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

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult female who presented to the hospital emergency department (ED) and was admitted with abdominal pain in the setting of recent cholecystectomy that had been performed ten-days earlier.  At the time of presentation, the patient was without fever and vital signs showed a heart rate of 95 beats per minute and blood pressure of 116/67 millimeters of mercury (mmHg).  She had a nontender abdomen.  The white blood cell (WBC) count was 6.1 thousand (4.5-10.8).  The complete metabolic panel identified elevated serum transaminases and bilirubin.  Computed tomography scan identified dilated biliary ducts.

The patient was admitted to the hospital.  She was initially treated with intravenous fluid and antibiotics.  Magnetic resonance cholangiopancreatography (MRCP) showed a surgically absent gallbladder and a normal common bile duct (CBD).  Gastroenterology consultation was obtained, and the patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction, sphincterotomy and stent placement.  The procedure dictation describes an uncomplicated ERCP procedure.

The patient was treated with post-procedure monitoring and intravenous fluids.  The immediate recovery was uncomplicated.  Following the endoscopic procedure, the patient had stable vital signs.  The diet was advanced.  She was discharged from the inpatient setting with instructions for gastroenterology follow up in six to eight weeks.

The proposed treatment was not medically necessary.

An inpatient level of care was not medically necessary in this case.  This patient is an adult female who presented to the emergency department and was found to have elevated serum transaminases and obstructive jaundice.  She was hemodynamically stable at the time of presentation and had no fever or elevated white blood cell count.  

The patient was admitted to the hospital and had further evaluation with MRCP.  Follow up lab data identified persistently elevated bilirubin and transaminases.  The patient underwent an uncomplicated ERCP procedure.  The patient remained hemodynamically stable during the period of pre-procedural care, during the ERCP procedure, and during the period of post-procedure monitoring.  

The records support that the indication for ERCP procedure was established.  The patient was discharged from the hospital 2 days post procedure.  A lower level of care would have allowed for monitoring, confirmation of clinical stability and the ERCP procedure.	

There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation.  There were no peri-operative complications or other clinical issues that mandated inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cystinuria. 
Treatment: Thiola EC (enteric coated) 300 mg (milligram) Tab (tablet). 

The insurer denied coverage for Thiola EC 300 mg TAB. 
 
The denial is upheld. 

This is a patient with a history of cystinuria. The patient's physician has recommended the patient take a Thiola EC (enteric coated) 300 mg (milligram) Tab (tablet) to treat her condition. 

There is no documentation of the kidney stones and no available 24-hour urine Cystine excretion to assess if Thiola is appropriate for this patient. 

This patient may benefit from repeated kidney imaging to assess if she had kidney stones and remeasure 24-hour urine to check Cystine excretion prior to starting Thiola.

This request is not medically necessary because the medical records did not show the patient had recurrent kidney stones secondary to Cystinuria. 

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

The insurer's denial of coverage for the Thiola EC 300 mg TAB is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lightheadedness and chest pain.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is an adult male that presented to the hospital complaining of lightheadedness and chest pain. Symptoms developed while having blood drawn just after a routine follow-up visit with his cardiologist. Past medical history was significant for ischemic heart disease, coronary stents x5, heart failure with reduced ejection fraction [left ventricular ejection fraction (LVEF) 45%], paroxysmal atrial fibrillation, and placement of implantable cardiac defibrillator. Upon arrival at the hospital, vital signs were stable. Physical examination revealed no significant abnormalities. 12 lead electrocardiogram (EKG) revealed normal sinus rhythm without ST or T wave abnormalities. Serum troponin levels were not elevated. Computerized tomography (CT) head revealed no acute stroke or intracerebral mass. The patient was admitted to the telemetry unit where he continued to note dizziness with head movement. Neurology evaluation was unrevealing, and the patient was treated for benign positional vertigo with meclizine. No rhythm abnormalities were noted on telemetry while the patient complained of symptoms. Ultimately, the patient was discharged home with follow-up. 

