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

Respiratory
Inpatient hospital

Diagnosis: Shortness of breath
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a woman with a history of hypertension, sleep apnea, anxiety, and smoking who was admitted to the hospital with a chief complaint of shortness of breath. She reported worsening shortness of breath for the past month and an associated dry cough and substernal chest pain. She also reported decreased exercise tolerance. She had been seen as an outpatient and her symptoms were thought to be due to sleep apnea. She denied fevers and chills. Her smoking history included one pack a day. Vital signs showed temperature 98 Fahrenheit, heart rate 81, respiratory rate 20, and blood pressure 136/72. On physical exam, heart was regular, breath sounds were normal, and she had trace lower extremity edema. Labs showed white blood cell (WBC) 9.6, hemoglobin 11.1, platelets 559, sodium 133, potassium 4.6, calcium 8.4, and troponin negative. Chest computed tomography (CT) angiography was negative for acute pulmonary embolus but did show several lymph nodes. Lower extremity ultrasound was negative for deep vein thrombosis (DVT). The patient was admitted for shortness of breath thought to be secondary to likely chronic obstructive pulmonary disease (COPD).

The inpatient emergency admission was not medically necessary. The patient presented with shortness of breath but had no evidence of acute heart failure, acute pulmonary embolus, severe anemia, interstitial lung disease exacerbation, COPD exacerbation, or other acute diagnoses typically requiring inpatient care. She primarily received a diagnostic work up and could have safely and effectively been managed at a lower level of care. She was hemodynamically stable and was seen by cardiology and pulmonary consultants with recommendations that did not involve interventional procedures. She primarily received a diagnostic evaluation during her hospital stay along with medical therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 
The insurer denied: DRG stimulator. 
The denial is upheld.

The patient is a male noted to have chronic right sided leg and groin pain. A request for coverage for a dorsal root ganglion (DRG) stimulator to address the patient's pain was denied by the insurance carrier as they are not considered medically necessary.
A letter of appeal from the patient indicates the patient has chronic pain noting that the patient had surgery to remove a tumor from the lower part of the spinal cord and following surgery noticed the right leg tingling. The patient describes his severe pain and reports nothing helped. The patient reports having undergone a DRG stimulator trial to help with pain in the groin area and reports that he was able to treat the pain, walk more and have better outcomes. The patient reports that the device failed to charge, and he started experiencing pain. The patient stopped doing exercise and walking like before. Due to the pandemic, hospital procedures were on hold. It was noted that as soon as hospitals started seeing patients again the patient contacted the provider.
The subject under review is the medical necessity for the requested stimulator.

The health plan's determination is upheld in whole.

The requested health service/treatment is not medically necessary for this patient. The patient is noted to have a history of prior spinal surgery to remove a tumor from the lower part of the spine and this resulted in neuropathic symptoms into the right leg and groin. It was noted the patient initially had a spinal cord stimulator implanted and reportedly had benefit with use, but ultimately the stimulator failed and needed to either be replaced or the provider wanted to change to a DRG stimulator, which has been requested. This device is not supported as medically necessary.
The requested procedure is not considered the standard of care. Per evidence based Official Disability Guidelines (ODG), "While Food and Drug Administration (FDA)-approved for severe chronic intractable pain of the lower limbs in adult patients with complex regional pain syndrome (CRPS) types I and II (based on the ACCURATE trial described below), there are few details to guide in patient selection, including which stimulation modality is best suited for a CRPS patient (DRG versus conventional stimulation). The optimal programming for DRG stimulation is still under development. The comparative trial is with conventional spinal cord stimulation (SCS) only. In the randomized trial, procedural events were significantly greater than with conventional spinal cord stimulation. There has been no discussion of how to place the leads in cases where there is presence of foraminal stenosis."  This treatment is not considered standard of care and the general medical community given the lack of high-quality studies available demonstrating the safety or efficacy or standards for implantation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: CHF (congestive heart failure), Coronary Artery Disease (CAD), Diabetes Mellitus (DM), low back pain and nasopharyngeal carcinoma.
Treatment:  Increase Personal Care Assistance to 56 Hours per Week. 

The insurer denied the  Increase Personal Care Assistance to 56 Hours per Week.  The denial is overturned. 

