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

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

This is an infant patient with asthma exacerbation. The Emergency Department (ED) respiratory rate (RR) was in the 30s, so there was no need for subcutaneous (SQ) epinephrine or for terbutaline.  There was no documentation that patient required continuous positive airway pressure (CPAP) or high flow nasal cannula (HFNC) after the ED and few hours in the observation care unit. At this point, it is clear that initial interventions in the ED were facilitating the recovery. The patient had only mild respiratory distress. There was no significant acidosis nor respiratory acidosis in the initial labs. There was also no need for multiple boluses for severe dehydration nor shock. The patient did not have underlying chronic lung disease nor congenital heart disease nor any neuromuscular deficits. The hospital course was representative of as expected clinical course, after the ED stabilization and hence the HFNC was deescalated to nasal cannula quickly. There was no need for continuous albuterol nebs after the ED course. The trajectory showed improving respiratory status. Also, there was no evidence of the patient needing continuous nebulizer after the ED stabilization nor epinephrine injection nor terbutaline drip in the Pediatric Intensive Care Unit (PICU). Intravenous (IV) fluids and nebulizers could be administered in observation status. If one were to evaluate the Pediatric Early Warning Score (PEWS), it would be less than 5 after the ED course which indicates a benign hospital course. Due to the above facts, this patient could have been managed at observational status.  

The patient's clinical status is mostly consistent with moderate asthma exacerbation which responded to ED intervention.  

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

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

Diagnosis: Dental Problems - Class I posterior occlusion on right and left.
Treatment: Dental/Orthodontic Procedure.
The insurer denied Braces and monthly visits.
The denial is upheld.

The patient is a female, who presents with Class I posterior occlusion on right and left, mild crowding on upper and lower, with estimated overjet of 5 millimeter (mm) and estimated overbite of 2mm. It does appear from radiographs that mandibular 2nd molars are trapped underneath distal of mandibular 1st molars.
At issue is the medical necessity of Braces and monthly visits.

The health plan's determination of medical necessity is upheld in whole.

No, the requested health service/treatment of Braces and monthly visits is not medically necessary for this patient.
Orthodontic treatment (braces upper and lower teeth) is not medically necessary in order to address eating, speech, breathing difficulties, or to prevent permanent damage to the teeth and/or supporting oral structures (temporomandibular joint(s), bones, soft tissues, intra and/or extra oral muscles). There does not appear to be a severe handicapping malocclusion as a result of the existing relationship between the maxillary (upper) and mandibular (lower) dental arches and/or teeth. The patient presents with Class I posterior occlusion on right and left, mild crowding on upper and lower, with estimated overjet of 5mm and estimated overbite of 2mm. Radiographs show that mandibular 2nd molars are trapped underneath distal of mandibular 1st molars.
A handicapping labiolingual deviation index (HLD) that typically requires a total of 26 points to deem an orthodontic case medically necessary reveals the patient's malocclusion generates a total 21 points in HLD index, and do not comprise of any of the automatic medical qualifiers used to denote a significant discrepancy. Furthermore, confirming that medical necessity cannot be established.
Additionally, another scoring index (Salzmann Evaluation Index that requires 25 points to deem an orthodontic case medically necessary) was utilized, and a score of 9 was attained. While the patient does have mild dental protrusion with increased overjet, there is no evidence of trauma to surrounding tissues clinically, nor defined by Salzmann scoring index. In addition, the patient does not meet any of the criteria for allowable automatic qualifiers or medical-exception conditions.
Therefore, the requested health service/treatment of Braces and monthly visits is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fast Heart Rate During Pregnancy
Treatment: Inpatient Admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is an adult female. She was hospitalized for a submitted diagnosis of symptoms of a Fast Heart Rate during pregnancy. Her PMH (past medical history) is significant for known WPW (Wolff-Parkinson-White) syndrome and migraine disorder. She was scheduled for an ablation, but then learned of her pregnancy.

In the ED (emergency department), the patient's HR (heart rate) was in the 270s by rhythm strip. Treatment included IV (intravenous) amiodarone bolus and IVFs (intravenous fluids) by EMS (emergency medical services) followed by EKG (electrocardiogram) showing SVT (supraventricular tachycardia) with WPW (Wolff-Parkinson-White) syndrome in the ED (emergency department). EP (electrophysiology) cardiology recommended flecainide. She was checked by OB/GYN (obstetrics/gynecology). 

The next day telemetry showed SR (sinus rhythm). 

By the day after, the patient's atrial flutter was treated with the addition of metoprolol and increase of flecainide. 

