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

Diagnosis: Osteomyelitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient is an adult with a past medical history significant for diabetes mellitus and foot ulcers. The patient presented to the emergency room (ER) with complaints of right hand pain and erythema.

Vitals on presentation included: Temperature 99.2  (degree) Fahrenheit (F), blood pressure (BP) 147/82, pulse (P) 103, respiratory rate (RR) 16, and oxygen (O2) saturation 94%(percent) on room air. Laboratory results included the following: white blood cell count (WBC) 5.97, hemoglobin (Hgb) 17.2, hematocrit (Hct) 50.4, creatinine 0.7, glucose 360, C-reactive protein (CRP) 4.12, and lactate 1.2.

The patient was started empirically on intravenous (IV) antibiotics (vancomycin and cefepime) for right hand cellulitis. An x-ray of right hand noted boney destruction of the distal aspect of the third finger consistent with osteomyelitis. Magnetic resonance imaging (MRI) noted abnormal marrow signal at the distal index and long finger concerning for osteomyelitis. Infectious Disease (ID) also consulted and recommended broadening antibiotic coverage to meropenem. Wound cultures grew extended spectrum beta lactamase (ESBL) Escherichia coli and Enterococcus faecalis. A peripherally inserted central catheter (PICC) line was inserted. The patient remained afebrile and hemodynamically stable. The patient clinically improved. The patient was discharged to continue IV Ertapenem for six additional weeks.

According to the documentation, the patient presented with right hand pain and erythema. Imaging studies including an x-ray and an MRI were suspicious for osteomyelitis. Vitals showed tachycardia. Laboratory results confirmed poorly controlled diabetes. The patient also failed outpatient intervention. Based on the above findings in a high risk patient, hospital admission was medically necessary for administration of long-term IV antibiotics for osteomyelitis.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is the case of a patient that presented to the hospital for cardiac catheterization after a computed tomography (CT) scan revealed coronary artery disease and a calcium score of 878. Baseline creatinine was 1.46.  Cardiac catheterization revealed triple vessel disease; 90 percent (%) occlusion of the left anterior descending artery, 90 % occlusion of the first diagonal artery, chronic total occlusion of the left circumflex artery and 70% occlusion of the right coronary artery. Complex revascularization of the occluded left circumflex artery was successfully performed. The patient had no complications overnight and was discharged the following day.

This patient presented for elective cardiac catheterization with possible percutaneous revascularization. The patient was noted to have triple vessel coronary artery disease and underwent revascularization of a chronic total occlusion involving the left circumflex artery.  Several investigators have studied the safety of same day discharge following percutaneous intervention.  Patients requiring circulatory support, multivessel revascularization and left main coronary artery revascularization were classified as high risk and could not be managed at a lower level of care (1-4). This patient had an uncomplicated course post procedure and could have been observed even overnight if needed. In conclusion, acute inpatient admission was not medically necessary. The patient could have been managed 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 the full hospital is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.
Treatment: Inpatient Stay.

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient, a female with a past medical history (PMH) of headaches, was admitted after experiencing multiple episodes of syncope. Vital signs were unremarkable, with negative orthostatic. Physical exam was notable for no apparent distress (NAD) and no focal deficits. Lab work was unremarkable. A computed tomography (CT) head scan showed no acute intracranial disease. A magnetic resonance imaging (MRI) brain scan and magnetic resonance angiography (MRA) brain and neck scan showed no acute abnormalities. 

The inpatient hospital admission was not medically necessary. This patient presented to the emergency department (ED) with complaints of (c/o) syncope. The patient did not have structural heart disease, hematocrit (HCT) < (less than) 30, shortness of breath (SOB), orthostasis, or a family history of sudden cardiac death. Additionally, the patient had no history of dilated cardiomyopathy, aortic stenosis, left ventricular outflow disease, pre-excitation syndrome, Brugada syndrome, Q-wave T-wave (QT) interval abnormalities, or conduction blocks. The patient did not have subarachnoid hemorrhage, pulmonary embolism, acute gastrointestinal (GI) bleed, malignant arrhythmia, sustained bradycardia, supraventricular tachycardia (SVT) or ventricular tachycardia (VT), confirmed acute coronary syndrome (ACS), evidence of heart failure, cerebrovascular accident (CVA), shock, coma, major trauma or cardiac arrest, or exertional syncope. The patient had an extensive workup, which was negative, with the remainder of the workup deferred to outpatient. The patient was diagnosed with syncope and treated with a syncope workup, IVF, and neurology consultation. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain.
Treatment:  Inpatient admission.

