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

Diagnosis: Chest Pain/Gastritis	
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The denial is upheld.

This adult male presented to the hospital complaining of dizziness, urinary hesitancy and burning, odynophagia, and mild chest pain that was exacerbated with deep inspiration. Past medical history was significant for hypertension, paroxysmal atrial fibrillation, nephrolithiasis, hematuria, and benign prostatic hypertrophy. On arrival, vital signs were stable: blood pressure was 138/74 and pulse 59. Physical examination was within normal limits. 12 lead Electrocardiogram (EKG) demonstrated sinus bradycardia 55 beats per minute (bpm) without ischemic ST or T wave (intervals on EKG) abnormalities. Serum blood testing revealed a hemoglobin of 14.1. The patient was admitted to the hospital. Computed tomography (CT) scan of the chest was unrevealing. Echocardiogram demonstrated a preserved left ventricular ejection fraction and myocardial perfusion testing demonstrated no evidence of ischemia. Urology was consulted for urinary retention and gastroenterology performed an evaluation for odynophagia. Endoscopy demonstrated evidence of gastritis. The patient was treated for gastritis and urinary retention and discharged home.
 
This patient presented with atypical chest pain and a past medical history of hypertension and atrial fibrillation. His pretest probability of coronary artery disease was low. [1] 

Utilizing HEART score (a cardiac risk score that considers history, EKG, age, risk factors, and initial Troponin) he was considered low risk. [2]  

Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati, et al. [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 Thrombolysis in Myocardial Infarction (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. [4] 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for an inpatient hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Supraventricular Tachycardia
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

The patient is an adult female. She presented to the hospital with a chief complaint of palpitations. Her past medical history was significant for short-lived episodic palpitations, attention-deficit/hyperactivity disorder (ADHD), and recent right breast lumpectomy surgery. She called emergency medical services (EMS) after palpitations persisted for hours. EMS (emergency medical services) documented supraventricular tachycardia, which they treated with adenosine injection. On arrival to the hospital, the patient's vital signs were stable (blood pressure 108/72, pulse 110). Electrocardiogram (ECG) revealed sinus tachycardia at a rate of 100 without other abnormality. Physical examination was within normal limits. Serum troponin was mildly elevated (0.12), toxicology screen was positive for amphetamines, thyroid function was within normal limits. 
Computed tomography (CT) of the chest demonstrated no evidence of pulmonary embolism. The patient was treated with metoprolol and admitted to the hospital for further treatment but signed out against medical advice.

The inpatient admission was medically necessary in this case.

This patient presented with supraventricular tachycardia that lasted for hours and required treatment with adenosine for termination. Such patients require workup for diagnosis and treatment (1). The patient also had an elevated troponin level, a known predictor for hospital admission and health care resource utilization (2, 3). Given symptomatic tachyarrhythmia and recent breast surgery, inpatient hospital admission was medically necessary.
Appeal type: Formulary Exception
Decision: Upheld


Diagnosis: obesity.
treatment: Wegovy.
The insurer denied Wegovy.
The health plan's determination is upheld. 

The patient is a female with obesity, with a previous body mass index (BMI) of 40.4. The patient has glucose intolerance with a family history of type 2 diabetes as well as nonalcoholic steatohepatitis. The patient was initiated on Ozempic and now has a body mass index of 34.57. Wegovy was prescribed.

The non-formulary drug is not clinically appropriate for the patient's condition.  It is noted that the patient lost a significant amount of weight while being treated with Ozempic and still has a body mass index of 34.57. However, there is no documentation of failure of an extended, comprehensive weight loss program including dietary changes and exercise. In summary, the non-formulary drug is not clinically appropriate for treatment of the patient's condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral vascular accident
Treatment: Increase in Consumer Directed Personal Assistance Program (CDPAP) Services, 9.5 Hours per Day, 7 Days per Week, for Total Amount of 66.5 Hours per Week
The insurer denied an Increase in Consumer Directed Personal Assistance Program (CDPAP) Services, 9.5 Hours per Day, 7 Days per Week, for Total Amount of 66.5 Hours per Week.
The denial is overturned.