The patient is a female with a history of CHF (congestive heart failure), Coronary Artery Disease (CAD), Diabetes Mellitus (DM), low back pain and nasopharyngeal carcinoma. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 56 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support. 

Yes, the proposed treatment of 56 hours/week Personal Assistance Services is deemed medically necessary. 

The patient is a female with a history of CHF (congestive heart failure), Coronary Artery Disease, Diabetes Mellitus, low back pain and nasopharyngeal carcinoma. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

Recent correspondence was received from the patient's medical provider who indicates that due to progressively worsening functional decline, the patient requires more assistance for completion of her activities of daily living (ADLs). Specifically, the patient requires assistance with meal preparation so she can maintain proper nutrition which is especially important given her notable 30 lb. (pound) unintended weight loss over the past year. Hence, the currently approved plan of 26 hours/week personal assistance services is not sufficient to meet the patient's current needs. For these reasons, the proposed treatment 56hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lichen Planopilaris. 
Treatment:  Oracea 40mg OR CPDR. 

The insurer denied the  Oracea 40mg OR CPDR. 
The denial is upheld. 

The patient is a female with lichen planopilaris/frontal fibrosing alopecia, treated with Oracea, Finasteride, Plaquenil and topical and intralesional steroids. Her provider is requesting continuation of Oracea. 

No, the treatment with Oracea is not medically necessary. 

There is no evidence based medical literature to support the use of Oracea in LPP/FFA (lichen planopilaris/frontal fibrosing alopecia). The standard of care for patients such as this includes Plaquenil and Finasteride as commonly supported therapies.  No guidelines or recommendations could be found to support widespread use of Oracea/doxycycline.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient Stay. 
The denial is upheld in whole.

The patient is a female who fell from a slide and sustained an injury to her left elbow. She was brought to the hospital and was found to have a displaced and angulated left radial neck fracture, a non-displaced proximal ulna fracture, and numbness and weakness in the ulnar nerve distribution. She was admitted to the hospital and the following morning underwent a closed reduction of the radial neck fracture, and application of a long arm cast. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

No, an inpatient stay was not medically necessary for this patient. An angulated and displaced radial neck fracture in a patient this age requires reduction in order to preserve elbow joint motion and forearm pronation and supination. However, this injury is not associated with a high risk of ischemia or neurovascular injury. It may be splinted and addressed at a lower level of care status, either by closed reduction, as was done here, or by open reduction if the closed reduction is unsuccessful. The associated non-displaced ulna fracture does not add significantly to the severity of the injury, and the ulnar nerve injury is simply observed, with the expectation of recovery over time. It is not medically necessary for an inpatient stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied the Braces.
The determination is overturned.

This is a patient with teeth number (#) 7 and #10 in anterior crossbite. The patient was treatment planned for 36-42 months of comprehensive orthodontics with palatal expansion. At issue is the medical necessity of braces.
It is a generally accepted practice guideline in orthodontics to treat anterior crossbites as soon as feasible because of the damage that can occur to the patient's dentition if left untreated.
Treatment for the patient's anterior crossbite in the mixed dentition is medically necessary. 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) These problems are much more time consuming to correct than the patient's existing orthodontic problem.
Appeal type: Medical necessity
Decision: Overturned

  
Diagnosis: Obesity
Treatment: Weight Loss Surgery with Anticipated Inpatient Hospital Admission. The health plan denied Weight Loss Surgery with Anticipated Inpatient Hospital Admission. The health plan's determination is overturned.

This patient is a woman under consideration for bariatric surgery. She was 65 inches tall and weighed 228 lbs. This corresponds to a body mass index (BMI) of 38 kg (kilogram)/m (meters squared). She has comorbid health conditions of hypertension, hyperlipidemia and knee arthritis for which she is prescribed Losartan and Atorvastatin. The patient has attempted weight loss with conventional weight loss programs as detailed in the history and physical (H&P). Unfortunately, she has not been successful with significant sustained weight loss.

