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

Diagnosis: Myofascial Pain Syndrome.
Treatment: Outpatient procedure code 20553 x 3, trigger point injections.

The insurer denied coverage for Outpatient procedure code 20553 x 3, trigger point injections.  The denial is upheld.

This is a patient with no documented history. She is requesting outpatient procedure code 20553 x3, trigger point injections. 

Official Disability Guidelines (ODG) Trigger Point Injection (TPI) Criteria for the use of TPIs:

TPI is considered an adjunct, not a primary treatment. Ultrasound guidance for trigger point localization is not recommended. TPIs with any substance (eg, saline, corticosteroid, glucose, Botulinum Toxin) other than local anesthetic are not recommended.

TPI with local anesthetic may be indicated for the treatment of myofascial pain syndrome when all of the following criteria are met:  1)  Documentation of circumscribed trigger point(s) with palpation producing a twitch response as well as referred pain, 2)  Symptoms have persisted > 3 months, 3)  Medical management such as stretching exercises, physical therapy, NSAIDs (non-steroidal anti-inflammatory drug) or muscle relaxants have failed to control symptoms, 4)  Radiculopathy is not present by exam, imaging, or neuro-testing, 5)  No more than 3-4 injections per session, 6)  No repeat injections unless > 50% (percent) pain relief with reduced medication use for at least 6 weeks after injection AND documented evidence of functional improvement, 7)  Frequency should not be at an interval < 2 months, 8) There should be documentation of continued ongoing conservative treatment including home exercise and stretching, since use as a sole treatment is not recommended, and 9) If pain persists or recurs after 2-3 injections the treatment plan should be reexamined and may indicate an inappropriate diagnosis.

Contraindications: Acute muscle trauma; Allergies to anesthetic agents; Bleeding disorders; Local or systemic infection; Anticoagulant use.

The scientific literature has recommended injection of anesthetic or corticosteroid for localized areas of pain or spasm. There should be documentation including a full history of the pain mechanism, localization and response to prior treatment. There should be a documented site of pathology and diagnosis. The records provided state: request for outpatient trigger point injections. No other information was provided. Based upon the above, there would be no indication for injections at this time.

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

Based on the above, the medical necessity for the outpatient procedure code 20553 x3, trigger point injections are not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prediabetes. 
Treatment: Ozempic. 

The insurer denied the Ozempic. 
The denial is upheld. 

The patient is a female with prediabetes. Denial of Ozempic is being appealed. The patient started the medication approximately four months ago. The request was denied because the patient does not have type 2 diabetes. The provider notes that the patient has low iron and B vitamins that will become further depleted with metformin. 

No, the treatment with Ozempic is not medically necessary. 

Ozempic is FDA (United States Food and Drug Administration)-approved as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. This patient has a diagnosis of prediabetes. Provider notes that metformin is contraindicated due to history of low iron and B vitamins. Metformin is contraindicated in patients with severe renal dysfunction. It is not contraindicated with low iron and B vitamins. There is no evidence of trial and failure. 

Medically necessary services are those which are: 
1) safe 
2) effective 
3) generally accepted national standard of medical practice 
4) not provided primarily for convenience of the patient or the practitioner 
5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The requested Ozempic is not medically necessary, because it is not in accordance with generally accepted national standard of medical practice for treatment of prediabetes. 

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

Diagnosis: varicose veins
Treatment: radiology services
The insurer denied sclerotherapy. 
The health plan's determination is upheld.

The patient is a woman. She is 4'9" and 153 lbs. She has a history of having one leg shorter than the other and also has back issues, according to her husband. The patient is followed by an orthopedic surgeon. She was seen by Vascular Surgery for "painful varicose veins" in the right leg which cause pain from the right mid-thigh to the heel. The physician noted no "ropey" varicosities and only very small varicosities behind the knee on the right. Graduated compression stockings were used and which did not alleviate the discomfort. The patient underwent a noninvasive venous ultrasonography which revealed no reflux in the greater nor small saphenous veins and she had no large (>2.5 millimeter (mm)) varicosities noted on the study.
Sclerotherapy was recommended and is under review.