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

This is an adult with morbid obesity and chronic abdominal pain, who presented to the emergency room (ER) with abdominal pain. She had a diagnosis of gastritis and celiac disease. She was on chronic narcotics. She reported having a fever at home but was afebrile in the emergency room (ER). After receiving intravenous (IV) morphine in the ER, her oxygen saturation dropped to 88% (percent) on room air but went up to 93% on 2 liters of oxygen. The abdomen had mild tenderness with no rebound or guarding. A computed axial tomography (CAT) scan showed mild hepatomegaly but no acute pathology. She had diabetes and was diagnosed with gastroparesis. Proton pump inhibitor (PPI) therapy and antiemetics were given. Her pain regimen was adjusted. She was found to have E Coli gastroenteritis. An outpatient gastric emptying scan while off narcotics was discussed. 

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, bowel perforation or obstruction, bacteremia or an inability to maintain oral hydration after observation care. The patient did not have these conditions.

Clinical indications for admission for Gastroenteritis (MCG M-170) include having a severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe dehydration, and severe electrolyte abnormalities. The patient did not have these conditions. 

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

Diagnosis:  Seizures/abdominal pain.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

This is a case of a female admitted for diagnosis of seizure disorder and abdominal pain. The patient presented with a chief complaint of seizures and abdominal pain. She had symptoms of intermittent abdominal pain in the upper belly. Vital signs demonstrated temperature 98.4F (degrees Fahrenheit), pulse 63, respiratory rate 16, and blood pressure 160/94. Physical exam showed no acute distress or altered mental status. White blood cell count was 4.7 with hemoglobin 11.6. Creatinine was 0.54. A computed tomography (CT) of the abdomen and pelvis showed no acute process. A CT of the brain showed no acute abnormality. 

The inpatient hospital admission is not medically necessary.
The patient in this case was admitted for abdominal pain thought to be from a flare of inflammatory bowel disease. She did not have status epilepticus. A neurological evaluation was requested, and they simply recommended continuing her home anti-epileptic medication. The abdominal pain was not from a cause known to be life-threatening, such as acute bowel obstruction, mesenteric ischemia, perforation, myocardial infarction or ectopic pregnancy. There were no unstable vital signs. There was no evidence of peritonitis.
Although the patient required services in the hospital setting, the monitoring, diagnostic testing and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Problems.

Treatment: D2751 white glass with metal crown, tooth # (number) 2.

The insurer denied coverage for D2751 white glass with metal crown, tooth (number) 2.
The denial is upheld.

Upon review of the submitted documentation, which includes copies of undated panoramic radiograph and unrelated single periapical radiograph, and insurer correspondence, it appears that this patient presented to the dentist for evaluation and comprehensive dental treatment. Based on the documentation, the aforementioned treatment of full coverage crown for tooth #2 was recommended.  The insurer has denied the services stating that these services are not medically necessary treatment, as the clinical documentation does not support the requested services and in addition carries was noted at the level of bone height.  The patient is appealing.

Based on the submitted objective relevant information for review, which consists solely of the panoramic radiographic examination, it is evident that the patient exhibits a heavily restored dentition with endodontically treated teeth and numerous fixed crown and bridge restorations.  The radiographs do not indicate any significant pathology, such as recurrent caries or other issue regarding the pre-existing restorations that would necessitate treatment.  The full coverage restorations in place appear to be intact and well adapted.  As this is the case, and there is no other objective clinical documentation provided for review, the radiographic documentation does not support the dental treatment recommended by the dentist.  There are no dental treatment notes, no dental charting, nor periodontal charting provided for review.  As the documentation is inadequate to support the treatment, these services are considered 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 D2751 white glass with metal crown, tooth 2 services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

This is a female patient who presented with right lower quadrant and right flank pain. She had a fever to 102 degrees that morning. She had nausea and vomiting. She had undergone non-operative management for appendicitis in the past. A computed tomography (CT) scan demonstrated evidence for tip appendicitis. The patient was hospitalized overnight with intravenous (IV) Zosyn. She was set up for a diagnostic laparoscopy versus laparoscopic appendectomy. The patient underwent a laparoscopic appendectomy. The patient was kept in the hospital overnight and was afebrile overnight. Infectious disease had been consulted and the workup had come back negative. The patient did have exudative enlarged tonsils. The patient was discharged home with 10 days of Augmentin. At issue is the medical necessity of an inpatient stay.

