Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Preconception genetic counseling and testing.
Treatment: Carrier Screen Testing.

The insurer denied coverage for Carrier Screen Testing.
The denial is overturned. 

This is a female patient whose husband's family has a history of cystic fibrosis. The patient is planning pregnancy. She consulted a medical geneticist who ordered expanded carrier testing. The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.

The patient underwent expanded genetic carrier screening. Because genetic testing technology has evolved rapidly over the past decade, it is now possible to screen for a large number of conditions simultaneously. This testing strategy is known as expanded carrier screening. Expanded carrier screening panels offered by laboratories typically include options to screen from 510 conditions to as many as several hundred conditions. Traditionally, panethnic screening has been defined as making screening for specific recommended conditions available to all patients, regardless of ethnic or racial background. This approach largely has been supplanted by expanded carrier screening because of its efficiency and economy. The American College of Obstetrics and Gynecology (ACOG), in its Committee Opinion, states: "Ethnic-specific, panethnic, and expanded carrier screening are acceptable strategies for prepregnancy and prenatal carrier screening. Each obstetrician gynecologist or other health care provider or practice should establish a standard approach that is consistently offered to and discussed with each patient, ideally before pregnancy. After counseling, a patient may decline any or all carrier screening. Pretest counseling that includes information on the types of potential results as well as the risks, limitations, and benefits of testing should be provided to all patients before performing any form of genetic test. After counseling, patients should have the option to decline any or all testing." The medical records confirm that the patient was counseled by the attending medical geneticist on expanded genetic carrier testing as specified in the ACOG guidelines. Therefore, the patient meets the standard of care.

The Carrier Screen Testing does have final approval from the appropriate regulatory bodies for this diagnosis.

The medical records confirm that the patient was counseled by the attending medical geneticist on expanded genetic carrier testing as specified in the ACOG guidelines. Therefore, the patient meets the standard of care.  

The patient is planning pregnancy. Therefore offering expanded carrier testing with counseling as specified by ACOG guidelines meets the standard of care for this patient, who is a good candidate.     

The Carrier Screen Testing is the best available treatment for this patient at this time.     
   
The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of the Carrier Screen Testing should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Preconception genetic counseling and testing.
Treatment: Carrier Screen Testing. 

The insurer denied coverage for Carrier Screen Testing.
The denial is upheld. 

This is a female patient who was referred by her obstetrician gynecologist to a geneticist to discuss family planning. The patient has no significant medical history. Her husband has no significant medical history. Her husband's family has a genetic history of cystic fibrosis. The patient was evaluated for preconception genetic counseling and testing. The treatment plan included an expanded carrier screening for the inheritance of genetic conditions. The patient underwent genetic testing as part of making an informed reproductive decision.

As per the American College of Obstetricians and Gynecologists (ACOG), "All patients who are considering pregnancy or are already pregnant, regardless of screening strategy and ethnicity, should be offered carrier screening for cystic fibrosis (81220) and spinal muscular atrophy SMA (81401). All other genetic carrier screening in the absence of a positive family history or personal history and in the absence of an ethnic background at high risk for these conditions is considered not medically necessary." ACOG based their recommendation on the fact that there is insufficient scientific evidence that the requested gene panel will have a significant impact on treatment planning or outcome.

Based on ACOG's recommendation and standard of care and the scientific evidence there is no benefit from panel testing. Note that this patient could have been tested for cystic fibrosis and spinal muscular atrophy only as recommended by ACOG and also based on the fact that her husband was a carrier of cystic fibrosis.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

This patient is not a good candidate for the Carrier Screen Testing.

The Carrier Screen Testing is not the best available treatment for this patient, at this time. The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient

The carrier's denial of the Carrier Screen Testing should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder. 
Treatment Braces and Monthly Visits. 

The insurer denied Braces and Monthly Visits. 
The determination is overturned. 

