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

Diagnosis: Shortness of breath
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He has history of COPD (chronic obstructive pulmonary disease) and ETOH (alcohol) abuse. He presented to ER (emergency room) with worsening SOB (shortness of breath). The patient was found to be in COPD (chronic obstructive pulmonary disease) exacerbation. The patient was admitted to the hospital for the management of COPD (chronic obstructive pulmonary disease) exacerbation and alcohol withdrawal.

In the emergency room and at the time of admission, the patient was tachycardic, tachypnic and hypertensive. The patient was started on CIWA (clinical institute withdrawal assessment) protocol. For COPD (chronic obstructive pulmonary disease) exacerbation, the patient was started on steroids as well as nebulization treatment. The patient's COPD (chronic obstructive pulmonary disease) exacerbation and alcohol withdrawal symptoms improved. The patient was ambulating. The patient was tolerating oral diet.

No, the Inpatient admission was not medically necessary.

In the Emergency room and at the time of admission, the patient was tachycardic, tachypnic and hypertensive. The patient was stated on CIWA (clinical institute withdrawal assessment) protocol. For COPD (chronic obstructive pulmonary disease) exacerbation, patient was started on steroids as well as nebulization treatment. The patient's COPD (chronic obstructive pulmonary disease) exacerbation and alcohol withdrawal symptoms improved. The patient was ambulating. The patient was tolerating oral diet. The entire admission was not medically necessary. The patient could have been safely and effectively be treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures
Treatment: Inpatient Hospital
The health plan denied the inpatient stay. 
The health plan's determination is overturned.

The patient is a male who presented to the emergency department after a staring episode.
He was well until approximately a month prior to presentation when he had his first episode of staring. The episodes occurred twice a day and lasted for a few seconds. He did not have any shaking or involuntary movements. He was seen by his primary doctor for his health supervision visit and had an episode of staring during the visit. He was subsequently referred to the emergency department for evaluation of these episodes. His past history was significant for premature birth. Upon presentation he had a temperature of 100 F. His physical examination was normal. Laboratory values were obtained, and he was admitted for evaluation of possible seizures.
He was admitted with seizure precautions and monitoring, with Ativan ordered as needed. A video electroencephalogram (EEG) was obtained as well as a consultation from the neurology team. He did not have staring episodes during the admission, and the video EEG did not show seizure activity. The neurology team also recommended a head magnetic resonance imaging (MRI), and he was given intravenous fluids in preparation for the study. The MRI was normal. He remained stable,  he was felt to be stable for discharge to home with follow up as an outpatient.
The hospitalization is under review for medical necessity.

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

Yes, the requested health service of the inpatient stay was medically necessary for this patient. This is a patient who presented with unexplained staring spells. He was referred to the emergency department after one of the events was observed in the primary care physician's office. He required prompt evaluation for possible seizures or other causes of paroxysmal behavior. His evaluation included video EEG monitoring, which needs to be done in an inpatient setting, as well as an MRI study, while monitoring for other possible etiologies and with administration of intravenous fluids in preparation for the study. While typical absence seizures cause staring episodes and are often benign, they typically present at an older age (mean age 6 years). Staring episodes in a can be a sign of a much more serious disorder, including seizures or sepsis, and require prompt evaluation with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Cardiac
Inpatient hospital

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

The patient is a woman with hypertension and obesity who presented to the emergency room complaining of chest pain with activity, such as working around the house. She reported easy fatigability and exertion dyspnea for 6 days. She had no chest pain on admission. Blood pressure was 178/89 mm Hg and pulse 77 beats per minute (bpm). Respiratory rate was 18, and she was afebrile. Oxygen saturation was 97% on room air. An electrocardiogram (EKG) showed sinus rhythm with no ischemic ST segment (interval between ventricular depolarization and ventricular repolarization) changes. Initial troponin was negative. She was admitted and ruled out for myocardial infarction with 3 sets of troponins being negative. 

An inpatient stay is not medically necessary for this patient. She meets criteria for a lower level of care, based on Milliman Criteria, as she had chest pain suspected to be due to myocardial ischemia, but with initial non-diagnostic cardiac evaluation (EKG and cardiac biomarkers). She does not meet criteria for inpatient admission, as she was not hemodynamically unstable, did not have respiratory distress, objective evidence of an acute coronary syndrome, or other serious cardiac or pulmonary diagnosis, such as aortic dissection or acute pulmonary embolus.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea.
Treatment: Procedure code 65468 (incision for implantation of cranial nerve (ex: vagus nerve) (neurostimulator electrode array and pulse generator) and code 0466T (insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator).
The insurer denied coverage for procedure codes 65468 and 0466T.
The denial is overturned. 