Inpatient admission was medically necessary for this patient. The patient had severe fevers and tachycardia upon presentation suggestive of a significant septic response. Her vital signs demonstrated a fever to 101.9 degrees Fahrenheit and heart rate of 135.The patient was monitored closely with numerous infectious disease tests and an infectious disease consult while receiving IV antibiotics. This required inpatient admission to be accomplished safely.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ashkenazi Jewish ancestry.
Treatment: Genetic Testing: Gene Panel Test (CPT 81412).
The insurer denied Genetic Testing: Gene Panel Test (CPT 81412). 
The health plan's determination is upheld. 

The patient is a female who desires genetic testing. She and her partner have Ashkenazi Jewish ancestry and she was evaluated by a genetic counselor. 

Genetic Testing: A Gene Panel Test (CPT 81412) is not medically necessary for this patient.
Noninvasive prenatal screening (NIPT) is one of several tests recommended by the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine (SMFM), and the American College of Medical Genetics and Genomics to screen for common aneuploidies in pregnancy is now widely used to screen for a handful of aneuploidies. However, there is now growing interest in expanding NIPT to include a wider range of fetal genetic abnormalities. More research is needed to determine the accuracy and effectiveness of expanded NIPT, which is central to determining whether its benefit outweighs its harms. Preliminary findings suggest that NIPT in a broad set of genetic conditions in a low-risk population is likely to result in a high number of false positive results.
As a result of the many open questions regarding the validity and utility of expanded NIPT screening as a screening tool, ACOG and SMFM do not support the use of NIPT for conditions other than trisomies 13, 18, and 21 and sex chromosome aneuploidies. In their most recent joint guideline, prenatal screening for microdeletions, large deletions, and duplications was not recommended, because the testing has not been validated clinically and the screening accuracy about detection and false-positive rate is not established.
The patient in this case has Ashkenazi Jewish ancestry and ACOG supports expanded carrier testing for these individuals; however, that is not what the patient obtained. She obtained expanded non-invasive testing which is not currently supported by ACOG.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spastic quadriplegic cerebral palsy
Treatment: Durable Medical Equipment (wheelchair and 
accessories) (E1161, E2671, E0955, E0960, E2607, E0953, E0950, E1028, and K0108) x 1 each; (E0952, E0951 E2213, E2211, K0040, E0971, and E0956) x 2 each
The insurer denied durable medical equipment (wheelchair and 
accessories) (E1161, E2671, E0955, E0960, E2607, E0953, E0950, E1028, and K0108) x 1 each; (E0952, E0951 E2213, E2211, K0040, E0971, and E0956) x 2 each.
The denial is upheld.

The records indicate that the patient is an adult female with a history of spastic quadriplegic cerebral palsy with seizure disorder, scoliosis, congenital hip dislocation, and spasticity of the extremities. She is non-ambulatory. She is dependent for transfers. She is dependent for wheelchair mobility. She has been using a manual wheelchair with tilt-in-space seating. The patient presented to clinic, "to get [a] new wheelchair." No rationale for a new wheelchair was provided.

The requested health service is not medically necessary.

The patient has been dependently transported using manual wheelchairs. No rationale for the requested new manual wheelchair is provided. It is not evident why the new wheelchair is needed to replace or use in conjunction with the patient's current/prior wheelchairs. It is not evident why the patient's current wheelchair(s) do not meet her needs.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with Crohn's disease and ulcerative colitis who was admitted with left renal colic. Vitals were stable. The white blood cell (WBC) count was 17,900. The creatinine was 1.59. Computed tomography (CT) imaging demonstrated a 10-millimeter (mm) left proximal ureteral calculus with moderate hydronephrosis. The urinalysis had leukocyte esterase. Intravenous (IV) pain medications, nausea medications, IV antibiotics, and IVF were administered.

