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

Diagnosis: Missing teeth

Treatment: D6240 false tooth for bridge, Tooth 18 D6750 white glass with high gold content cap for bridge, Tooth 17 D6750 white glass with high gold content cap for bridge, Tooth 19 and D5214 partial lower denture

The insurer denied coverage for D6240 false tooth for bridge, Tooth 18 D6750 white glass with high gold content cap for bridge, Tooth 17 D6750 white glass with high gold content cap for bridge, Tooth 19 and D5214 partial lower denture
The denial is upheld

Upon review of the submitted documentation which included copies of full mouth series radiographs and insurer correspondence it appears that this patient presented for dental treatment. Recommended treatment was for placement presumably of a fixed bridge spanning teeth #1719 in addition to a removable mandibular partial denture. The Insurer has denied these services stating the services requested do not appear to be indicated on the teeth submitted. 

The only objective information provided for review is the radiographic series. The radiographic images indicate several missing and remaining teeth but there appear to be a discrepancy between the teeth presented on the radiograph and the requested services. It appears that the tooth #17 is endodontically treated and present in the arch. Tooth #18 and tooth #19 are missing, Tooth #20 remains an endodontically treated carious root tip and is deemed non maintainable. As both teeth #18 and 19 are missing the requested treatment of a bridge is not indicated nor possible.

As regards the partial denture, this may be an indicated service but not as requested by the dentist. If indeed a fixed bridge were to be fabricated as requested this would completely invalidate and obviate a need for a mandibular partial denture. 

There is no other clinical documentation provided for review. As the information provided to complete this review is inadequate /inaccurate to support the recommended treatment, the bridge and partial denture is deemed not medically necessary until such time the documentation adequately supports it.

Recommendation: Uphold denial of coverage for D6240 false tooth for bridge tooth 18; D6750 white glass with high gold content cap for bridge tooth 17; D6750 white glass with high gold content for bridge tooth 19 and DS214 partial lower denture as not medically/dentally necessary as the documentation provided is inadequate to support the recommend treatment. 

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

The insurer's denial of coverage forD6240 false tooth for bridge, Tooth 18 D6750 white glass with high gold content cap for bridge, Tooth 17 D6750 white glass with high gold content cap for bridge, Tooth 19 and D5214 partial lower denture is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Preeclampsia postpartum
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a female. She presented to the hospital  approximately 10 days post-op from a Cesarean section. Her pregnancy was complicated by preeclampsia without severe features. She reported that at home, she had been taking her blood pressures, and they were as high as the 180s systolic.

On evaluation in the ED (emergency department), the patient's blood pressure was as high as 161/96, P/C (protein to creatinine) ratio 3.43. She denied any headache, visual changes, abdominal pain, or face or hand edema. She was admitted with a diagnosis of preeclampsia postpartum with severe features. She was given MgSO4 (Magnesium Sulfate) intravenous infusion for 24 hours and started on Procardia. Her blood pressures resolved and she was discharged home.

The health plan contends that the admission was not medically necessary because she was not unstable, had hemolysis, confusion, abnormal liver functions, renal failure, pulmonary edema, intracranial hemorrhage, myocardial infarction, and cites MCG (Milliman Care Guidelines) 25th edition. The facility contends that the admission was medically necessary and reasonable but does not cite any specific criteria.

Yes, the Inpatient admission was medically necessary.
Per the American College of Obstetricians and Gynecologists, preeclampsia with severe features is an absolute indication for admission during pregnancy and the puerperium. Patients with preeclampsia with severe features are at risk of seizures which require admission for intravenous administration of magnesium sulfate under careful monitoring. In addition, these patients are at risk for pulmonary edema, renal failure, liver failure, intracranial hemorrhage, and death, and therefore require a high level of monitoring. Therefore the admission was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The health plan declined to cover the appropriate level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mastitis
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is overturned

The patient is a female with a past medical history significant for a normal spontaneous vaginal delivery and recent mastitis. She presented to the emergency room with complaints of worsening left breast pain. 