Sclerotherapy is not medically necessary for this patient. The varicose veins are less than 2.5 mm in diameter, have not bled, and are not the etiology of the patient's pain. Sclerotherapy will not improve the discomfort described by the patient. Very small varicosities, behind the knee, do not cause the type of discomfort described by the patient. It is more likely that the pain may be related to back issues as opposed to "very small varicosities" without venous reflux.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with diabetes mellitus, hypertension, and history of polysubstance abuse. He presented with chest pain, shortness of breath, back pain, malaise, nausea, polydipsia, and polyuria.

The patient's vital signs were as follows: BP (blood pressure) 124/78, temperature 36.8, heart rate 90, respiratory rate 18, O2 (oxygen) 99%. The patient's glucose was 235 mg/dL (milligrams per deciliter), serum osmolality 312 mOsm/kg (milliosmoles per kilogram), beta-hydroxybutyrate 6.15, pH (potential of hydrogen) 7.28, bicarbonate 16, and creatinine 1.14. His troponin was 0.024. His EKG (electrocardiogram) was with age undetermined septal infract and prolonged QTc (corrected QT interval).

The patient was treated with intravenous insulin and fluids. He was bridged with Lantus and then transitioned to insulin 70/30. The patient remained chest pain-free and thought to be related to drug-induced coronary vasopasm.

No, the Inpatient admission was not medically necessary.
This patient presented with known diabetes with moderate diabetic ketoacidosis. Patients with diabetic ketoacidosis can be safely managed in observation units unless they present with severe alteration of mental status or with critical illness such as sepsis [1], which is not documented in this case. This patient did not have alteration in his mental status. He was hemodynamically stable. He responded quickly to treatment with improvement in hyperglycemia and acidosis. He presented with chest pain and was not found to have a myocardial infarction or other acute illness requiring inpatient stay. Therefore, no, the acute inpatient admission was not medically necessary. 

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

The requested inpatient stay was not medically necessary and it was appropriately denied by the health plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems- Syncope.
Treatment: Inpatient Hospital Stay.
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld the health plan's determination.

This case involves a patient with a history of tobacco use, and human immunodeficiency virus (HIV) who presented to the hospital with lightheadedness, dizziness, and palpitations. The patient reported polydipsia recently. During 1 (one) of these dizziness spells, the patient fell, striking their knee, with no loss of consciousness. The patient has been taking hormonal therapy weekly for the past three months. Vital signs in the emergency department (ED) included a temperature of 36.7, blood pressure 128/75 and a pulse rate of 103. Respirations were 22. On exam, no evidence of external trauma. Lungs are clear to auscultation bilaterally, and the cardiac exam shows regular rate and rhythm. The admitting team documents positive orthostatic blood pressures on admission. The principal admitting diagnosis is near syncope. The patient received 1 Liter of normal saline. The medical team ordered an echocardiogram given an incomplete right bundle branch block on electrocardiogram (EKG). The D-dimer was negative. After hydration, orthostatics were repeated and normalized. The next day the patient felt improved and did not wish to remain in the hospital for further treatment. The  patient signed out against medical advice (AMA).

No. The requested health service/treatment of inpatient stay is not medically necessary. Near syncope, due to orthostasis, is typically a lower level of care admission. A typical patient stay is less than 24 hours, and treatment includes intravenous (IV) fluid hydration, monitoring for arrhythmias, and repeating orthostatic blood pressures. Based on the provided documentation, there is no evidence of malignant arrhythmias, or persistent orthostasis. Imaging of the head is negative, and with a negative D-dimer, there was very low suspicion for thromboembolic events. The patient did not suffer true syncope, as documented per the admitting note, but was mainly experiencing symptoms of positive orthostasis.
Based on the provided documentation, there are no clinical indications to admit this patient under the inpatient level of care. The patient has orthostatic hypotension with near syncope, which resolved after IV fluid hydration. The rest of the evaluation and treatment can be performed in a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Enteritis.
Treatment hospital admission.
The insurer denied coverage for hospital admission.
The denial is upheld.