The inpatient hospital admission was not medically necessary. The patient's care could have been provided at a lower level of care. He was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis. Following admission, there were no unstable vital signs reported. He did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, or severe vomiting. Pain control, IV antibiotics and IVF followed by stent placement in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Umbilical Wound with Drainage
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male who was approximately one week status post umbilical hernia repair. There was reported to be bloody fluid draining from the umbilical incision. He was treated with the anticoagulant, Xarelto for atrial fibrillation.
He was admitted to the hospital and surgical consultation was obtained. Examination showed a 5-centimeter (cm) umbilical wound with packing in the subcutaneous tissues via a 1.7-cm opening on the right side of the incision. The packing was removed and there was no bleeding noted.
He was considered to be stable for discharge from the hospital.
At issue is the medical necessity of an inpatient stay.

An inpatient level of care was not medically necessary in this case based on the submitted clinical documentation. The care and treatment provided could have reasonably been provided with a lower level of care.
This patient presented to the hospital approximately one-week post umbilical hernia repair. He had a draining umbilical incision. His evaluation with examination, lab data, and surgical assessment supported the diagnosis of a superficial wound hematoma as a complication of a surgical procedure that was performed approximately one week earlier. He was clinically stable with normal vital signs and a normal white blood cell count (WBC) count at the time of presentation. The patient remained hemodynamically stable throughout the period of inpatient care. This patient's clinical needs could have been satisfied without inpatient admission and with a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fractured teeth

Treatment: procedure code 2740 on tooth numbers 14 and 15

The insurer denied coverage for procedure code 2740 on tooth numbers 14 and 15

The denial is overturned

 

Based on the submitted documentation which includes copies of chart progress notes, pretreatment bitewing and periapical radiographs, post treatment periapical radiograph, intraoral clinical photo in addition to insurer correspondence and insurer Dental Handbook, it appears that this patient presented for dental care with caries and mesiobuccal (MB) cusp fracture on #14 and 15 which had large pre-existing amalgam restorations. The dentist is requesting placement of full coverage crowns due to significant tooth cusp fracture. The insurer has denied the full coverage crowns stating that the services are not medically necessary as the documentation did not demonstrate findings to support the treatment and therefore the circumstance does not fulfill the insurers stated criteria for approval. Also, the insurer denial letter states that radiographic and clinical imaging was not provided at the time of the initial claim submission, hence the reason for the denial. The patient is appealing the decision.

Upon review of radiographs, copy of clinical photograph and chart progress notes, these support the recommended treatment. Tooth #14 exhibits a large MB cusp loss with coronal fracture. Large failing pre-existing amalgam restorations are also noted. Radiographic examination demonstrates recurrent caries affecting both teeth.

These teeth have adequate coronal structure for support of full coverage crowns and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be placement of crowns as recommended, which would have an excellent long-term prognosis with the recommended treatment. Further, the clinical situation meets the insurer criteria for approval.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for dental crowns, procedure code 2740 on tooth numbers 14 and 15 is substantiated.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: Class II malocclusion 
Treatment: Braces and Monthly Visit 
The insurer denied Braces and Monthly Visit 
the health plan's determination is upheld. 

The patient is a male with a Class II malocclusion with 4 millimeter (mm) overjet and 5mm overbite. He has maxillary and mandibular crowding. Teeth 6 and 11 are unerupted. The orthodontist stated in the diagnosis that #6 and #11 are impacted. The patient is treatment planned for braces.

Braces and monthly visits are not medically necessary for the patient at this time. He is in the process of losing his remaining primary teeth as they are replaced with permanent teeth. The patient is in the mixed dentition phase of development. Neither teeth #6 nor #11 appear to be erupting at a poor angle on the radiograph, and it is too early to determine if it will require an exposure as maxillary canines usually erupt at 11-12 years of age. However, there is a great discrepancy in this timing. There is still much time to see if the maxillary canines will erupt successfully on their own without orthodontic intervention. The standard treatment would be to extract the remaining primary canine (tooth c) to see if the permanent teeth can erupt.