The patient is an adult male with history of cerebral vascular accident (CVA) with right hemiplegia, expressive aphasia and also diabetes mellitus. A Uniform Assessment System for New York (UAS-NY) completed 5 months ago concluded that the patient requires limited assistance for eating while totally dependent and requiring extensive assistance for upper body dressing, personal hygiene, bed mobility, walking, toilet transfer, and maximum assistance for lower body dressing, locomotion, bathing, meal preparation, and medication management requiring the physical presence of an aide while also totally dependent for housework. The patient lives alone and not with the nephew as stated. The patient's activities of daily living (ADLs) are limited. The patient had Consumer Directed Personal Assistance Program (CDPAP) services approved for 6.5 hours a day for 7 days a week making a total of 45.5 hours per week. He is instead, requesting Consumer Directed Personal Assistance Program approval for 9.5 hours per day for 7 days a week for a total of 66.5 hours a week. The denial for increased Consumer Directed Personal Assistance Program is based on time needed for essential tasks to be performed.

The requested health service is medically necessary.

The requested increase for Consumer Directed Personal Assistance Program from 45.5 hours per week (6.5 hours per day, 7 days a week) to 66.5 hours per week (9.5 hours per day, 7 days a week) is medically necessary because based on the most recent Uniform Assessment System for New York (UAS-NY) of 5 months ago, the patient requires limited assistance for eating while totally dependent and requiring extensive assistance for upper body dressing, personal hygiene, bed mobility, walking, toilet transfer, and maximum assistance for lower body dressing, locomotion, bathing, meal preparation, and medication management requiring the physical presence of an aide while also totally dependent for housework. The patient lives alone and not with his nephew as stated. His activities of daily living (ADLs) are limited. The patient has expressive aphasia making it difficult to express himself to the understanding of people listening to him. His forgetfulness, aphasia and extensive limitations in mobility with extensive limitation in his activities of daily living (ADLs) are good and tenable reasons for the medical necessity. The reasons stated by the health plan as reasons for denial do not reflect the findings in the Uniform Assessment System report of 5 months ago as summarized in the clinical summary above.
Therefore, 66.5 hours per week (9.5 hours per day, 7 days a week) as requested should be approved.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Persistent atrial fibrillation (AF)

Treatment: Procedure to treat a rapid heart rate (catheter ablation for atrial fibrillation); codes 93657, 93613, 93662 and 93623

The insurer denied coverage for procedure to treat a rapid heart rate (catheter ablation for atrial fibrillation); codes 93657, 93613, 93662 and 93623

The denial is upheld

 
As per the visit note, this is an adult with a history of hypertension, hyperlipidemia, and persistent atrial fibrillation (AF) originally noted on an electrocardiogram (ECG) taken during a routine visit. The patient has not had any symptoms related to their atrial fibrillation. The patient is taking metoprolol and Xarelto. The patient's body mass index (BMI) is 31. The patient has a congestive heart failure, hypertension, age, diabetes, stroke, vascular disease, age and sex category (CHADS VASC) (a point-based system used to stratify the risk of stroke in AF patients) score of 1. An echocardiogram showed normal ventricular function, no valve disease, and mild enlargement of the left atrium. The left atrial volume is noted as 34 with the laboratory normal of less than (<) 34. Despite being asymptomatic, the patient is interested in catheter-based therapy to convert to sinus rhythm. The provider writes that the patient is a good candidate for ablation therapy.

There is a dearth of guidelines on managing asymptomatic patients in regard to catheter ablation (CA). Up to Date summarized the approach to patient selection. "A major clinical goal of CA is a reduction in atrial fibrillation (AF)-related symptoms. CA is superior to medical therapy at improving quality of life. Therefore, it is generally reserved for individuals with symptoms attributable to the arrhythmia, which most often include palpitations, shortness of breath, or generalized fatigue [1,2]. Even if they have no AF-related symptoms, older individuals with early AF (duration <1 year) and additional cardiovascular conditions also benefit from therapies aimed at maintaining sinus rhythm; these therapies include CA [3]." Note that the study supporting ablation for symptoms in older patients (>65) noted improved quality of life at 12 months. In addition, a recent meta-analysis of 6 randomized trials comparing catheter ablation to antiarrhythmic therapy in symptomatic patients with a followup of 1- 2 years. No statistically significant differences were noted for overall any type of adverse events  and cardiovascular adverse events  respectively."
The patient has had persistent atrial fibrillation of unknown duration and, as per the most recent note, is asymptomatic.
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 heart procedure to treat a rapid heart rate (catheter ablation for atrial fibrillation); codes 93657, 93613, 93662 and 93623 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory failure
Treatment: Inpatient acute rehabilitation
The insurer denied inpatient acute rehabilitation
The health plan's determination is overturned. 

This is a female with morbid obesity who was hospitalized for cellulitis and acute respiratory failure. She was ventilated and trached. She is now extubated and participating in therapies. She was denied acute level rehabilitation. This is under review.