The patient presented with 2 days of abdominal pain. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The white blood count (WBC) count was 15.22. A CAT [computed axial tomography] scan revealed inflammation in the cecum. She was started on antibiotics and then discharged on a course of oral antibiotics.

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

Clinical indications for admission for Gastroenteritis (MCG M-170) include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting or dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had an enteritis involving the cecum. Intravenous [IV] hydration and pain medications could have been given In the ER [emergency room] as an outpatient. Afterwards, she could have been discharged on a course of oral antibiotics. No surgical interventions were needed. She did not meet MCG [Milliman care guidelines] criteria for admission for either Undiagnosed Abdominal Pain or Gastroenteritis. 

The health care plan acted reasonably and with south medical judgement. An inpatient admission was not medically necessary.

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

Diagnosis: asthma.
Treatment: inpatient admission.
The insurer is denied coverage for inpatient admission.
The denial is overturned. 

This male patient has a history of asthma.

The patient was treated appropriately in the ER for stridor, a cough, wheezing and respiratory distress. He had been taking albuterol at home and following treatment in the ER he continued to have ongoing respiratory distress with persistent wheezing and increased work of breathing, it was appropriate and consistent with the standard of care to admit him to the hospital for ongoing treatment with albuterol and oxygen. He had a hospitalization one month prior to this admission and failed outpatient management during the current respiratory illness. He continued to be in respiratory distress with a diagnosis of status asthmaticus and not stable enough to be sent home.  

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

The carrier's denial of coverage for inpatient admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: pediatric growth hormone deficiency.

Treatment: Genotropin.

The insurer is denied coverage for Genotropin.

The denial is overturned. 

This male patient has a history of craniopharyngioma, growth hormone deficiency, obstructive hydrocephalus, primary central diabetes insipidus, recurrent brain tumor, and secondary adrenal insufficiency.

This patient has had pituitary surgery twice as well as radiation to the area and clearly documented growth hormone deficiency based on failed growth hormone stimulation testing. The patient's height velocity is currently normal but the patient's height is far below mid parental target height. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

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

The carrier's denial of coverage for Genotropin is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overbite, Anterior Crowding. 

Treatment: Insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit). 

The insurer denied coverage for insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit). 

The denial is upheld. 

The clinical photos for orthodontics show right sided crossbite.  Tooth #6 is also erupting. Cephalometric and Panoramic images are provided. The patient has complete adult dentition. Handicapping Labio-Lingual Deviation (HLD) Index score from the treating provider is submitted with a score totaling 26 for 4 millimeters (mm) overjet, 4mm overbite, anterior crowding on the anterior of the maxilla and the mandible, 4mm labiolingual spread and the presence of posterior unilateral crossbite. HLD score sheet from the insurer shows 3mm overjet, 3mm overbite, anterior crowding in the maxilla, 1mm labiolingual spread and posterior unilateral crossbite. This score totals HLD score of 16. The clinical records verify the findings on the insurer's HLD score sheet. Their scoring is more consistent with the clinical documentation provided in the medical records. 

Therefore, the health care plan did act reasonably and with sound medical judgement. 

Coverage of insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit) is not considered medically necessary for this patient. 

The insurer's denial of coverage for insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lumbar pseudoarthrosis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. The patient had surgery and had an inpatient level of care. The prior of denial reason was that the inpatient level of care was not medically necessary. The patient had a procedure which went well, and there were no reported complications and the patient remained stable while being monitored. The patient was able to go home. Thus, based upon the criteria, the health plan denied the hospital admission as not medically necessary. The reason for the appeal was at the hospital indicated that the admission was clinically and medically necessary for the patient's condition and diagnosis.