The patient presented with a skeletal Class I malocclusion and significant crowding. He has an anterior open bite. He is treatment planned for 30-36 months of orthodontics with extraction of teeth 5, 12, 21, and 28 to address the crowding and open bite. The treatment was denied due to lack of medical necessity. At issue is the medical necessity of braces and monthly visits. 

The braces and monthly visits are medically necessary. Patients with an anterior open bite are among the most difficult patients to treat. 1) One side effect of an anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. 2) Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite. 3) This patient is treatment planned for extractions, which is less invasive than orthognathic surgery. Orthodontic treatment is medically necessary for this patient due to the side effect described and the fact that this is not something that will self-correct without orthodontic intervention.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain, troponinemia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of diabetes mellitus type 2 (DM2), hypertension (HTN), myocardial infarction (MI) and heart failure with reduced ejection fraction (HFrEF) status/post (s/p) automatic implantable cardioverter defibrillator (AICD), diverticulitis, and hyperlipidemia (HLPD) who was admitted with complaints of (c/o) right-sided neck pain associated with right eye pain. Vital signs were notable for hypotension. The physical exam was notable for no apparent distress (NAD). Lab work was notable for an elevated troponin and acute kidney injury (AKI). A chest x-ray (CXR) showed no acute pathology, computed tomography (CT) scan of the head showed no acute intracranial pathology, a transthoracic echocardiogram (TTE) showed a severely reduced left ventricular ejection fraction (LVEF) at 25% and severe global hypokinesis and unchanged from prior. An electrocardiogram (EKG) showed ST segment (the flat section between the end of the S and the start of the T wave) with right bundle branch block (RBBB) and Q-waves. The patient was noted to have non-sustained ventricular tachycardia (NSVT), and cardiology recommended no intervention. The patient was diagnosed with troponinemia and an acute kidney injury (AKI) and treated with serial troponins, cardiology consultation, fluids, and holding nephrotoxins. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o neck pain that was associated with eye pain. An EKG did not demonstrate any acute ischemic changes and he was evaluated by cardiology, who did not recommend any acute interventions. While the patient did have a detectable troponin, he did not have any active chest pain. It was documented to be most likely related to the patient's elevated creatinine, and cardiology did not recommend any invasive procedures or interventions, only conservative therapy. In addition, while the patient had an elevated creatinine above baseline, he did not have any severe electrolyte abnormalities and responded well to intravenous (IV) fluids. Given that the patient had stable vital signs, no unstable co-morbidities, a non-ischemic EKG and stable cardiac biomarkers, no new left bundle branch block (LBBB) or newly ischemic EKG, and no classic anginal symptoms or other serious or life-threatening cardiopulmonary etiologies, this patient could have been safely and appropriately treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer.
Treatment: OncotypeDx testing.
The insurer denied the OncotypeDx testing. 
The health plan's determination is upheld. 

This patient is a man with elevated prostate-specific antigen (PSA) of 3.7. A magnetic resonance imaging (MRI) was performed, followed by a prostate biopsy. He was found to have Gleason Grade Group 1 prostate cancer as well as stromal tumor of the prostate. He has clinical T1c disease. In an effort to guide treatment planning, Oncotype Dx testing was performed and is under review.

The Oncotype DX Testing is not medically necessary.
The patient has Gleason grade Group 1 prostate cancer with PSA of 3.7 and clinical stage T1c. He has coexistent stromal tumor. Oncotype Dx testing has not been studied for stromal tumor. For adenocarcinoma, per National Comprehensive Cancer Network (NCCN) guidelines, the test has not been subjected to randomized controlled studies and has been marketed with notable industry influence. Long term benefit has not been established.
Current American Urological Association (AUA) guidelines note, " Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance."
ASCO (American Society of Clinical Oncology) guidelines note that the test under review has not been established as standard of care and has not been shown to impact long term health outcomes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient hospital. 
The insurer denied inpatient hospital stay. 
The denial is upheld.