Inpatient Acute Rehabilitation is medically necessary for this patient.
The patient is young and was previously independent in all activities. She has had a complex medical course. She is now minimal assist for transfers, ambulation and activities of daily living. She is weak and deconditioned but improving with physical therapy (PT) and occupational therapy (OT). She has a tracheostomy, but her swallow is intact. She can tolerate 3 hours of physical and occupational therapy.
Inpatient acute rehabilitation is indicated. She had a complex medical course and must be monitored carefully. She needs nursing and physician care daily. She would benefit from 3 hours of daily therapy.
Appeal type: Medical necessity
Decision: Overturned



Diagnosis: right leg claudication.
Treatment: Peripheral Artery Revascularization.
The insurer denied Peripheral Artery Revascularization.
The health plan's determination is overturned.

The patient is a man with diabetes, congestive heart failure, coronary artery disease, hypertension, and peripheral artery disease, who presents for a month's follow-up after left iliac and superficial femoral artery (SFA) stenting and left toe amputation.
The patient's left stump site is fully healed with a left ABI (ankle-brachial index) of 1.19. The patient complained of right leg pain after walking 2 blocks with a right ABI of 0.92. The patient was diagnosed with right leg claudication.

Peripheral Artery Revascularization is medically necessary for this patient.
The patient has right leg claudication that requires treatment. The patient complained of right leg pain after walking 2 blocks with a right ABI of 0.92. The recommended treatment, right leg angiogram with revascularization is medically necessary and is the standard of care for treating claudication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left wrist pain
Treatment: MRI of Arm Joint (Wrist, Elbow or Shoulder) without Contrast (Dye)
The insurer denied MRI of Arm Joint (Wrist, Elbow or Shoulder) without Contrast (Dye.)
The denial is upheld.

This patient is an adult male with left wrist pain for several years. He had sustained a previous angulated fracture. His physician reported the ulna styloid had not healed. The physician noted previous treatments of injections and splinting. Physical therapy also had been completed in the past. The physical examination was significant for good motion but styloid pain. The x-ray report noted post-traumatic fragmentation to the distal ulna. The physician recommended magnetic resonance imaging (MRI). He had concern for triangular fibrocartilage complex (TFCC) diagnosis. This was to aid in treatment recommendations.

The requested health service was not medically necessary.

The physician has considered the diagnosis of triangular fibrocartilage complex (TFCC). The records show the last treatment of injection was provided several months ago. Physical therapy was completed last year. Criteria require six weeks of conservative treatment within the last 12 weeks prior to the special study. As this was not completed, there would be no indication for the magnetic resonance imaging (MRI). Therefore, the requested health service was not medically necessary. 
Guidelines for advanced imaging recommend the special study if additional information can aid in treatment decisions, i.e., possible surgery. There should be a course of conservative treatment prior to the study. The records show this was not completed. There were no "red flags" to require immediate study, i.e., tumor, infection, fracture.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath; wheezing
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is upheld.

The patient is an adult male with a history of asthma. He presented to the emergency room with worsening shortness of breath and wheezing. The patient was found to have asthma exacerbation and received intravenous steroids, intravenous magnesium, and epinephrine with improvement. The patient was admitted to hospital for further management. The acute hospital admission was denied coverage by the health plan due to lack of medical necessity. This denial is being appealed.

The Inpatient admission was not medically necessary.

The patient presented to the emergency room with asthma exacerbation. The patient's symptoms improved with emergency room treatment. At the time of admission, the patient's respiratory distress was mild. The patient's oxygen levels were above 90% (percent) on minimal supplemental oxygen. The patient was started on home asthma medications and home blood pressure medications. The patient was not on invasive drips or on non-invasive ventilation. The patient was tolerating diet. The patient did not receive any treatment that could not have been provided at a lower level of care. The acute hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, Cough and Trouble Breathing.
Treatment: Inpatient Hospital Admission.

The insurer denied Inpatient Hospital Admission.  The denial is upheld.