The patient was admitted and had surgery for removal of spinal instrumentation from L1-S1 (first lumbar spine vertebra-first sacral vertebra) with application of posterior lateral bone graft and fusion. The patient had a drain placed postoperatively. The patient was admitted to the post anesthesia care unit and was hemodynamically stable. The patient was transferred to the floor. Postoperatively, the patient had a CBC (complete blood count) showing an elevated white count of 16.87. The patient was given IV (intravenous) fluids, IV (intravenous) Ancef, oxycodone and IV (intravenous) Tylenol. The patient was provided physical therapy and occupational therapy. The drain was removed and the patient was advanced on his diet. The patient was discharged to home. The appeal indicated that the patient required preoperative management with IV (intravenous) fluid hydration, IV (intravenous) antibiotic therapy and postoperative IV (intravenous) antibiotics and oral pain medication. This is a review for the inpatient hospital care.

No, the Inpatient admission was not medically necessary.
Based upon the procedure as well as the postoperative course, the patient would not require an inpatient level of care. There was no associated diagnosis or complications that would require a higher level of care for postoperative treatment. The patient had a lumbar fusion surgery which is considered an outpatient procedure. There was no need for inpatient hospitalization. There were no additional diagnoses that require treatment in the postoperative time frame that was support the need for inpatient level of care based upon the criteria provided. Thus, the treatment with inpatient level of care was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
The decision to deny coverage of the inpatient level of care was appropriate. The patient would receive the same services at a lower level of care, and thus the inpatient hospital admission was not medically necessary, as it would not affect the patient's healthcare.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ear/Nose/Throat. 
Treatment: Surgical Services. 
The insurer denied rhinoplasty. 
The denial is overturned. 

The patient is a male followed by pediatric plastic surgery. He has a history of bilateral complete cleft lip and cleft palate. He had a complex double jaw surgery. He is now ready for the final surgery; a cleft septorhinoplasty. He does wear glasses which do not stay in place due to his nose being extremely flat from the bilateral complete cleft lip and cleft palate. His nose is collapsed at the dorsum and wide at alar base, prolapsed and bulbous tipped.
Due to the nature of his deformity, he will require a rib graft. His surgeon plans to use the cartilage from the right chest to augment his nose and work on the tip to improve the appearance. According to the surgeon, the surgery is medically necessary and will improve the patient's breathing as well as correcting the nose so he can wear glasses appropriately.
The subject under review is the medical necessity for the rhinoplasty.

The health plan's determination is overturned.

Yes, the rhinoplasty is medically necessary. The rhinoplasty is appropriate and the standard of care to treat the patient's cleft lip nasal deformity. He has the typical bilateral cleft lip nasal appearance with insufficient dorsum and collapsed nasal tip. Almost all cleft patients require a corrective rhinoplasty to correct the typical nasal deformities associated with cleft lip. Reconstructive surgery is performed on abnormal structures of the body caused by congenital deformity, trauma, infection, tumors, or disease. It is generally performed to improve function. This rhinoplasty is reconstructive to normalize the appearance as well as improve the function of this patient's congenitally disfigured nose. The rhinoplasty will improve the patient's breathing and allow the patient to properly wear glasses.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned. 

The patient is a female with chronic obstructive pulmonary disease (COPD), coronary disease, and diabetes presenting to the emergency department (ED) with days of shortness of breath. The dyspnea is exertional and present for at least a few weeks. The patient reportedly ran out of her inhaled corticosteroid medications. She tried to alleviate her symptoms with Ventolin and sublingual nitroglycerin; she was experiencing concurrent chest pain, and the nitroglycerin helped. Additional symptoms included episodes of diarrhea without fevers or chills.

The requested health service/treatment of inpatient stay is medically necessary for this patient. The patient has evidence of COPD exacerbation, treated with corticosteroids, bronchodilators, nocturnal BiPAP. In addition, there is an exacerbation of heart failure, with volume overload, requiring diuretic therapy. Furthermore, there is evidence of acute kidney injury on admission, though not severe, still contributing to morbidity and mortality. Multiple comorbidities often interplay and are more challenging to treat. Corticosteroids tend to cause fluid retention, thereby exacerbating congestive heart failure, which requires aggressive diuretic therapy. At the same time, the patient is suffering from acute kidney injury, which can be exacerbated by aggressive diuresis. This type of presentation requires intense monitoring and significant deployment of resources, which far exceeds lower level of care status.