This is a female patient with a history of severe obstructive sleep apnea (OSA) with symptoms of increased daytime tiredness and partial intolerance to continuous positive airway pressure (CPAP) therapy. A sleep study found that the patient has severe OSA hypopnea. The overall apnea hypopnea index (AHI) was 34.0 events/hour, and the overall respiratory disturbance index (RDI) was 34.0. Sleep is frequently disrupted by respiratory events. Lowest fall in oxygen saturation is 93.0%. A Drug induced sleep endoscopy found that there was an anterior -posterior collapse at the level of velopharynx, the tongue base did not demonstrate collapse; at the level of the oropharynx there was concentric collapse, and the epiglottis was self-retaining without collapse. The patient had a body mass index (BMI) of 32.3. 

There is extensive literature showing the efficacy of hypoglossal nerve stimulation and the treatment of OSA. The use of hypoglossal nerve stimulation has been approved by international and national professional societies. The Food and Drug Administration (FDA) has approved the use of hypoglossal nerve stimulation for the effective treatment of OSA. The patient fulfilled all of the FDA requirements for the uses of hypoglossal stimulation which included patients with an AHI of greater than or equal to 15 and less than or equal to 65, the patient's was 34; who have been confined to fail or cannot tolerate positive airway pressure, this has been documented; and who do not have a complete concentric collapse at the soft palate level, which was documented by the endoscopy.

The procedure code 65468 and code 0466T as applied to the hypoglossal nerve stimulator has been approved twice by the FDA.

The patient is a good candidate for the procedures under codes 65468 and code 0466T as she meets all of the FDA criteria for implantation.

The procedure codes 65468 and 0466T are the best available treatment for this patient at this time. The only alternative would be a tracheotomy which carry significant morbidity and mortality and would not be utilized at this point in the care of this patient.

The procedure codes are much more beneficial than any other treatment which is available for the patient's condition of severe sleep apnea, obesity as documented by a high BMI, and inability to use CPAP.

The denial should be overturned for the use of hypoglossal nerve stimulation as it has been approved twice by the FDA and is considered an efficacious intervention for OSA. The patient fulfilled all the criteria prescribed by the FDA.

The insurer's denial is overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea.
Treatment: Procedure code 65468 (incision for implantation of cranial nerve (ex: vagus nerve) (neurostimulator electrode array and pulse generator) and code 0466T (insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator).
The insurer denied coverage for procedure codes 65468 and 0466T.
The denial is overturned. 

This is a female patient with a diagnosis of severe obstructive sleep apnea (OSA). The physician detailed the prior polysomnogram eliminated the possibility of central sleep apnea or complex sleep apnea. The results revealed an apnea hypopnea index (AHI) of 34. The patient has also undergone a prior sleep endoscopy confirming she does not have complete concentric collapse. She has a body mass index (BMI) of 32.29 according to the physician. The physician does detail this patient has had a trial and failure of continuous positive airway pressure (CPAP). She has been partially able to utilize CPAP however it caused bilateral ear pressure associated with overinflation. Due to the severity of OSA, the patient is not a viable candidate for oral appliance therapy. The request has been made for the implantation of the neurostimulator electrode array. 

The current scientific evidence in peer-reviewed literature supports the result of improvement in health outcomes for this device. 

The hypoglossal nerve stimulator (ie. the Inspire system) has final approval from the Food and Drug Administration (FDA) for severe OSA.

This patient meets all inclusion criteria to be a candidate for this device, which are:  BMI<32, age requirement, moderate to severe OSA, intolerance to CPAP therapy, <25% central apneas, no concentric collapse of the velopharynx on drug induced sleep endoscopy.

This is the best available treatment for this patient at this time. Other surgical procedures for the treatment of OSA have poorer outcomes with higher morbidity. 

The requested procedure (Hypoglossal nerve stimulator) is likely to be more beneficial than any of the standard treatments. Especially since this patient cannot tolerate CPAP due to over-pressurization of the ears. 

The insurer's denial of coverage for procedure code 65468 (incision for implantation of cranial nerve (ex: vagus nerve) (neurostimulator electrode array and pulse generator) and code 0466T (insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator) is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure-like activity. 

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.

