the TIMI (score of risk for heart problems and death) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days.  Risk assessment of patients presenting with chest pain and no significant ST (heart rhythm) changes on electrocardiogram (ECG), was reviewed by Hedayati et al.  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.  Recent American College of Cardiology expert consensus statement for treatment of acute onset chest pain places this patient in a low risk group and eligible for outpatient workup. In conclusion, admission to the hospital to treat an acute cardiac event 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 inpatient admission services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain, laminectomy
Treatment: Skilled Nursing Facility
The insurer denied the Skilled Nursing Facility.
The determination is overturned.

This is a male patient with a past medical history significant for recent laminectomy, deep vein thrombosis (DVT), hypertension, hyperlipidemia, coronary artery disease. He had a recent admission to the hospital secondary to urinary retention/infection. He was previously admitted to skilled care and then readmitted to the hospital. The patient was then transferred to continue physical therapy post spinal surgery. The patient was then admitted for inpatient hospitalization for surgical treatment of a lumbar (L) 5-sacral (S) 1 fracture. At issue is the medical necessity of skilled nursing facility.
Skilled Nursing Facility (SNF) care is medically necessary. The services are medically necessary for continued treatment for urinary sepsis/infection and also therapeutic services status post laminectomy including occupational therapy (OT) and physical therapy (PT).
The patient was initially admitted to the hospital secondary to a surgical procedure resulting in a laminectomy. The patient went to skilled care and then subsequently went back to the hospital for urinary sepsis. After the hospitalization, the patient was readmitted to skilled care. The patient had continued treatment for the urinary infection along with therapeutic services. He was dependent upon others for activities of daily living (ADLs), physical therapy notes state that the patient was maximal assist for ADLs, bathing and toileting. The patient was nonambulatory and required maximal assistance for transfers. There was very limited progress in the first 2 weeks which was the time period the patient was initially evaluated by his insurance for continued coverage. However, the patient did make some progress, although limited. Due to the extensive nature of the patient's surgery, it would be expected that the patient may need more of an extended time to recover. Therefore, it is reasonable for the requested services.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male admitted to the hospital with recurrent right upper quadrant (RUQ) pain, now severe; pain occurred at 3 am and awoke him from sleep. He has a chronic history of gastroesophageal reflux disease (GERD). Pain was worse with specific foods such as spicy meals and associated with progressive nausea. On admission, vital signs were stable and the patient afebrile. The patient was tender in the epigastrium without guarding or rebound and found to have markedly abnormal LFT's (liver function tests), mixed hepatocellular and cholestatic with a T bili (total bilirubin) of 4.4 and an aspartate aminotransferase (AST) = 473. A normal lipase was noted. An admission computed tomography (CT) was with gallstones but no evidence of cholecystitis.

The inpatient hospital was not medically necessary.
The patient had the classic presentation for acute biliary tract disease. The pain was sudden onset, epigastric/RUQ, occurred in the middle of the night, awakening the patient from sleep. The Liver Function Test (LFT) pattern was consistent. Imaging demonstrated gallstones with no dilation of the common bile duct. By day 2 of the hospitalization the LFT's were actually peaking, up slightly from admission. The usual approach is to then perform an magnetic resonance cholangiopancreatography (MRCP) or an endoscopic ultrasound (US) of the biliary tree to determine if a common bile duct (CBD) stone is present. If there is no stone, then the conclusion is that the stone (s) passed, and the patient will recover quickly and can be sent home. If a stone is present, an endoscopic retrograde cholangiopancreatography (ERCP) is indicated. Without this testing, one must rely on the clinical picture and trend LFT's. That was the approach in this case. With the latter approach, there really is no need for an inpatient level of care. He was significantly improved clinically after admission and the main focus of the hospital course was simply trending the LFT's. This could have safely and effectively been accomplished at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ehlers-Danlos syndrome
Treatment: Pain Injection (27096 x2)
The insurer denied: Pain Injection (27096 x2)
The denial is overturned.

The patient is an adult female with history of Ehlers-Danlos syndrome who also has sacroiliac joint pain/sacroiliitis. She has tenderness over the sacroiliac (SI) joint. She has failed conservative treatment. A sacroiliac joint injection has been recommended.

The requested health service is medically necessary.

The patient is an adult female with history of Ehlers-Danlos syndrome who also has sacroiliac joint pain/sacroiliitis. She has tenderness over the sacroiliac joint. She has failed conservative treatment. A sacroiliac joint injection has been recommended. The patient has failed physical therapy and home exercise. Physical exam reveals three provocative maneuvers, consistent for sacroiliac joint pain. Given that the patient has clinical and physical exam features consistent with sacroiliac joint pain, she has failed conservative treatment, sacroiliac, joint injections are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity

Treatment: Wegovy 2.4 mg / 0.75 ml injection, for a date yet to be determined

The insurer denied coverage for Wegovy 2.4 mg / 0.75 ml injection, for a date yet to be determined

The denial is upheld 


This is an adult female diagnosed with obesity who states she has lost 50 pounds with Wegovy. She states that she was pre-diabetic with peripheral neuropathy before taking Wegovy. 

Semaglutide is a glucagon-like peptide 1 receptor (GLP1R) agonist that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity. Recent studies published in major peer reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity. This medication is now available for the treatment of obesity in the form of Wegovy. 

The standard of care based on multiple societal guidelines requires that the patient participate in lifestyle modification. It also requires that the patient has a body mass index (BMI) of 30 or greater or a body mass index (BMI) of 27 or greater with comorbidities such as hypertension, and hyperlipidemia.
 
There is no documentation of the patient's pretreatment body mass index (BMI) and current body mass index (BMI). There is no submission of medical records indicating the patient's current treatment plan and participation in lifestyle modifications. 

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 a Wegovy 2.4 mg / 0.75 ml injection, for a date yet to be determined and filled at a network pharmacy is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient presented to the emergency department (ED) with periumbilical and right lower quadrant (RLQ) pain. The patent has a past medical history of seizure (no longer on medication) and kidney stones. The patient was seen the day prior at an urgent care center where a computerized tomography (CT) scan showed nonspecific morphology to the appendix. On admission he reported fever and nausea with decreased appetite.  Examination revealed right lower quadrant (RLQ) mild tenderness. No rebound or guarding was noted. 

Labs included white blood cell (WBC) count of 11.3. The plan was abdominal ultrasound and discuss with surgery. The patient was afebrile with stable vital signs. Surgery noted that the sonogram did not reveal the appendix. The assessment was acute appendicitis. The plan was to reassess in the morning and if pain persisted to discuss surgery.

The progress note on Day 2 indicated no acute events overnight. The pain was adequately controlled. The patient was nothing by mouth (NPO) since midnight in anticipation of the possibility of surgery. He denied fevers. White blood cell (WBC) count was 9.1. Laparoscopic appendectomy was performed. The finding was acute appendicitis. There were no complications noted. Pathology revealed acute appendicitis. The patient did well and was discharged the day of surgery to home.

Based upon the records provided the patient did not require acute inpatient admission but rather observation status as he did not have any complications from the surgery that warranted inpatient care. The laparoscopic appendectomy was uneventful and there was no perforation. There was no evidence of a complicated post operative course requiring hospitalization and the patient was discharged within 23 hours. 

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 the full hospital admission is not substantiated.