The patient is a school aged female child, who presented to the emergency department with one-week history of cough and nasal congestion and a one-day history of fever to 102 and labored breathing. In the emergency department, the patient was noted to be wheezing, so she was treated with DuoNebs, magnesium, and dexamethasone. Chest x-ray revealed a moderately dense right upper lobe pneumonia. She was admitted for further management of lobar pneumonia with acute asthma exacerbation. Vital signs upon admission included temperature 37.1, heart rate 134, and respiratory rate 29, with 97% (percent) saturation in room air. Examination was significant for congestion, moist mucous membranes, decreased air movement, no wheezing or retractions, bronchial breath sounds marked on the right lung field, and non-focal neurologic exam. Laboratory evaluation included white blood cell (WBC) count 15.6 thousand (K) with 61.9 percent neutrophils and 22.2 percent lymphocytes, venous potential of hydrogen (pH) 7.27 with partial pressure of carbon dioxide (pCO2) 52.3, alkaline phosphatase 259, rapid viral screen negative, and rapid group A Strep negative. Admission orders included continuous cardiopulmonary monitoring, regular diet, half-maintenance intravenous fluids, ampicillin (after a dose of ceftriaxone), and albuterol. The patient remained stable overnight and was discharged the following day to complete a course of amoxicillin.

The acute inpatient was not medically necessary. 

This young female child with unremarkable medical history presented with week-long history of cold symptoms and acute onset fever and difficulty breathing. Evaluation included bronchial breath sounds on the right, leukocytosis, and right upper lobe infiltrate on chest x-ray. While it was not unreasonable to monitor the patient in the hospital for resolution of distress versus decompensation, she was overall hemodynamically stable with no need for supplemental oxygen, no evidence of impending respiratory failure, and no significant metabolic derangements. She did not require acute inpatient admission and could have been safely managed at lower level of care such as observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Short Stature
Treatment: Lab Testing for Vitamin D Level 
The insurer denied: Lab Testing for Vitamin D Level.
The denial is upheld.

The patient is a preschool male with short stature for whom vitamin D testing was requested. The health plan denied coverage of the testing, as he did not have any signs or symptoms of vitamin D deficiency. No clinical records are provided aside from other laboratory testing. Other 
labs were obtained including a vitamin A level, complete blood count (CBC), zinc, iron, mitochondrial antibody, carnitine, magnesium, acylcarnitines, comprehensive metabolic panel (CMP), and ferritin. These labs were requested by a functional medicine practitioner.

The requested health service is not medically necessary.

The child received testing for vitamin D level testing for short stature. This testing is indicated when signs or symptoms of a vitamin D deficiency are present. No signs or symptoms of a vitamin D deficiency are documented. Therefore, the requested Vitamin D testing is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Edentulous

Treatment: Crowns for teeth #'s 6, 7, 8, 9, 10, 11, 12, 21, and 25, core build up for teeth #'s 6, 7, 8, 9, 10, 11, 12, 21, 22, 24, and 27, and fixed bridge for teeth #'s 22, 23, 24, 25, 26, and 27

The insurer denied coverage for crowns for teeth #'s 6, 7, 8, 9, 10, 11, 12, 21, and 25, core build up for teeth #'s 6, 7, 8, 9, 10, 11, 12, 21, 22, 24, and 27, and fixed bridge for teeth #'s 22, 23, 24, 25, 26, and 27

The denial is upheld

 
Upon review of the submitted documentation which includes copies of full mouth series radiographs 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 crowns, core buildup and fixed bridge were 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. The patient is appealing stating that her underlying medical condition of lupus predisposes her to infections necessitating this extensive dental treatment.

Based on the submitted objective information for review, which consists solely of the radiographic examination, it is evident that the patient exhibits a heavily restored dentition with endodontically treated teeth and numerous fixed crown and bridge prostheses. The radiographs do not indicate any significant pathology such as recurrent caries or other issue regarding the pre-existing restorations that would necessitate this extensive treatment plan. 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. Further, a pre-existing medical condition of lupus has no bearing on her dental treatment.

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 crowns for teeth #'s 6, 7, 8, 9, 10, 11, 12, 21, and 25, core build up for teeth #'s 6, 7, 8, 9, 10, 11, 12, 21, 22, 24, and 27, and fixed bridge for teeth #'s 22, 23, 24, 25, 26, and 27 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes. 
Treatment: Mounjaro 5mg (milligrams)/0.5ml (milliliter) Pen. 
The insurer denied: Mounjaro 5mg/0.5ml Pen. 
The denial is upheld. 

The patient is an adult female. She has obesity, with BMI (body mass index) 32.94, and prediabetes, with Hemoglobin A1c (glycated hemoglobin) of 6.4. Her provider is requesting Mounjaro. 

The requested Mounjaro is not medically necessary. 

The patient has prediabetes, with hemoglobin A1c (glycated hemoglobin) of 6.4. Mounjaro is not indicated for management of prediabetes. Mounjaro is indicated as an adjunct to diet and exercise to improve glycemic control in patients with type 2 diabetes. The patient does not have a documentation of type 2 diabetes. Therefore, Mounjaro is not medically necessary.