This patient is a male child who was brought to the Emergency Department (ED) due to having jerking movements according to his mother. The documentation indicated the patient has a past history of chronic lung disease (CLD), necrotizing enterocolitis (NEC), and intraventricular hemorrhage (IVH). The patient upon arrival was not making any abnormal movements. The physical examination revealed no significant abnormalities.  The patient was active and in no acute distress. It was recommended the patient undergo laboratory and diagnostic studies. The documentation did not reveal any significant findings or laboratory studies. The recommendation was made for the patient to continue with admission for further evaluation. The patient was recommended to undergo additional studies to include a video electroencephalography (EEG). The EEG was notable for lack of complexity with no focal abnormalities. Patient monitoring continued.  Given there was a lack of further adverse events he was discharged on day 3 of admission. 

The acuity of this case is considered to have required observation. Upon arrival the patient was not considered to be in status epilepticus. No events concerning for seizures were noted during the stay. Precautionary testing with EEG were performed without abnormality. No other interventions were necessary. The patient was described as interactive and left on day 3 of admission. The patient did not require an escalated level of care.

The current literature indicates a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe persistent or there is evidence of hemodynamic instability. The submitted documentation does not detail the patient had a trial and failure of care at a lower level such as observation. The documentation detailed the patient was back at his baseline and was discharged after 24 hours. The requested inpatient admission would not be the most appropriate level of care and therefore, the inpatient hospital admission was not medically necessary.

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

The medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple dentoalveolar fractures of the anterior maxillary and mandibular teeth.
Treatment: Dental services from an out-of-network provider; CPT codes 70355, 13152, 21440 x 2 and 21453.
The insurer denied coverage for the dental services received from an out-of-network provider; CPT codes 70355, 13152, 21440 x 2 and 21453.
The denial is overturned. 

This is a male patient who suffered multiple dentoalveolar fractures of the anterior maxillary and mandibular teeth.  The patient also suffered lacerations of the associated tissues and a comminuted symphysis fracture of the anterior mandible.  The patient was treated by an oral and maxillofacial surgeon (OMS) for the traumatic injuries.  The hospital that evaluated this patient had no OMS on staff and did not refer to any specific provider but just to a dentist and an OMS.  

The patient suffered a severe traumatic event.  The patient had multiple open fractures that required immediate treatment.  This is not elective surgery.  These are medical procedures.  The treatment is medically necessary and appropriate. The fractures required fixation and this includes the loose or dislocated teeth.  Fracture stabilization is critical to proper healing, especially open fractures.

"Optimal treatment timing must take into consideration the type and severity of injury. Concomitant injuries that require attention for patient stabilization need to be addressed in an expeditious manner, prior to management of mandibular fractures." (Koshy, J.C., 2010).

"The ultimate goal of treatment is to re-establish the patient's preinjury dental occlusion. Fractures that are nondisplaced and exhibit no occlusal changes may be amenable to nonsurgical management, but the majority of mandible fractures will require stabilization for satisfactory healing and to restore pre-traumatic maxillomandibular orientation.   Various treatment strategies have been described and vary widely depending on the fracture location and surgeon's preference.  The patient's demographics, comorbidities, dentition, and fracture characterization will all influence the choice of fixation by the treating surgeon" (Pickrell, B.B., Serebrakian, A.T., Maricevich, R.S., 2017).

The dental services received by the out-of-network provider are considered medically necessary for this patient.  The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for dental services received from an out-of-network provider; CPT codes 70355, 13152, 21440 x 2 and 21453 is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion. 
Treatment: Orthodontic treatment (Braces) and periodic orthodontic treatment visits. 

The insurer denied the Orthodontic treatment (Braces) and periodic orthodontic treatment visits. 
The denial is upheld. 

The patient is a female. The request is for dental benefits for Orthodontic treatment (Braces) and periodic visits. Per the provided records, there is Class II malocclusion, excessive overjet and overbite, ectopic eruption of teeth in the maxilla and mandible. 

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

The severity of the overall conditions as stated in the clinical summary, namely ectopic eruption, excessive overjet and overbite is not supported by the x-rays and photos submitted. As such, the proposed orthodontic treatment is not warranted. Therefore, the Orthodontic treatment (Braces) and periodic orthodontic treatment visits are not medically necessary. 

Based on the records presented, the severity of the clinical conditions is not substantiated, and therefore, the orthodontic treatment is not warranted.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Screen for malignant colorectal neoplasm. 

Treatment: Colonoscopy, code 45380.

The insurer denied coverage for the colonoscopy, code 45380. 

The denial is overturned. 

This is a male patient with a history of gastroesophageal reflux disease (GERD), hypertension, and hyperlipidemia. He presented to a hospital facility for an outpatient colonoscopy to screen for malignant colorectal neoplasm. The procedure was performed without complications. The impression was external hemorrhoids and diverticulosis. The results were otherwise normal.  