Vitals on presentation included: T (temperature) 101.8 F (Fahrenheit) BP (blood pressure) -105/65, P (pulse)-130, RR (respiratory rate)-20, 02 (oxygen), sat (saturation)-98% on RA (room air). Laboratory results included the following: WBC (white blood cell count) -19.7, HGB (hemoglobin)-12.4, HCT (hematocrit)-39.1, creatinine-0.67, glucose-98.

The patient was started on intravenous antibiotics (clindamycin). She had an ultrasound of the breast that showed a 7 cm (centimeter) abscess of the left breast. Surgery was consulted for an incision and drainage procedure. Wound cultures were sent for diagnosis. The patient remained afebrile, hemodynamically stable and was discharged to continue oral antibiotics (clindamycin) as an outpatient.

According to the documentation, the patient presented to the emergency department with complaints of worsening left breast pain despite an outpatient course of antibiotics. She was febrile, tachycardic, and described as "ill-appearing, diaphoretic... Laboratory results were notable for a significantly elevated WBC (19.7). Based on above findings including failure of outpatient intervention, a hospital admission was medically necessary for surgical intervention and administration of intravenous antibiotics. 

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

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

Diagnosis: Abdominal pain - Constipation.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld

The patient had a history of chronic chest pains and presented with epigastric pain and constipation. There was a 10-year history of chest pains and he had a stress test a month earlier. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. An abdominal CAT (computed axial tomography) scan was negative for acute disease. He was treated with laxatives. There was a troponin of 0.063 that on repeat was 0.041.

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG [Milliman care guidelines] M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

This patient had chronic chest pains. ACS could have been excluded in the ER (emergency room) with serial troponins. There was no evidence of an acute cardiac event. The patient was complaining of epigastric pain and constipation. He could have been treated with a laxative regimen as an outpatient. No acute interventions were required for the abdominal pain. He did not meet MCG criteria for Undiagnosed Abdominal Pain. The denial is upheld.

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

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

Diagnosis: Intermittent chest pain.
Treatment: Inpatient Hospital Stay.
The insurer denied inpatient hospital stay. 
The denial is upheld.

The patient is a female who presented to the emergency department (ED) with intermittent chest pain of 3 days duration associated with nausea. The patient had had a transthoracic echocardiogram within the last month which was normal. A recent Zio patch showed no frequent premature ventricular contractions (PVCs) and some episodes of non-sustained ventricular tachycardia (NSVT). Physical examination was unremarkable. Electrocardiogram (ECG) showed no ischemia. Troponin was normal. Patient was admitted. Myocardial infarction (MI) was ruled out by repeat troponins. The patient was discharged with follow-up with electrophysiology (EP) for frequent PVCs. The subject under review is the medical necessity for the inpatient hospital stay.

The health plan's determination is upheld.

There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at this facility at a lower level of care status rather than admission to inpatient level of care.

The inpatient hospital stay was not medically necessary. The patient had chest pain which may have been an acute coronary syndrome, although this was unlikely. It was reasonable to monitor the patient to rule out myocardial infarction. This could have been performed at a lower level of care status. Further, it was reasonable to perform a stress test, but this could have been performed at a lower level of care status. There was no medical necessity requiring inpatient hospital admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroesophageal reflux disease (GERD).
Treatment: Gastric procedure (procedure code 43239).
The insurer denied coverage for gastric procedure (procedure code 43239).
The denial is upheld.

The patient has a history of chronic gastroesophageal reflux disease (GERD). He has been treated with omeprazole and his symptoms have been controlled. An upper gastrointestinal (GI) endoscopy revealed chronic gastritis and duodenitis. He was not found to have esophagitis. 

Milliman Care Guideline (MCG) ACG: A-0203 lists indications for Upper GI Endoscopy. GERD is an indication under certain circumstances. The patient needs to have one or more of the following: anemia, dysphagia, epigastric mass, gastrointestinal bleeding, over 50 years of age with additional symptoms, planned bariatric surgery, recurrent vomiting, follow up for severe esophagitis, or weight loss. The patient did not have these conditions. There was also no history of achalasia, Barrett's esophagus, suspected cancer, persistent dyspepsia unresponsive to medical therapy, or gastrointestinal bleeding. 

