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

Diagnosis: postoperative bleeding

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This male patient has a history of ulcerative colitis. The patient presented to the Emergency Room (ER) with complaints of bleeding after having a tonsillectomy.  The patient had a tonsillectomy on the day prior to arrival (PTA).  The patient stated that he was taking only liquids and soft food by mouth (PO).  The patient was hemodynamically stable and communicating through writing.  The physical examination of the oral cavity revealed multiple raw and erythematous areas throughout the tonsil.  There was no active bleeding.  The patient was initially kept nothing-by-mouth (NPO) and intravenous (IV) fluids were given.  The patient was admitted with postoperative bleeding.  Otolaryngology consulted over the case for difficulty swallowing, and they recommended trying a clear liquid diet after 4 hours of NPO.  The patient was monitored and there was no more active bleeding during the admission.  The patient was discharged after a period of medical stability.  At that time, the patient was ambulating and tolerating a clear liquid diet. The patient's pain was well-controlled.    

Postoperative tonsillectomy bleeding tends to occur in the first few days post-surgery or at approximately 10 days post-surgery (when clots tend to come off or dissolve).  This patient had a tonsil postoperative bleed on postoperative day #1 (POD#1).  The amount of blood noted over the two hours of bleeding appeared substantial (quoted as filling two small bags) but the bleeding stopped on presentation to the ER.  Additionally, when the blood clot was removed from the tonsil, there was no active bleeding and silver nitrate was applied.  The notes also described this patient's hospital course overnight as was "observed overnight...no further episodes of bleeding...stable...ambulating... tolerating a clear liquid diet and pain was controlled".  The physical exam next day showed "breathing comfortably on room air...not In acute distress (NAD)]...no stridor...no blood noted in saliva....no hematoma".  The notes of appeal by the hospital also note tachycardia but this is often seen when a patient is or was bleeding and is understandably anxious.  The patient's normal hemoglobin and hematocrit, and healthy young status are indicative that this patient was not in distress and as the hospital notes stated the patient  was hemodynamically stable.  Typical guidelines/medical necessity/criteria for admission versus observation appear to be fulfilled for observation/ambulatory admission since the records show that the patient was hemodynamically stable, afebrile, controlled pain, and the patient ambulated, was not actively bleeding, and was tolerating oral intake.  

The health plan did 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 upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder. 
Treatment: Crown Tooth # 12. 

The insurer denied the Crown Tooth #12. 
The determination is overturned. 

The patient presented for evaluation and treatment of tooth number (#) 12. Provided for review are previous letters of appeal and denial, clinical notes from the provider's office, a panoramic radiograph, and bitewing radiographs from unknown dates. The treating provider noted that the tooth had recurrent decay, previously heavily restored tooth, and lack of contact with tooth #13. This was denied on the basis that the tooth does not have a good prognosis and that extraction would be an alternative and less expensive option and that the tooth did not have adequate bone support. At issue is the medical necessity of the treatment of tooth #12 with a crown. 

Yes, the requested health service/treatment of crown for tooth #12 is medically necessary for this patient as there is not another restoration to replace the one affected by decay that was previously present. Extraction of the tooth is not an equivalent option in this case. As there is documented decay, as the previous restoration is large, the appropriate therapy is that of full coverage. From the provided documentation, there is not evidence of a poor periodontal prognosis. Therefore, the crown is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolus
Treatment: Inpatient Hospital
The health plan denied the inpatient hospital stay. 
The health plan's determination is upheld.

This case involves a man with extreme obesity, and a history of bronchitis, who presents to the emergency department (ED) with a 3-day history of chest pain. The patient described the chest pain is sharp, left-sided radiating from the chest towards the back and then to the neck. It was not exertional, but worse with deep inspiration. The pain progressively worsened over a period of 3 days. The patient had a chest x-ray performed at an urgent care center, which showed a left lower lobe consolidation; therefore, he was sent to the ED for an evaluation.
On exam, lungs were clear to auscultation with no crackles, rhonchi, or wheezing; the cardiac exam shows regular rate and rhythm. The rest of the exam is fairly unremarkable.