By the third day, the patient was deemed stable for discharge to home. This is an appeal of the denied claim of the requested Acute Inpatient Hospital Stay. 

The Inpatient Admission was not medically necessary. 

Based on the peer-reviewed medical literature and this reviewer's expert medical opinion, there was not a medical need for the acute inpatient hospital stay. The severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient admission are not met, including myocardial ischemia, persisting dizziness, weakness, lightheadedness, dyspnea, hypoxia, heart failure, hemodynamic instability, thyrotoxicosis, need to initiate antiarrhythmic therapy or cardioversion or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. The care she received, including medication for rhythm/rate control in hemodynamically stable patients like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the Inpatient Admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Treatment: Personal Care Aide Services: 56 Hours per Week
The insurer denied Personal Care Aide Services: 56 Hours per Week. 
The health plan's determination is overturned.

The patient is a male with a past medical history of diabetes mellitus (DM) type 2, hyperlipidemia, chronic obstructive pulmonary disease (COPD), anxiety/depression, obstructive sleep apnea (OSA), neuropathy, and osteoarthritis who had been assigned PCA (personal care aide) services.

Personal Care Aide Services: 56 Hours per Week, Consumer Direct, 1 Client is medically necessary for this patient.

The patient's medical provider recommended an increase in PCA services. The plan did not reassess the patient with Uniform Assessment System (UAS) despite the last assessment being performed 5 months before the denial decision. The tasking tool estimated assistance needs with walking, locomotion, transfer toilet, and toilet use once daily which is an underestimation of the patient's needs during the time the patient does not have informal help. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs when the patient does not have informal help. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 56 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support functions is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma exacerbation 

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.
 
Patient is a female with history of mild intermittent asthma. She presented to Emergency Department (ED) with complaints of wheezing and shortness of breath. She was using only inhaler which belonged to her mother. Last asthma attack was 6 years ago. Patient had been intubated 10 years ago. She was possibly 6 weeks pregnant.

Vital signs at presentation included peak expiratory flow (PEF) 200, heart rate (HR) 93, respiratory rate (RR) 18, blood pressure (BP) 113/78 and oxygen (O2) saturation 100% (percent) on room air (RA). Patient was noted to have some respiratory distress. Wheezing also heard and accessory muscle use was noted. She was speaking in short sentences.

Patient was treated with intravenous (IV) steroids, bronchodilators via nebulizers and magnesium IV. She was placed on bilevel positive airway pressure (BiPAP) 10/5 with fraction of inspired oxygen, (FiO2) 40%.

Labs showed white blood cell (WBC) count 9.8, hemoglobin (Hgb) 10.2, electrolytes within normal limits (WNL), venous blood gases (VBG) 7.35/carbon dioxide (CO2) 42/oxygen (O2) 63/sodium bicarbonate (HCO3) 22. Chest x-ray (CXR) was WNL.

Patient was continued on BiPAP as she was still complaining of difficulty breathing.

As per History & Physical (H&P), her PEF was 280-300, vital signs were HR 112, RR 19, BP 141/71, O2 saturation 97% on RA. Lungs were clear. 

Patient was switched to oral (PO) prednisone (received 1 dose of IV solumedrol 125 in ED) and continued on bronchodilators via nebulizers. Patient remained stable after admission.

Her lungs were clear, she was ambulatory on PO steroids, bronchodilators, and inhaled corticosteroid (ICS)/long-acting beta-agonist (LABA) inhaler. WBC was 20.7 with no signs of infection. The elevated WBC was likely steroid induced.

This patient did not need acute inpatient hospitalization. She had asthma exacerbation but started improving after a few hours on BiPAP and with treatment in ED. As per H&P, she was afebrile and hemodynamically stable with clear lungs, normal labs, no evidence of pneumonia on CXR and tolerating PO. She was off BiPAP by 12 noon (after less than 5 hours). She was maintaining O2 saturations 97-98% on RA with improved PEF to 280-300. 

This patient could have been place in observation status (which could be for up to 48 hours) instead of acute inpatient medical admission. Patient had stabilized after a few hours of treatment. She could have been kept under observation status and could have been discharge once off BiPAP and on PO meds. She could have been followed up in an outpatient setting.

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

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

Diagnosis: Chest pain, abdominal pain - pneumomediastinum, right pneumothorax
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a male with no significant past history. The presented to the ER (emergency room) with chest pain and abdominal pain and was found to have pneumomediastinum and right pneumothorax.

The patient was admitted to acute hospitalization on 100% oxygen. The patient was monitored in the hospital.

