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

Diagnosis: Burns to left hand

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

The health plan did not act reasonably. An inpatient admission was medically necessary. This patient had a partial thickness burn that required wound care, pain medication and instruction on range of motion and outpatient wound care. According to the MCG (Milliman Care Guidelines), 26th Edition, admission to a burn unit is required for any of the following indications:

o	Hemodynamic instability
o	Full-thickness (third-degree) burn
o	Partial thickness (second-degree) burn greater than 10% of total body surface area[A]
o	Partial thickness (second-degree) burn of face, hand, foot, genitals, or perineum
o	Partial thickness (second-degree) burn that crosses major joint or is circumferential
o	Inhalation injury (7)(8)
o	Burn accompanied by other significant medical problems or injuries (e.g., altered mental status, arrhythmia, inability to maintain oral hydration, significant wound, or fracture)
o	Serious chemical burn (9)(10)(11)
o	High-voltage (e.g., 1000 volts or more) electrical burn (12)(13)
o	Pain management requiring inpatient care (e.g., IV (intravenous) narcotics)

In this case, the patient had a second degree burn of the hand. The presence of blisters indicates a second-degree burn. Per the MCG guidelines, admission is medically necessary for hand burns due to the high risk of secondary problems including finger contractures and chronic joint stiffness. The admission was medically necessary to treat this high risk burn to the hand.
The insurer's denial of coverage for inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite.
Treatment: Braces and monthly visits.

The insurer denied braces and monthly visits.  The denial is overturned. 

The patient is a female with a crossbite of anterior teeth 8 and 9. She presents with a skeletal Class I malocclusion with moderate spacing in the maxilla and mandible. She is treatment planned for orthodontics to address the spacing and crossbite, but the treatment was denied due to lack of medical necessity. The subject under review is the medical necessity for braces and monthly visits.

The health plan's determination is overturned.

The requested treatment of braces and monthly visits are medically necessary for this patient. This patient presents with an anterior crossbite on teeth 8 and 9, as well as moderate spacing. 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. (1,2,3)  It appears the lower anterior teeth are migrating labially in the arch.

If left untreated the damage that will likely occur to the patients teeth will be much more time consuming and complicated to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructed airway on induction of anesthesia.

Treatment inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient is a male with history of dysplasia of the hip, hypospadias, and autism spectrum disorder. He presented to the hospital for a coronal hypospadias repair. He was admitted to the telemetry unit for an obstructed airway on induction of anesthesia. On induction of anesthesia, the patient's airway became severely obstructed requiring significant jaw thrust and positive airway pressure. After the procedure was completed, he was extubated without difficulty. An ENT (ear, nose, and throat) physician was consulted post-operatively to evaluate the airway and recommended an admission overnight for apnea monitoring. During the hospital course he had desaturations to 89% oxygen saturation lasting for approximately one minute. He also had isolated premature ventricular contractions and occasional sinus pauses. He was discharged.

The patient had respiratory issues during intubation with obstructed airway. During the hospital course he had desaturations to 89% oxygen saturation lasting for approximately one minute. He also had isolated premature ventricular contractions and occasional sinus pauses. The admission was appropriate and medically necessary.      

"Conclusions: Very few children referred to a paediatric tertiary referral centre actually require pediatric intensive care unit (PICU) admission following surgery. This may be in part due to the use of a nasopharyngeal airway in patients where postoperative obstruction is anticipated. In children with severe obstructive sleep apnea (OSA) [Apnea Hypopnea Index (AHI) >10] and an American Society of Anesthesiologists (ASA) grade of 3, nasopharyngeal airway insertion and potential admission to the PICU should be considered." (Sharma, S. D. et al. 2018)

"Conclusion: The current polysomnogram practice patterns for responding pediatric otolaryngologists are not aligned with the clinical practice guideline of the American Academy of Otolaryngology-Head and Neck Surgery Foundation. The threshold for overnight observation when a preoperative polysomnogram has not been performed may be too low. A campaign is necessary to educate clinicians who take care of children with obstructive sleep-disordered breathing and to obtain more evidence to further define best practice. " (Friedman, N. R. et al. 2019)

"Conclusion: Based upon these results, we describe our current criteria for elective admission to the paediatric intensive care unit following adenotonsillectomy for severe obstructive sleep apnoea." (Walker, P. et al. 2013)                                                      

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: Renal stones.

Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.

The denial is upheld.

This is a male with past medical history of appendectomy and surgical repair of testicular torsion. The patient presented to the emergency room with complaint of abdominal pain. Computed tomography scan revealed right hydronephrosis due to renal stones in the right distal ureter. Patient was admitted, given intravenous fluid, intravenous antibiotics, testing including blood/ urine cultures. Patient was being prepared for possible urologic procedure, but he passed most of his stones prior to the procedure. He was deemed stable for discharge home later that day with outpatient follow up. The insurer has denied coverage for the inpatient admission as not medically necessary they noted the prior spontaneous stone passage, and a lack of serious medical tissues such as low blood pressure, high fever or worsening of kidney function. The appeal on behalf of the hospital is noted and read in detail. Per MCG (Milliman Care Guidelines) Health (25th) Renal Colic and kidney stone: patient fails to meet clinical indications for admission to inpatient care, but does appear to meet guidelines for observation care:

1) Insufficient pain relief despite emergency department care.
2) Suspected infection (fever, pyuria).