The patient is a female who presented to the hospital to undergo a scheduled cholecystectomy and ventral hernia repair. She had a history of diabetes, hyperlipidemia, hypertension and morbid obesity. At the time of presentation, the patient was without fever and vital signs were normal. A computed tomography (CT) scan showed a large ventral hernia containing non-obstructed bowel.

She was admitted to the hospital and underwent laparoscopic (robotic assisted) cholecystectomy and concomitant laparoscopic ventral hernia repair with mesh. The operative dictation describes a robotic assisted ventral hernia repair procedure for a 9-centimeter (cm) ventral hernia defect.

The patient was treated with post-surgical monitoring, intravenous (IV) fluid, and IV analgesia. The immediate post-surgical recovery was uncomplicated. The patient had stable vital signs. The diet was advanced. She was discharged from the inpatient setting. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld in whole.

An inpatient level of care was not medically necessary in this case. This patient is a female with comorbid health conditions of diabetes, hyperlipidemia, hypertension and morbid obesity. She presented to the hospital and underwent a scheduled cholecystectomy and ventral hernia repair procedure. The robotic assisted procedure was performed without complication and the patient remained hemodynamically stable during the period of post-surgical monitoring.

There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation or in the post-operative period. There were no peri-operative complications or other clinical issues that mandated inpatient care. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Benign Prostatic Hypertrophy (BPH)

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld. 

This male patient has a history of benign prostatic hypertrophy (BPH), lower urinary tract symptoms (LUTS), and nicotine abuse. The patient presented to the hospital for scheduled transurethral resection of the prostate (TURP) to alleviate his LUTS secondary to BPH. The patient had his scheduled procedure performed without complications. The patient was transferred to the post anesthesia care unit (PACU). Sequential compression devices (SCD) were applied for deep vein thrombosis (DVT) prophylaxis, intravenous (IV) fluids given and intake and output (I/O) monitored. The patient was in the hospital overnight and then discharged home with outpatient follow up arranged. 

The insurer has denied coverage for the inpatient admission as not medically necessary. They noted the TURP procedure and lack of pre- and post-operative complications. The appeal on behalf of the hospital was read in detail. Per MCG (Milliman Care Guidelines) Health (24th) Urologic Surgery or Procedure General Recovery Guidelines (GRG), the patient is noted to have met the GRG discharge parameter within 24 hours post-procedure. Also, per MCG Health (24th) Prostatectomy - Transurethral Resection (TURP), the patient is noted to have met the optimal recovery course discharge parameter within 24 hours post-procedure, and fails to meet guidelines for external stay (post-operative bleeding, TURP syndrome, concerns for sepsis, etc.). Goal length of stay (LOS) for TURP is ambulatory or one day post-operative, usually an overnight (observation) stay to ensure a safe discharge, if needed. 

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

Based on the above, the medical necessity for inpatient hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: White glass with high gold content crown Tooth 24. 
The insurer denied the White glass with high gold content crown Tooth 24. 
The determination is upheld.

The patient presented for dental treatment. The provided information including x-rays was reviewed. At issue is the medical necessity of a white glass with high gold content crown Tooth 24. 

The requested treatment, white glass with high gold content crown is not medically necessary/ appropriate for tooth #24.
Tooth #24 has an existing porcelain fused to metal (PFM) crown with existing root canal treatment (RCT) and screw retained post. Although x-rays do not show caries under the existing crown, extensive radiolucent periapical (RLPA) lesion exists in #24, 25.
Tooth #24 has a poor prognosis due to horizontal bone loss and enlarged periodontal ligament (PDL) space. Because tooth #24's prognosis is poor, the requested crown is not medically necessary. As indicated in the citations below, re-treatment of a tooth with an existing RCT and removal of existing post, are most frequently affected by vertical fractures requiring extractions.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and monthly visit x 4 for medical necessity. 
The denial was overturned. 

The patient is a male with a Class I malocclusion and anterior crossbite of #7. This patient presented with severe crowding. Tooth #27 is showing some recession and is blocked out of the arch. He has treatment planned for orthodontics to correct his malocclusion.
At issue is the medical necessity for braces and monthly visit times (x) 4. 