This patient has chronic GERD, but the medical record states that it was controlled by the omeprazole. He did not meet MCG criteria for performing an Upper GI Endoscopy. 

The health care plan acted reasonably and with sound medical judgment. The endoscopy was not medically necessary for this patient. 

The insurer's denial of coverage for gastric procedure (procedure code 43239) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain.
Treatment: Facet joint injections.
The insurer denied facet joint injections.
The health plan's determination is upheld. 

This is a patient diagnosed with back pain. Records provided show that a request for facet joint injections was denied by the health plan. On appeal, the provider states that oral non-steroidal anti-inflammatory drugs (NSAIDs) are contraindicated due to medication interaction and the patient failed exercises due to worse pain with exercise several months prior to the appeal. The provider states that the injection is used as diagnostic for possible radiofrequency ablation, the patient has failed conservative treatment, there is pain on spinal extension, there is tenderness over the facet joints, and pain is worse at night. It was stated there is no obvious explanation for the back pain as radiculitis resolved with epidural steroid injection.

The requested facet joint injections are not medically necessary for this patient. In this case, the records indicate the patient has a history of lumbar radiculopathy and underwent a lumbar epidural injection about a month prior to the appeal. Reportedly, this improved symptoms, yet there was still noted to be lower extremity paresthesias and increase sensation in the left S (sacral) 1 distribution. There was no official magnetic resonance imaging (MRI) report submitted for review to rule out other obvious causes for the pain and x-rays to show other findings likely responsible for symptoms. Additionally, the provider states the patient previously had too much pain to participate in physical therapy, yet reportedly had significant improvement in symptoms following the epidural injection and no indication that the patient re-attempted any other active conservative treatments such as physical therapy, chiropractic or a daily home exercise program. Therefore, the requested facet injections are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple sclerosis
Treatment: Increase Consumer and Self Directed Personal Assistance Service (CDPAS) to 40 Hours Per Week
The insurer denied the Increase Consumer and Self Directed Personal Assistance Service (CDPAS) to 40 Hours Per Week
The denial is upheld

The patient is a female with multiple sclerosis (MS) and concomitant gait impairment. She uses a walker to ambulate.  The provider is requesting increased Consumer and Self Directed Personal Assistance Service (CDPAS) from 32 hours per week to 40 hours per week.

No, the requested Increase Consumer and Self Directed Personal Assistance Service (CDPAS) to 40 Hours Per Week is not medically necessary.
The patient is able to ambulate with a walker and transfer independently. There is no documented reason her needs cannot be met with the provided 32 hours per week. There is no significant change in her condition to support additional hours.

Therefore, the requested increase in service hours is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Skilled Nursing Facility. 

The insurer denied skilled nursing facility. 
The denial is upheld. 

The patient is a male, who has a diagnosis of Acute Calculous Cholecystitis. Additional diagnosis include coronavirus 2019 (COVID-19), alcohol dependence with withdrawal, alcoholic cirrhosis of liver without ascites, nontraumatic intracerebral hemorrhage, unspecified essential hypertension, essential tremor, repeated falls, chronic hepatitis, nonrheumatic mitral valve prolapse, anxiety disorder, anemia, malaise, other disorders of electrolyte and fluid balance, pancytopenia, difficulty in walking, muscle weakness, other lack of coordination, moderate protein-calorie malnutrition, alcohol abuse, acidosis, chronic persistent hepatitis, disease of pancreas, systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction, unspecified foreign body in respiratory tract, thrombocytopenia, healed traumatic fracture, left artificial hip joint, testicular hypofunction, male erectile dysfunction, problem related to social environment, rhabdomyolysis, other specified abnormal findings of blood chemistry, magnesium deficiency, fracture of right clavicle, major depressive disorder, gastro-esophageal reflux disease with esophagitis without bleeding, asthma, and acute cholecystitis. 