According to the European Society of Cardiology syncope guidelines, this patient was at low risk for future morbidity and mortality. (Reference 1) In a study of individuals presenting to the emergency room with dizziness, near syncope, and syncope, patients that were at low risk for cardiac events (no acute cardiac findings on initial evaluation) had an excellent prognosis and did not require admission to the hospital for further testing. (Reference 2) This patient was low-risk and was diagnosed with positional vertigo. In conclusion, acute inpatient admission was not medically necessary.

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

The insurer's denial of coverage for inpatient admission is upheld.  Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Partial lower denture, lower right part of mouth 
The insurer denied the Partial lower denture, lower right part of mouth.
The determination is overturned. 


The patient presented for the treatment of a mandibular partial denture 5214 for the lower right part of the mouth. Provided for review are a letter from the patient, letters of appeal and denial, radiographic images  and a single page of American Dental Association (ADA) claim forms. According to the health plan, to qualify for partial dentures, there must be less than eight back teeth that touch in order to qualify for a partial denture. At issue is the medical necessity of partial lower denture, lower right part of mouth.

The requested health service/treatment of partial lower denture, lower right part of mouth is medically necessary for this patient.
The standard of care for patients with a diagnosis of partial edentulism is to replace the missing teeth, either with a partial/full denture, or implant/tooth retained prosthesis. The requested treatment is considered medically necessary based on the diagnosis itself and a residual dentition that can provide support stability and retention which is the case for this patient.  As the patient is missing teeth, they do require replacement, this is the entire basis for the field of removable prosthodontics and removable partial dentures. Hence, the treatment of lower partial denture 5214 is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decay.
Treatment: of D6750 white glass with high gold content cap for bridge teeth 18 and 20. 
The insurer denied: of D6750 white glass with high gold content cap for bridge teeth 18 and 20.
The denial is: Overturned.

The patient is a female presenting to her dental provider for the treatment of the mandibular left sextant. Included for review is a letter from the dental provider describing the decay and failed fixed partial denture from #18-20 with possible replacement with another fixed partial denture or separate crowns for #18 and 20 and an implant in site #19, letters of appeal and denial, peri-apical radiographs of the fixed partial denture, and a single page of American Dental Association (ADA) claim forms. The subject under review is the medical necessity for D6750 white glass with a high gold content cap for bridge teeth 18 and 20.

The health plan's determination is overturned.

The requested health service/treatment of D6750 white glass with a high gold content cap for bridge teeth 18 and 20 is medically necessary for this patient.
Based on the provided documentation the patient has a failed restoration from #18-20 due to decay which requires replacement. As a result of the decay and the failed restoration, the current options as described by the provider are correct as either a replacement of the current restoration with another restoration or two separate crowns for #18 and 20 with a single dental implant in site #19. Hence the current plan of D6750 white glass with a high gold content cap for bridge teeth 18 and 20 is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems - Chest Pain
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a female. No actual medical records were provided for review. Per an appeal letter submitted by the hospital, this patient presented to the emergency department (ED) complaining of chest pain. Her medical history was remarkable for hypertension, hyperlipidemia, and breast cancer. Her electrocardiogram (EKG) was normal. She was treated with aspirin, a statin, and a beta-adrenergic blocker. Myocardial perfusion imaging showed no evidence of ischemia, and the patient was discharged.

At issue is the medical necessity of the inpatient admission.

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

 No medical records were provided for review. In the absence of medical records, it cannot be determined if an inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Human Papillomavirus (HPV)
Treatment: Cidofovir Dihydrate Compound
The insurer denied coverage for Cidofovir Dihydrate Compound.
The denial is overturned.

The patient is a male who has requested Cidofovir Dihydrate Compound for wart treatment after failure of liquid nitrogen, topical salicylic acid, intralesional candida antigen, oral cimetidine and imiquimod. The patient had the request denied. The warts have inhibited activities of daily living and are painful.