The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of braces and monthly visit x 4, is medically necessary for this patient.
This patient presents with an anterior crossbite and severe crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. These problems are time consuming and more difficult to correct at a later time.
The patient has severe maxillary and mandibular crowding with #7 in crossbite. This tooth has a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Tooth #27 already has slight recession, and further movement of #27 is likely due to its position relative to #26 and will lead to the need for future periodontal grafting on this tooth. Orthodontic treatment now will prevent the need for future periodontal and restorative procedures. For these reasons orthodontic treatment is medically necessary.
Therefore, the requested health service/treatment of braces and monthly visit x 4 are medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient admission.
The denial is upheld. 

The male patient who has an unremarkable past medical history who presented to the Emergency Department (ED) with complaints of pain, swelling, and erythema of the right foot and ankle. The patient's vital signs on presentation included: temperature 98.1, blood pressure 107/75, and pulse 85, and respiratory rate 20, oxygen saturation 100% on room air. The patient's laboratory results included the following: white blood cell (WBC) count 6.7, hemoglobin 10.8, hematocrit 30.9, creatinine 0.7, and glucose 124. The patient was started empirically on intravenous (IV) antibiotics (i.e., cefazolin, doxycycline, and Levaquin) for a right foot cellulitis. The patient's chest x-ray was unremarkable. The patient's x-ray of the foot showed no evidence of osteomyelitis. The patient's venous Doppler scan was negative for deep venous thrombosis (DVT). Podiatry consulted over the case, and their impression was venous stasis ulcer; no surgical intervention was deemed necessary. Infectious Diseases (ID) also consulted over the case. The patient remained afebrile and hemodynamically stable. The patient was discharged home and was instructed to continue oral antibiotics as an outpatient. 

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient presented with a right foot cellulitis. Otherwise, the patient was afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC count. The patient did not have any evidence for a disseminated infection and no surgical intervention was required. Based on these clinical findings, the patient did not meet criteria for acute hospital admission. The patient's care could have been safely provided at a lower level of care, such as observation level of care. 

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

Based on the above, the medical necessity for inpatient hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a woman. Her medical history included gallstones and cocaine-use (and obesity, hypertension, reflux, tobacco-use, and marijuana-use). Her surgical history included C-section. She presented to an emergency department with a three-day history of chills, nausea, vomiting, and epigastric and right-upper-quadrant abdominal pain.

The patient's vitals were as follows: temperature 37.8, pulse 98, blood pressure 122/80, respirations 20, and oxygenation 99%. Physical examination demonstrated tenderness-to-palpation of the epigastrium and the right-upper-quadrant of abdomen.

The patient's serum laboratories demonstrated leukocytosis to 14.1. Abdominal ultrasound demonstrated gallstones. Abdominal computed tomography demonstrated acute cholecystitis.

The patient was admitted at an acute inpatient level of care with a diagnosis of acute cholecystitis. Her surgeon recommended anesthesia evaluation (due to cocaine use) and laparoscopic cholecystectomy. However, the patient elected to forgo surgery, preferring outpatient, non-operative management for her gallstones.

Having returned to her baseline health and function, the patient was discharged home in good and stable condition with prescriptions for oral antibiotics and outpatient surgical follow-up.

No, the Inpatient admission was not medically necessary.

The Tokyo Guidelines [TG18] are the international, gold-standard recommendations for the diagnosis and treatment of diseases of the biliary tree. According to these guidelines, patients who prefer/undergo non-operative management may be observed for 24 hours. After this period, patients who demonstrate clinical improvement may continue with non-operative management, and patients who demonstrate clinical worsening may convert to operative management.

Based on the provided medical documentation and in accordance with international guidelines Tokyo Guidelines [TG18], for this patient, admission at an acute inpatient level of care was not necessary. The patient could have been treated at lower level of care.