Given this patient's diagnosis, her current health condition and the evidence based literature, the proposed weight loss surgery with anticipated inpatient hospital admission is medically necessary for this patient. Inpatient admission is consistent with the standard of care. This patient has a BMI in excess of 35 kg/m2 with weight related comorbid health conditions that include hypertension and hyperlipidemia for which she is prescribed medication. These are weight-related health conditions that will respond favorably to the sustained weight loss associated with sleeve gastrectomy. She has successfully completed a multidisciplinary bariatric evaluation. She has had appropriate dietary counseling and has been cleared for bariatric surgery from a mental health standpoint and a medical standpoint.
The proposed sleeve gastrectomy is medically necessary for this patient and is consistent with the standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems-Braces
Treatment: Dental/Orthodontic Procedure-Removal of Braces and Placement of Retainers
The health plan denied the dental procedure as not medically necessary. 
The reviewer has upheld in whole, the health plan's determination of medical necessity.

The patient is requesting retainers. There are no orthodontic records nor history of orthodontic treatment or banding included in the records received for review.
There is no history of completed comprehensive orthodontic treatment or history of banding included in the records for review. Without a history of orthodontic treatment and orthodontic records including photos, panoramic x-ray, retainers are not medically necessary.

Although the additional information of cephalometric x-ray shows the presence of braces, the files are still missing the standard pre-treatment records including a panoramic x-ray, a cephalometric x-ray, and photos, along with any other progress records. Therefore, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He has a past medical history significant for hypertension, obesity, diverticulosis, GERD (gastroesophageal reflux disease), diabetes, diastolic heart failure with normal EF (ejection fraction), and obstructive sleep apnea. He presented to the ER (emergency room) for evaluation of non-exertional chest pain, abdominal pain, cough and dyspnea.

The patient was hemodynamically stable. ECG (electrocardiogram) revealed no acute ischemic changes. The cardiac troponins were normal. The patient was admitted to telemetry unit for monitoring to rule out acute coronary syndrome. He was found to have influenza infection and was started on Tamiflu. No stress test or other inpatient ischemic work-up was planned. The patient was discharged home with a plan for outpatient follow-up.

No, the Inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. No inpatient ischemic work-up was planned. The patient tested positive for influenza, and he was treated with oral Tamiflu. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission. The care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep pockets
Treatment: Dental Procedures D0120, D1999, D4341, D4341, D1208, D1999, D4341, D4341
The insurer denied the Dental Procedures D0120, D1999, D4341, D4341, D1208, D1999, D4341, D4341
The denial is upheld. 

The patient is a female requesting periodontal treatment benefits for four quadrants of scaling and root planning.

No, the proposed treatment is not medically necessary.

There is no evidence of calculus (tartar) on any of the teeth in any of the x-rays presented. There also is no evidence of any bone loss on the x-rays. The pocket depths greater than (>) three millimeters presented on the periodontal charting may be a result of "pseudo-pockets". This is when the gingival tissue gets inflamed and swells up creating what appears to be a gingival pocket, however then is no associated bone loss.

If there is no subgingival calculus to be removed, which there wasn't in this case, and when there is no bone loss, which, again there wasn't, then quadrant scaling and root planning is not warranted.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Generalized musculoskeletal pain.

Treatment: Chiropractic services (codes 98941, 97124 and S8948).

The insurer denied coverage for chiropractic services (codes 98941, 97124 and S8948).

The denial is upheld. 

This female patient had complaints of generalized musculoskeletal pain, including but not limited to head, neck, shoulders, arms, back, buttocks and legs. The patient's treatment included chiropractic treatment. Under review is the medical necessity for chiropractic services (codes 98941, 97124 and S8948).

The chiropractic treatment notes provide insufficient objective clinical information to support the medical necessity for the date of service under review. The chiropractic notes over the several months of treatment (36 visits) are much the same. For example, the physical examination findings with reported "moderate to severe muscle spasms" were unchanged. Physical examination findings via manual muscle testing were also unchanged. The patient's pain ratings varied without consistent improvement. The provided treatment for reported generalized musculoskeletal pain, with the lack of significant quantitative functional improvement, is consistent with maintenance treatment. Therefore, the chiropractic treatment at issue is not considered medically necessary.  

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, coverage for chiropractic service (codes 98941, 97124 and S8948) was not medically necessary.