"Genital condylomata acuminata are nonmalignant human papillomavirus (HPV)-induced tumors in which HPV types 6 and 11 are most commonly found. Usual treatments for condylomata acuminata are nonspecific and are based on the destruction or removal of infected tissue. These procedures are often painful and are characterized by a high relapse rate. We report here what is to our knowledge the first double-blind, placebo-controlled study of the use of cidofovir, a nucleotide analogue, for the treatment of genital papillomavirus infections. Thirty patients were enrolled in the study; 19 received cidofovir, and 11 received placebo. The median number of warts and the median baseline wart area were comparable for both groups. Nine (47% [percent]) of 19 patients in the cidofovir group had a complete response (total healing), compared with 0 of the patients in the placebo group (P=.006). None of the patients in the cidofovir group experienced progression of the disease, compared with 5 (45%) of 11 patients in the placebo group. The side effects recorded for both groups were comparable." (Snoeck, et al, 2001)

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

The insurer's denial of coverage for the Cidofovir Dihydrate Compound is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Bronchiolitis.
Treatment:  Inpatient admission.

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

This is the case of a male toddler who had been sick for 1 day with a cough, nasal congestion, and a runny nose. His mother also noted that he had diarrhea and a decrease in oral intake of fluids. He had a history of eczema and a family history of asthma in his mother. The mother brought the child to the pediatrician who noted hypoxemia, and on physical examination the pediatrician noted wheezing and rales over the right base of the lung. The pediatrician recommended that the child be taken to the emergency department (ER) for treatment.  In the ER, he was noted to be in respiratory distress with increased work of breathing, retractions, and increased use of accessory muscles of respiration. He was treated with steroids and 3 doses of albuterol and atrovent. A chest x-ray was consistent with bronchiolitis and a venous blood gas demonstrated an elevated partial pressure of carbon dioxide (PCO2) of 43. When he continued to have respiratory distress, the decision was made to admit the child to the hospital with a diagnosis of bronchiolitis for continued treatment with duoneb every 2 hours.

The patient was treated appropriately in the ER for respiratory distress with wheezing. The presence of persistent respiratory distress, chest congestion with wheezing are all signs of significant respiratory distress and the need for continued treatment with bronchodilator nebulization treatments every 2 hours. The decision to admit to the hospital for ongoing treatment was appropriate and consistent with the standard of care. 

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

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a pregnant female with a twin gestation. She had a history of gastritis, gastroesophageal reflux disease (GERD), depression, gestational diabetes, cholestasis of pregnancy and previous cesarean section. She was sent to the emergency room for worsening of the swelling of her lower extremities. Vital signs were normal except for a blood pressure of 143/98. She was admitted as an inpatient for management of her edema and blood pressure. Labs were drawn and she received steroids for fetal lung maturity, heparin and observation. Fetal ultrasound was normal. She left against medical advice (AMA).

The Inpatient Hospital Admission is not medically necessary for this patient.
The patient had pedal edema and high blood pressure in pregnancy. There were no severe findings in her vital signs nor on exam to support the need for inpatient admission. She could have been monitored in the clinic as an outpatient with labs and a 24 hour urine to evaluate for preeclampsia and this is standard of care. She also could have been observed in the hospital as an outpatient or under extended monitoring (less than 24 hours) if further observation was warranted. She had no evidence of end organ disease such as renal, hepatic nor pulmonary concerns/disease. She had no hemodynamic instability or any cardiac concerns. She had no diagnosis of eclampsia and seizures. Her labs showed only mild thrombocytopenia and never dropped below 100. Her vital signs including blood pressure remained stable and not in severe range, greater than 160/110. Further testing and work up is usually conducted with close follow up in the outpatient office setting. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical Chest Pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This is a patient with a past medical history of hypertension who presented to the hospital with chest pain radiating to her left arm. On arrival to the hospital, vital signs were stable blood pressure (BP) 140/91 mmHg (millimeters of mercury), Pulse 67 bpm beats per minute)). Physical examination revealed reproducible chest and shoulder pain with palpation. A12-lead ECG (electrocardiogram) revealed sinus rhythm with no evidence of ischemic ST (interval on ECG) or T (interval on ECG) wave abnormalities and poor R (interval on ECG) wave progression across the precordial leads. Serum troponin levels were not elevated (<0.012 ng/ml (nanogram per milliliter)). Stress echocardiogram demonstrated a normal LVEF (left ventricular ejection fraction) without evidence of ischemia. The patient was treated with antihypertensive medication and discharged with cardiology follow up.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient. This patient presented with atypical chest pain and a past medical history of hypertension. Her pretest probability of coronary artery disease was low (Reference 1). Utilizing the HEART (history, age, risk factors, and troponin) score she was considered low risk (Reference 2). Utilizing the TIMI (thrombolysis in myocardial infarction) risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 3). 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. In conclusion, this patient could have been treated at a lower level of care.