A computed tomography (CT) scan of the chest with contrast was done, showing the bolus' suboptimal timing; however, right upper and lower lobe segmental pulmonary emboli were noted. The patchy left lower lobe opacities to represent atelectasis, but questionable pulmonary infarct in the lingula is noted. A twelve-lead electrocardiogram (EKG) shows normal sinus rhythm without ST-segment changes.
The patient was admitted to the hospital with a pulmonary embolus. Per the medical team, the patient is hemodynamically stable with oxygen saturations greater than 95% on room air and he was able to ambulate. They stated it is unclear if this is provoked or unprovoked pulmonary embolus and recommended at least 3 months of anticoagulation; they started the patient on Eliquis 10 mg twice daily.
The next day the patient feels better, no shortness of breath, residual chest pain is present. At this point, he was started on Eliquis and discharged home the following day, with recommendations for at least a 3-month treatment course.
The question at hand is whether inpatient stay is medically necessary for this patient.

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

No. Inpatient medical stay is not warranted for this presentation.
This is a patient who presents to the hospital with hemodynamically stable segmental pulmonary emboli. There is no hypoxemia evidence, with the patient maintaining oxygen saturations greater than 95% on room air. There is no evidence of right heart strain, causing hemodynamic compromise. There were no cardiac arrhythmias noted during the observation timeframe. There is no evidence of syncope or any other complications related to the pulmonary embolus. The patient has mild residual chest pain 24 hours into the hospitalization, with no dyspnea symptoms as documented in the progress notes. There is no reason to initiate inpatient anticoagulation with Heparin, as there was no contraindication. There is no history of bleeding diathesis to warrant ongoing monitoring in the hospital and requiring inpatient hospitalization as a result.

In summary, this is a stable thromboembolic disease, which can be treated as an observation level of care for 24 hours, with subsequent discharge home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right knee pain
Treatment:  Genvisc 850 hyaluronan injection
The health plan denied the Genvisc 850 hyaluronan injection.
The determination is upheld.

The patient has a history of right knee pain. An office visit note documented that the patient complained of lateral sided right knee pain. The patient attempted oral medications to control her pain. A magnetic resonance imaging (MRI) scan of the right knee was obtained and revealed thinning of the articular cartilage in the lateral compartment with no obvious meniscal or ligament tear. The orthopedic provider recommended administering a series of Genvisc supplementation injections to provide the pain relief. At issue in this case is the medical necessity of the requested Genvisc injections for the right knee.

The requested health service/treatment of Genvisc 850 hyaluronan injection is not medically necessary for this patient. The provided medical records in this case do not clearly document that the patient has a diagnosis of right knee osteoarthritis. This diagnosis was not established based upon the right knee MRI scan documented in the records. Thus, the patient does not meet the Food and Drug Administration (FDA) approved indication for viscosupplementation injections and the medical necessity of the injections is not established.

The current, peer-reviewed orthopedic literature, including articles published by Tammachote and colleagues and by Jevsevar and associates, both in the Journal of Bone and Joint Surgery, found that viscosupplementation injections such as the Genvisc requested in this case not an effective treatment for knee osteoarthritis. The Tammachote article concluded that "Conclusions: Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with Hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week." The Jevsvear artilce determined that "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of hyaluronic acid treatment over placebo. When all literature was added to the analysis, the overall effect was greater but was biased toward stronger treatment effects because of the influence of nonblinded or improperly blinded trials." Therefore, the current, peer-reviewed literature does not support the medical necessity of injections such as Genvisc for the treatment of knee osteoarthritis.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male. He presented to Emergency department with low back pain radiating to right leg. He had history of laminectomy several years prior. He reported numbness and weakness.

The patient's physical examination revealed limited strength in right lower extremity with decreased sensation in L5 (fifth lumbar spine vertebra) and S1 (first sacral vertebra) distribution. He had been treated with diclofenac and baclofen. MRI (magnetic resonance image) of lumbar spine revealed disc herniation with desiccation at L4-5 (fourth lumbar spine vertebra fifth lumbar spine vertebra).

The patient was admitted. He underwent L4-5 (fourth lumbar spine vertebra fifth lumbar spine vertebra) right microdiscectomy and he was discharged a few days later.

No, the Inpatient admission was not medically necessary.

Lumbar discectomy is typically performed on an outpatient basis. This patient could have had an outpatient work-up. The surgery could have been arranged to be done as an outpatient procedure. A lower level of care would have been reasonable. There is no documented reason for this patient to have needed to stay in the hospital for so many days prior to and after surgery. The records do not support such a long hospital stay. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Cimzia. 
The denial is upheld.

The patient is a female with moderate to severe psoriasis (5% body surface area involvement) that is particularly severe on the hands and the feet (palms and soles as well). The patient has tried and failed topical triamcinolone and clobetasol. The patient is of childbearing potential, so Cimzia has been prescribed for this patient's psoriasis. The subject under review is the medical necessity for Cimzia.