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 the chiropractic service (codes 98941, 97124 and S8948) is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: coronary artery disease 
Treatment: Computed Tomography Angiography 

The insurer denied Computed Tomography Angiography (CTA) of the Neck, without and with Contrast (Dye). The health plan's determination is overturned.

The patient is a female with a history of coronary artery disease status/post (s/p) coronary interventions and hypertension with left renal artery stenosis s/p stent. She underwent a carotid duplex which demonstrated a flow acceleration in the proximal right internal carotid artery to 387 cm (centimeters) (diastolic in this location 124 cm/s) consistent with a greater than 70% stenosis of the right internal carotid artery (right internal carotid artery (ICA) / CCA (common carotid artery) ratio 2.98). There are no reports in the notes provided of any recent strokes or transient ischemic attacks.
Under review is the medical necessity of computed tomography angiography (CTA) of the neck, without and with contrast (dye).

The CTA of the neck with and without contrast is medically necessary. 

The recent carotid duplex demonstrated significant (> (greater than)70%) stenosis of the right proximal internal carotid artery and the CTA of the neck being requested was medically necessary based on the standard of care.

Saxeni et al in their review article writes, "DUS (duplex ultrasound) is usually the initial recommended CAS (carotid artery stenosis) diagnostic examination. However, for the therapeutic intervention, either magnetic resonance angiography (MRA) or CTA is recommended for confirmation."

If the stenosis is confirmed by the CTA, this asymptomatic patient may benefit from carotid intervention (carotid endarterectomy or endovascular stent) based on the standard of care to reduce her risk of stroke.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg swelling and chest pain.  
Treatment: Inpatient admission.
The insurer has denied coverage for inpatient admission.
The denial is upheld. 

The patient is a male with a past medical history significant for polysubstance abuse including intravenous heroin abuse, hepatitis C virus (HCV) infection, asthma, and chronic skin lesions who presented to the Emergency Department (ED) with complaints of lower extremity swelling, shortness of breath, and chest discomfort. The patient's vital signs on ED presentation included: Temperature 99.1 F, Blood Pressure 135/77, and Pulse 91, Respiratory Rate 18, and Oxygen (O2) saturation 96% on Room Air.  The patient's laboratory results included the following: white blood cell (WBC) count 8.3, hemoglobin 9.2, hematocrit 28.6, creatinine 0.76, and glucose 86. The patient was started empirically on intravenous (IV) antibiotics (i.e., vancomycin and Unasyn) for possible lower extremity cellulitis.  The patient's chest x-ray showed mild interstitial prominence at the lung bases.  X-ray of tibia/fibula showed no fracture or dislocation, but noted subcutaneous soft tissue edema with gas.  Infectious Diseases recommended holding intravenous antibiotics due to no fever or leukocytosis.  The patient remained afebrile, clinically, and hemodynamically stable.  The patient signed out against medical advice (AMA). 
   
According to documentation, the patient presented with lower extremity swelling, admitting to active substance abuse.  Otherwise, the patient remained afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC count.  Additionally, Infectious Diseases recommended stopping antibiotics due to "no fever or leukocytosis." Based on the above findings, the patient did not meet criteria for acute hospital admission.

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

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

Diagnosis: Chronic Migraines. 
Treatment: Trigger Point Injections to Treat Migraines.
The insurer denied coverage for Trigger Point Injections to Treat Migraines.
The denial is overturned. 

This is a female patient who has epilepsy and chronic migraine.  She has in the past received trigger point injections which were 100% effective in improving her migraines.  

Trigger point injections were stopped because her insurance company denied them.  The insurance company wanted to know for how long the patient experienced more than 50% relief with each injection and whether injections were given at least 2 months apart for up to 12 months (with a maximum or 4 total sessions).  

While this information is still not provided, it is not relevant to determining the medical necessity of trigger point injections.  It is well documented in the medical record that trigger point injections are effective for this patient, and they are an accepted treatment for migraine.1, 2  

An effective, non-pharmacologic treatment for migraines is especially important in this patient already taking an anti-epileptic medication for epilepsy.  Trigger point injections are medically necessary for this patient.  

The health plan did not act reasonably in the best interest of the patient.

The carrier's denial of coverage for Trigger Point Injections to Treat Migraines is overturned.  The medical necessity is substantiated.