The inpatient admission was not medically necessary for this patient.

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

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

Diagnosis: Neuropathy

Treatment: Gammaked

The insurer denied coverage for Gammaked

The denial is overturned.

This case involves a male with a history of fibromyalgia, axonal neuropathy, chronic migraine, torticollis, who was being recommended for Gammaked infusions. The patient was seen for follow-up. Sensory symptoms and weakness were worsening since his last visit, and he continued to have manual disimpaction for bowels and bladder incontinence with sensory loss from the legs up to the waist. On examination, the patient had proximal and distal weakness of the arms and legs. The patient had a diagnosis of inflammatory neuropathy, progression of loss of reflexes, a decrease in motor strength, and an increase in sensory loss over time.  Previously, the patient received a notice of adverse determination regarding coverage for Gammaked. It was determined that common symptoms of chronic inflammatory demyelinating polyneuropathy include gradual weakness or sensation changes in the arms or legs. It was previously determined that there was no documentation provided that demonstrated the patient had motor weakness upon neurological examination. Handwritten notes on the pharmacy policy document indicated that the patient met clinical criteria for the proposed treatment. This review pertains to denial of coverage for Gammaked.  

The health plan did not act reasonably and with sound judgment and in the best interest of the patient. Patient has a clinical history of an inflammatory neuropathy which was confirmed on nerve conduction study/EMG (electromyography). Patient also has notable weakness appreciated on physical examination. Gammaked is an immune globulin which is FDA (food and drug administration) approved for the treatment of demyelinating/inflammatory neuropathy and has been demonstrated to improve overall motor functionality and strength in patients with demyelinating/inflammatory neuropathy. Gammaked is medically necessary for this patient. 

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 Gammaked is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Esophageal ulcer

Treatment is EGD (esophagogastroduodenoscopy) (procedure code 43239)
 
The denial is overturned EGD (procedure code 43239)

The patient has a history of an esophageal ulcer and presented with epigastric pain and reflux. An endoscopy was being done to evaluate for healing of the ulcer and the erosive esophagitis. The endoscopy reported that the patient now had non erosive esophagitis and no ulcer was found. Endoscopic biopsies found chronic gastritis without H (Helicobacter) Pylori. 

MCG (Milliman Care Guidelines) guideline ACG: A-0203 lists indications for Upper GI (gastrointestinal) Endoscopy. Among the indications for the procedure is having gastroesophageal reflux disease with a history of known severe erosive esophagitis requiring follow up after treatment with a PPI (proton pump inhibitor). 

This patient had severe erosive esophagitis with an esophageal ulcer in the past. She was now having epigastric pain and reflux. Doing an endoscopy to evaluate if the severe erosive esophagitis was still present met MCG criteria for the procedure. 

The health care plan did not act reasonably or with sound medical judgment. The endoscopy was medically necessary. 

The insurer's denial of coverage for EGD (procedure code 43239) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This patient was admitted and underwent ventral hernia repair with mesh, bilateral trunk muscle myocutaneous flaps via component separation, panniculectomy, and bilateral mastopexy. Postoperatively, her pain was controlled with epidural patient-controlled analgesia (PCA).

The inpatient hospital stay was not medically necessary. The records document that the patient was physiologically stable as of the date in question. The patient required assistance with ambulation and had urinary retention that required straight catheterization, but both of these services could have been provided at a lower level of care. Records document that the patient had no complaints and her pain was well controlled. She was tolerating liquids. Physical therapy notes indicate she was able to ambulate. She could have been discharged or transferred to a lower level of care as of this date. Inpatient care was not required for assistance with ambulation or straight catheterization, and she has no other medical issues that required inpatient hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental Caries.

Treatment: 41899 unlisted procedure, dentoalveolar structures, anesthesia.

The insurer denied coverage for 41899 unlisted procedure, dentoalveolar structures, anesthesia.

The denial is overturned.

This is a male who requires extensive dental treatment consisting of restorations, all parties, grounds and extractions. This treatment is planned in the operating room due to the age of the patient and the extensive treatment. This was denied due to lack of documentation. The providers' office stated the information has been sent to the insurance company twice.

Children occasionally present with behavioral considerations that require more advanced techniques. These children often cannot cooperate due to lack of psychological or emotional maturity and/or mental, physical, or medical disability. The advanced behavior guidance techniques commonly used and taught in advanced pediatric dental training programs include protective stabilization, sedation, and general anesthesia.

According to the Academy of Pediatric Dentistry, General anesthesia is indicated for: 

1) Patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability. 

2) Patients for whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy. 

3) Extremely uncooperative, fearful, anxious, or uncommunicative child or adolescent. 