The treatment with Cimzia is not medically necessary for this patient.
Standard of care supports the use of all oral/traditional and injectable/biologic treatments for this patient's pustular psoriasis, and although different patients might have different responses, there is no evidence to refute the conclusion that this patient would likely have some significant response to all systemic oral or injectable therapies.
As per Wang et al. and as with other reviews for psoriasis as a whole, the biologics that treat pustular psoriasis are the same that treat plaque psoriasis. Some biologics are better than others, and certainly pustular psoriasis in general is more treatment-resistant than other forms of psoriasis; however, the disease mechanisms are virtually identical, despite their different presentations between plaque and pustular psoriasis. Therefore, the request for treatment with Cimzia is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

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

The patient presented to the emergency department after having had several brief episodes of chest pain. Her medical history was remarkable for diabetes, hypertension, coronary artery disease, myocardial infarction and congestive heart failure with a left ventricular ejection fraction of 45-55%. In the emergency department, the patient was pain-free. Her blood pressure was 132/92 millimeters of mercury (mmHg) with a heart rate of 83 beats/minute. Her respiratory rate was 18/minute with a room air oxygen saturation of 99%. Her physical exam was unremarkable. An electrocardiogram showed sinus rhythm without acute changes. Her serum troponin level was normal. A chest x-ray showed no acute pathology. She was treated with enoxaparin and dual antiplatelet therapy and admitted to the hospital to rule out acute coronary syndrome. Repeat serum troponin levels were normal. An echocardiogram showed a left ventricular ejection fraction of 40-50% without regional wall motion abnormalities. Cardiac catheterization was performed and showed no obstructive disease. There was a patent stent in the left anterior descending coronary artery. The patient was discharged. At issue is the medical necessity of an inpatient admission.
An inpatient level of care was not medically necessary.
This patient, with known coronary artery disease, presented with atypical symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was reasonable and prudent. On the other hand, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion and titration of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Multiple sclerosis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a past medical history of ulcerative colitis, tobacco use, diabetes, hypertension (HTN), multiple sclerosis (MS) on steroids, seizures, chronic thromboembolism on anticoagulation, who presented to the emergency room (ER) with left sided facial, left upper extremity, and left lower extremity tingling. She had associated pain in the back. She was transferred from another facility. Her exam was significant for pallor, mild left buccal edema, and posterior midline lumbar tenderness. The patient was admitted for a possible multiple sclerosis exacerbation. Neurology was consulted. She was given intravenous (IV) steroids and IV fluids. She ultimately left against medical advice (AMA).
The initial vital signs were a blood pressure (BP) of 128/93, heart rate (HR) 70, temperature 36.8 degrees Celsius, respiratory rate (RR) 18, and oxygen saturation 100% on room air. Lab results were normal.
An electrocardiogram (EKG) showed normal sinus rhythm with left atrial enlargement, right axis deviation. A computed tomography (CT) scan of the  head and cervical spine showed no acute findings. At issue is whether the patient's hospitalization was medically necessary at an inpatient level of care.

This patient's hospitalization was medically necessary at an inpatient level of care. The patient presented with symptoms concerning for an MS flare. She required close monitoring of neurological symptoms, neurology consult, high dose IV steroids, and MRI imaging was ordered. She took oral prednisone at home but required high dose IV steroids in the hospital.
"Good level I and II evidence supports the use of steroids for decreasing the duration of symptoms during MS exacerbations [Table 1]. MRI(Magnetic resonance imaging)and cerebrospinal fluid (CSF) parameters support these findings. IV steroids are the preferred route of administration. High doses of IV methylprednisolone, used in clinical trials show effectiveness, dosage vary from 500-1000 milligrams (mg) daily for 3-5 days."
Furthermore, this patient had risk factors for a severe MS flare, including vascular co-morbidities (HTN, history of blood clots), and current tobacco use. These risk factors made inpatient admission more necessary.
"Vascular comorbidity, whether present at symptom onset, diagnosis, or later in the disease course, is associated with a substantially increased risk of disability progression in multiple sclerosis." "Patients with comorbid disease, in particular vascular disease and smoking, have a poorer outcome with more rapidly progressive disease"
Using Milliman Care Guidelines, 24th edition, for Neurology General Recovery Guidelines (GRG), this patient met inpatient criteria.
She was diagnosed with a multiple sclerosis flare requiring inpatient care with at least one of the following findings:
- acute severe deterioration requiring inpatient treatment (eg, IV steroids, plasmapharesis, close observation)
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Dental Problems/Dental/Decay/Root Involvement.  
Treatment: Root Canal Therapy and Crowns. 