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

Diagnosis: Ulcerative Colitis
Treatment: Entyvio every 4 weeks
The insurer denied: Entyvio every 4 weeks
The denial is: Overturned

This male has severe ulcerative colitis. He previously tried and failed 5-Aminosalicylic acids (ASA) agents and steroids. He was started on Entyvio standard dosing in 2019 and initially responded but later lost response. He had symptoms suggestive of a flare of his ulcerative colitis and active inflammation on his colonoscopy. Therapeutic drug monitoring revealed low ustekinumab levels. Therefore, the attending gastroenterologist escalated the dose of Entyvio to 300 milligrams (mg) every 4 weeks to treat the patient's severe ulcerative colitis. His ulcerative colitis is in remission on the escalated dose of Entyvio. Therefore, the attending gastroenterologist is requesting the continued use of Entyvio at the escalated dose to treat this patient's ulcerative colitis. The subject under review is the medical necessity for the request for Entyvio every four weeks.

The requested health service/treatment of Entyvio (every 4 weeks) is medically necessary for this patient. This patient failed standard dosing of Entyvio. He has responded to an escalated dose of Entyvio, and his ulcerative colitis is in remission. Dose escalation is the standard of care in patients with inflammatory bowel disease (IBD) who are on biological medication and not responding to standard dose of the medication.
Dose escalation in biologic therapy used in inflammatory bowel disease can be done either based on clinical symptoms or laboratory markers or endoscopic or radiological features with or without therapeutic drug monitoring. Dose escalation is done either by increasing the dose of the medication or shortening the interval between doses or sometimes a combination of both. There are only a finite number of biological agents used to treat inflammatory bowel disease and the standard of care is to optimize dose of the biological agent before switching to another agent. Therefore, it is medically necessary to use Entyvio 300 mg intravenous (IV) every 4 weeks to treat this patient's severe ulcerative colitis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Vomiting, Pancreatitis, Alcohol Abuse.
Treatment:  Inpatient Hospital.
The insurer denied the Inpatient Hospital Stay.  
The determination is upheld.


This is a patient with a past medical history (PMH) of alcohol abuse, pancreatitis, alcohol withdrawal and withdrawal seizures who was admitted with complaints of (c/o) coffee-ground emesis and alcohol withdrawal. Her vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD). Lab work was notable for anemia and thrombocytopenia. A chest x-ray (CXR) showed no acute pathology. An electrocardiogram (EKG) showed no acute ischemia. The patient was diagnosed with alcohol withdrawal and coffee-ground emesis and treated with a proton pump inhibitor (PPI) and CIWA. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o coffee-ground emesis and alcohol withdrawal. The patient did not have associated high-risk features, such as renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability. In addition, the patient did not have a bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable and did not have sepsis, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, abnormal mentation, age greater than (>)70, sustained tachycardia, or immunosuppression. The patient presented with alcohol withdrawal and abdominal pain with reports of associated coffee-ground emesis, gastroenterology (GI) evaluated the patient and due to lack of recurrence and stable hemoglobin, deemed an outpatient esophagogastroduodenoscopy (EGD) to be medically appropriate, and the patient had non-severe alcohol withdrawal symptoms, for which benzodiazepines (BZDs) were administered. The patient's Rockall score was also not high-risk. Given the patient's clinical stability, lack of active bleeding, and benign imaging and non-severe findings, this patient could have been safely treated at a lower level of care.