4) Patients requiring significant surgical procedures; 

5) Patients for whom the use of general anesthesia may protect the developing psyche and/or reduce medical risk.

6) Patients requiring immediate, comprehensive oral/dental care.

The patient in this case meets the guidelines for general anesthesia because of the significant surgical procedures and the age of the patient. 

The insurer's denial of coverage for 41899 unlisted procedure, dentoalveolar structures, 3 units, 00170 anesthesia for intraoral procedures, including biopsy is overturned. Medical Necessity is substantiated
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive decline
Treatment: Increase Personal Care Services, Level 2 to 9 Hours Per Day 7 Days Per Week, total of 63 Hours Per Week
The insurer denied the Increase Personal Care Services, Level 2 to 9 Hours Per Day 7 Days Per Week, total of 63 Hours Per Week
The denial is overturned

The patient is a female. The request is for increase in personal care service hours.

The requested increase is to 9 Hours Per Day 7 Days Per Week, total of 63 Hours Per Week from 42 hours per week.

Yes, the requested increase in personal care service to 63 hours/week is medically necessary.
The patient resides alone in a one-bedroom apartment with elevators. She needs extensive assistance with bathing and dressing. She also needs assistance with walking, transfers and toileting. She can walk with a cane. She needs assistance with meal preparations, housework and shopping. She also has reported a fall at home.

The patient is experiencing rapid cognitive and functional decline. The requested increase in personal care services are medically necessary for patient safety.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient is experiencing rapid cognitive and functional decline. The requested increase in personal care services are medically necessary for patient safety.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD), right eye blindness and Alzheimer's dementia

Treatment: Home Care/ Personal Care HHC (home health care) - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift)

The insurer denied coverage for Home Care/ Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift)

The denial is upheld

This is a female with chronic obstructive pulmonary disease (COPD), right eye blindness and Alzheimer's dementia. She lives with her daughter and granddaughter in a 2-bedroom apartment on the third floor of a walk-up building. The insurer approved an increase in Personal Care HHC - from 84 hours/week to 24 hours/day live-in. Under review is the request for increase Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift).

According to the Uniform Assessment System (UAS) report, the patient's cognitive skills are "severely impaired." She is totally dependent for bathing. She requires extensive to maximal assistance for personal hygiene and dressing. She also requires maximal assistance for toilet use. The patient is bowel and bladder incontinent. She requires extensive to maximal assistance for bed mobility and ambulation. She reportedly has not been able to walk or transfer. The patient lives with her daughter and granddaughter. This physician agrees with the insurer's approved 24 hours/day live-in as clinically appropriate and allows the patient to continue living safely in a home setting. The requested increase Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift) is not medically necessary.  

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

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested increased Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift) is not medically necessary for this patient.  

The insurer's denial of coverage for Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness and cough (pneumonia).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with HIV (human immunodeficiency virus) or ART (anti retroviral) therapy, anxiety, PTSD (post-traumatic stress disorder) who presented to ER (emergency room) with cough, chest pain, headaches and fevers. The patient appeared weak, frail with rhonchi at the lung bases. The patient was treated with IVF (intravenous fluids), Tylenol, and antibiotics. The chest x-ray showed pneumonia and the patient was continued with IV (intravenous) antibiotics. The inpatient admission was determined not medically necessary. This denial is being appealed.

No, the proposed treatment, Inpatient Hospital Admission is not medically necessary.
The patient has generalized fatigue and fevers due to pneumonia. After ER (emergency room) treatment, the patient's fever was controlled. The patient was in no distress. The patient was admitted to an acute in-hospital level of care for 48 hours. However, the patient's condition improved significantly with ER (emergency room) care and within 24 hours of hospitalization. The acute in-hospital level of care is not medically necessary as the patient could be safely and effectively treated at a lower level of care.

Yes, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.
The patient presented with generalized fatigue, and fevers due to pneumonia. After ER (emergency room) treatment the patient's condition improved significantly with ER (emergency room) care and within 24 hours of hospitalization. The patient could be safely and effectively treated at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Non-small cell lung cancer. 
Treatment: Genetic Testing (0037U). 

The insurer denied the Genetic Testing (0037U). 
The denial is upheld. 

The patient is a female. The patient in this case was diagnosed with non-small cell lung cancer. 

No, the health plan should not cover the requested health service. 

The Genetic Testing (0037U) is not among testing for validated genomic alterations in patients with non-small cell lung cancer. 

Foundation One testing is a next generation sequencing assay that is done to look for genomic alterations in tumor tissue. This test includes over 300 genes.  It is done to try to find potentially effective treatment options.  There is currently no evidence based on the results of any prospective clinical trial that has shown use of broad molecular profiling can improve overall health outcomes.  Therefore, this test has not been shown to improve overall health outcomes and should be considered experimental/investigational. 

No, the Genetic Testing (0037U) is not more beneficial. 

As noted above, there is no evidence in any published clinical trial showing that this type of broad molecular profiling assay can improve outcomes compared to testing of validated gene mutations.