The American College of Gastroenterology advises in their guidelines that a screening colonoscopy should be performed every 10 years beginning at a certain age. The American Cancer Society also advises patients to have colon cancer screening. An option is to have a colonoscopy every 10 years. Their recommendation is to start screening at an earlier age.

The patient required a colonoscopy. It is a recommended test both by the American College of Gastroenterology and the American Cancer Society. It is a standard procedure to perform colonoscopies on an outpatient basis at a hospital facility. 

The healthcare plan did not act reasonably and with sound medical judgement or in the best interest of the patient. The colonoscopy was a medically necessary procedure.
 
Based on the above, the medical necessity for the colonoscopy, code 45380 is substantiated. The insurer's denial is overturned.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Asthma.
Treatment:  Pharmacy/Prescription Drugs (Alvesco).

The health plan denied the requested pharmacy/prescription drugs (Alvesco).  The health plan's determination is overturned.

The patient is a man with long-standing asthma and adrenal insufficiency (related to high dose steroids). His physician requests inhaled Ciclesonide as treatment, as it carries a lower risk of affect adrenal function. The insurance company lists Arnuity, Asmanex, Flovent, Pulmicort, and QVAR as approved formulary alternatives. The patient has been taking Ciclesonide (Alvesco) and tolerating it well with good control of asthma.

At issue is the medical necessity of the requested prescription medication.

The health plan's determination is overturned, in whole.

I think the patient should have Alvesco. The formulary drugs are all medications which can cause adrenal insufficiency, an issue the patient has had in the past. There is definitely a subset of patients who are sensitive to inhaled steroids and can develop adrenal insufficiency; all the formulary alternatives have all been implicated in patients developing adrenal insufficiency. Alvesco is the only available inhaled steroid that seems to fairly clearly not cause adrenal insufficiency and as such, is probably the most reasonable and safest medication for him to be on.

This medication is Food and Drug Administration (FDA) approved for this indication. The dose/quantity is the FDA approved dose. I do not think it is reasonable to ask the patient to try 3 formulary alternatives, as there is a contra-indication: he has developed adrenal insufficiency before, and all formulary alternatives are known to cause adrenal insufficiency; to ask the patient to try a formulary alternative would be to expose him to undue risk. As such, I think he satisfies all criteria to have the non-formulary medication (Alvesco) authorized.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal-Abdominal pain
Treatment: Inpatient Stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan determination.

The patient presented to the emergency department with abdominal pain for four days. He had sudden onset of epigastric/periumbilical pain characterized as "sharp burning" radiating to the left initially at 3/10 in intensity and reaching 7/10 in intensity, worse with food, motion, and cough. He subsequently developed biliary vomiting consisting of food contents, and loss of appetite. He had been drinking 10-12 drinks of vodka daily, and recently had been started on vilazodone for depression. Vital signs were notable for tachycardia with pulse rate of 112/minute, and elevated blood pressure of 142/81 mm Hg. Labs showed elevated aspartate aminotransferase of 217, elevated alanine aminotransferase of 106, and lactate of 4.3. Computed tomography scan of the abdomen and pelvis showed new diffuse hepatic steatosis and a dilated common bile duct. Magnetic resonance imaging showed a dilated common bile duct and diffuse hepatic steatosis. The assessment was tachycardia, elevated lactate, alcoholic pattern of transaminase elevation, bacteremia, abnormal imaging, and abdominal pain at 7/10; the decision was made for inpatient admission for work-up and therapy. He was treated with intravenous fluids, lorazepam, morphine, ondansetron, and magnesium sulfate. Surgery recommended cholecystectomy, but the patient wanted a second opinion. He was discharged with a plan for Primary Care and Surgery follow-up.

The inpatient level of care is not supported and not medically necessary. In this case, the patient presented with abdominal pain and vomiting in the setting of significant alcohol use, and commensurate elevation in liver enzymes [1]. Although there was a dilated common bile duct and concern for cholecystitis, cholecystitis and gallbladder dysfunction were not established by testing [2-4]. There were no other documented complications such as complicated choledocholithiasis, ascending cholangitis, hepatic abscess, or fistula. Although there was an elevated lactate and tachycardia, there was no documented leukocytosis, and sepsis was not established [5]. There was a possibility of alcohol withdrawal given tachycardia, but the patient did not have alcohol withdrawal during the hospital stay [6,7]. All of the measures that were undertaken, including monitoring, labs, intravenous fluids, pain medication, Surgery consultation, and magnetic resonance imaging scan, could have been performed without acute inpatient level of care, at a lower level of care [1-5].