At issue is the medical necessity of the Skilled nursing facility. 

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

The requested health service/treatment of Skilled nursing facility is not medically necessary for this patient. 

Treatment at the Skilled Nursing Facility (SNF) from and beyond was not medically necessary for this patient. Criteria for inpatient skilled nursing generally includes that the patient must have medical necessity for physical, occupational, or speech therapy for a minimum of 1 hour per day and 5 days per week. In addition, the documentation must show that  the patient has demonstrated sustained gains, progress towards pre-established goals, improvement in function and reduction in limitations. For the time period in question, based on the documentation provided, the patient did not meet these criteria. For the time period in question, the patient did not have complex skilled nursing needs, did not require intravenous (IV) or intramuscular (IM) medication management, was not dependent on parenteral nutrition, and did not have complex wound care needs. His needs could safely have been met at home with continued therapies of physical, occupational, and speech therapy being received at home or in an outpatient setting. 

Therefore, the requested health service/treatment of Skilled nursing facility is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient admission. The denial is upheld. 

The patient is a male with a history of stroke with residual left sided weakness and mild expressive aphasia, diabetes, chronic kidney disease, legal blindness, glaucoma, hypertension, peripheral vascular disease, tobacco use, chronic leukocytosis, and benign prostatic hyperplasia (BPH). He presented to the emergency room for slurred speech which appeared to have improved when he put in his dentures. Vitals were notable for a blood pressure of 195/92 and a pulse of 126. Physical exam revealed 4 out of 5 muscle strength of the left upper and lower extremities. His speech was "normal" and he was oriented. Labs were remarkable for a glucose of 286 milligrams per deciliter (mg/dL), creatinine 1.36 milliequivalents per deciliter (mEq/dL), white blood cell (WBC) count 11,200, and hemoglobin 12.4 grams per deciliter (g/dL). The chest x-ray was non-contributory, and the head computed tomography (CT) scan showed no acute findings. The magnetic resonance imaging (MRI) of the brain showed "possible tiny acute or subacute infarct in the left occipital lobe. The magnetic resonance angiography (MRA) showed no hemodynamically significant lesions. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The patient was admitted for further treatment and evaluation. 

Upon admission, the patient was treated with oral medications and low dose of insulin. Soon after admission the blood pressure was 113/64 and the pulse was 88. The following day, the creatinine was 1.15 mEq/dL, and the glucose was 204 mg/dL. The remainder of the stay was clinically uneventful, and the patient was discharged. 
The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld. 

The requested health service/treatment of inpatient stay was not medically necessary for this patient. 

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. The slurred speech had resolved by the time he got to the emergency room (ER) and there were no new focal neurologic findings. Neuroimaging was negative for clinically important findings, and the blood pressure came under control very quickly. There was no serious metabolic disarray. Therefore, based on the standard of care, and the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal - Vomiting.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a female who was admitted for worsening abdominal pain and vomiting. An abdominal X-ray was negative for an acute process. A computed tomography (CT) of the abdomen and pelvis was negative for bowel obstruction, hydronephrosis and appendicitis. The patient was treated for a pelvic infection with antibiotics and was discharged in stable condition.
At issue is the medical necessity for the inpatient stay.

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

During this admission, the patient was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolytes disturbance or irreversible kidney failure. She did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting. There was no documentation of refractory pain and she was able to tolerate an oral diet and did not require total parenteral nutrition and her condition responded to intravenous fluid.
An alternate level of care is appropriate when oral replacement therapy is feasible for individuals with mild or moderate dehydration who can drink and have no significant dehydration-related cognitive or physical compromise.
A randomized study of 13,347 non-critically ill adults requiring IV fluid treatment in the emergency department randomized to treatment with isotonic crystalloid or normal saline found no difference in hospital-free days, but found that patients treated with the isotonic crystalloids had a lower composite outcome of death, need for renal-replacement therapy, or persistent renal dysfunction than the saline-treated group.
There is no evidence-based literature that an inpatient level of care was medically necessary; the patient's condition could be treated safely under an alternate of care.