The health plan denied the dental treatment plan. 
The health plan's determination of medical necessity is overturned, in part. 

The patient is a female who presents with a medical history of von Willebrand's disease. RCT (root canal therapy) and crowns are being requested at this time. 
At issue is the medical necessity of the requested dental treatment plan. 

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

There are hemostatic agents that help control bleeding tendencies in patients with von Willebrand's disease during dental procedures and surgeries; therefore, RCTs and crowns are not the only dental treatment options available for patients with bleeding tendencies. The need for RCTs and crowns is based on the prognosis of the tooth and size and location of the decay, not due to patient's bleeding disorder. 

According to the submitted radiographs, tooth #21 has fractured and is missing a large portion of tooth structure from decay. The pulpal nerve is exposed. Tooth #28 has minimal decay that is not close to the pulpal nerve. Tooth #27 had a large decay that was in close proximity to the pulpal nerve that required RCT treatment. RCT was performed on tooth #27. A tooth that has been root canal treated will require a crown to prevent the tooth from fracturing. As such, a RCT and crown for tooth #21 is medically necessary to restore the tooth to proper function. A RCT and crown for tooth #28 is not medically necessary. Tooth #28 can be restored with a filling. A crown on tooth #27 is medically necessary to protect the root canal treated tooth from fracturing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior crossbite
Treatment:  Braces And Monthly Visits, Pre-service
The insurer denied the  Braces And Monthly Visits, Pre-service.
The denial is upheld. 

The patient is a female. The request is for dental benefits for Orthodontic treatment and monthly visits.

The patient's dental clinical summary states that the patent has a skeletal Class I, Class II canines, moderate maxillary and mandibular crowding.

Anterior crossbite with gingival attachment loss (mandibular left canine) is noted.

No, the proposed treatment of orthodontic therapy and monthly visits are not medically necessary.

A crossbite exists when upper tooth/teeth are positioned inside or palatal to the corresponding lower tooth/teeth. The photos submitted do not exhibit this positioning of the left mandibular/lower canine as indicated in the clinical summary.

A Class II Canine exists when the distal surface of the mandibular/lower canines are mesial to the mesial of the maxillary/upper Canine by at least the width of a premolar. This clinical condition is also not evident in the photos and is again unsupported by the documentation submitted.

Although the patient does show a few teeth that are not fully aligned, the clinical claims of a crossbite and Class II Canines are not evident in any of the documentation submitted; therefore this case would not warrant the proposed treatment of orthodontic therapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Blood Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was overturned. 

The patient is a female, with a history of hypertension, asthma, and major depressive disorder. The patient had been experiencing exertional dyspnea, and generalized weakness, for 2 weeks. She followed up with her family doctor and was instructed to go to the emergency department because of anemia. 
Her laboratory studies revealed a white blood cell count of 4.4, with a hemoglobin of 4.1, hematocrit of 17.9, and platelets of 143. Prothrombin time was 13.9, with an international normalized ratio (INR) of 1.1. 
The patient was admitted to the hospital with gastrointestinal (GI) consultation for an esophagogastroduodenoscopy (EGD) and colonoscopy. She was placed on Protonix intravenous (IV) twice daily. The medical team established a target hemoglobin of greater than 7. A fecal occult blood testing was done, which was negative.
The patient received an additional 2 units of packed red blood cells. The EGD showed a small hiatal hernia, Roux-en-Y gastric bypass, with gastric pouch showing mild erythema but no ulceration. The colonoscopy showed no evidence of active bleeding.
At issue is the Inpatient stay for medical necessity.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of Inpatient stay is medically necessary for this patient.
Based on the profound nature of the anemia, it was reasonable to expect the patient would require multiple blood transfusions to improve the hemoglobin. Each blood transfusion must be delivered slowly and safely to prevent rapid fluid overload and pulmonary edema while watching for reactions.
At the hemoglobin level of 4.1, there is an extreme likelihood of end-organ damage to both the cardiopulmonary system, central nervous system, and renal system, which are extremely sensitive to anemia. The patient was at high risk for decompensation, especially at the initial evaluation, when an active GI bleed was suspected. The patient, in this case, required 5 units of packed red blood cells.
Therefore, the requested Inpatient stay was medically necessary for this patient.