Coverage for the inpatient admission was denied by the health plan due to lack of medical necessity. This denial is being appealed.

Yes, the Inpatient Hospital Admission was medically necessary.
The patient had right pneumothorax as well as pneumomediastinum. He was started on 100% FiO2 (fractional inspired oxygen concentration) as well as antibiotics for esophageal tear. Despite Emergency room care, the patient remained on 100% oxygen and the pneumomediastinum were evidenced to be worsening in subsequent imaging. Given the patient's signs and symptoms, it would not have been reasonable to expect significant improvement within 24 hours, as is what happened with the patient. The patient's treatment course would have been expected to require treatments or interventions that could not have been provided at a lower level of care. The treatment that was provided was reasonably expected to require an acute inpatient level of care. The acute hospitalization was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Given the patient's signs and symptoms, it would not have been reasonable to expect significant improvement within 24 hours. The patient's treatment course would have been expected to require treatments or interventions that could not have been provided at a lower level of care. The treatment that was provided was reasonably expected to require an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma.

Treatment is an inpatient admission. 

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

This is a patient with a past history of asthma who was sick with fever, difficulty breathing and a cough for 4 days. She was seen in the ER (emergency room) 2 days prior to admission with similar symptoms and was discharged after treatment with 2 doses of combivent and dexamethasone. She has been hospitalized on 10 occasions for asthma and on 7 occasions she was treated in the PICU (pediatric intensive care unit). She was diagnosed with asthma on 2 previous occasions, and she had required BIPAP (bilevel positive airway pressure) treatment in the PICU in the past. The last admission was 2 months prior to this illness. She is maintained at home on asmanex and montelukast. When her symptoms were not improving, and her fever persisted her mother brought her to the hospital for additional treatment.

In the ER the child was noted to have suprasternal retractions and a pulse oximeter reading of 90%. On physical examination she was noted to have decreased air entry and wheezing. She was treated with oxygen and 3 doses of combivent. A chest x-ray was consistent with pneumonia with airspace opacity of the left lower lung. Her blood work was also significant for an elevated sedimentation rate of 56. She was diagnosed with pneumonia and status asthmaticus and admitted to the hospital with antibiotics and continued treatment with albuterol every 2 hours. Her blood culture was subsequently positive for bacteria. Based on the prolonged illness with persistent fever, increased respiratory effort and the chest x-ray documenting pneumonia and blood testing with an elevated sedimentation rate the decision was made to admit her for antibiotics and albuterol every 2 hours. The insurer has denied coverage for acute inpatient admission to the hospital.

The patient was treated appropriately in the ER for a diagnosis of pneumonia following a prolonged febrile illness. She had an elevated sedimentation rate and a past history of 2 episodes of pneumonia and multiple admissions to the PICU for asthma. The decision to admit to the hospital was consistent with the standard of care for treatment of pneumonia in a child with status asthmaticus and pneumonia.

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 an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Severe Hearing Loss (in one ear).
Treatment:  Cochlear Implant (procedure 69930 & L8614).

The insurer denied the Cochlear Implant (procedure 69930 & L8614).  The denial is upheld.

The patient is a female. She has a history of an asymmetric SNHL (sensorineural hearing loss), significantly greater on the right. Intratympanic steroid injections did not resolve the hearing loss. MRI (magnetic resonance imaging) was without abnormalities. Right CNC (Maryland consonant-nucleus-consonant) scores were 0%, left 82%. The provider is requesting placement of a right Med-el cochlear implant.

The request was previously denied coverage by the health plan as not meeting Plan criteria, and the provider is appealing the denial.

No, the requested Cochlear Implant is not medically necessary.

All records were reviewed. The patient has an asymmetric SNHL (sensorineural hearing loss).There is support in the scientific literature and FDA (United States Food and Drug Administration) guidelines for the efficacy of cochlear implantation for the treatment of the patient's condition. MRI (magnetic resonance imaging) reported a normal inner ears and IACs (Internal Auditory Canal). CNC (Maryland consonant-nucleus-consonant test) score on the right is 0%. However, there is no documentation of a failed trial of a CROS (contralateral routing of signals) hearing aid. Despite this reviewer agreeing with the appeal letter's assertion regarding the benefits of cochlear implants for patients with Single Sided Deafness and asymmetric SNHL (sensorineural hearing loss), the request is not consistent with the standard of care, because there is no documentation of a failed trial of a CROS (contralateral routing of signals) hearing aid. Therefore, based on the information provided, the medical necessity of the requested Cochlear Implant (procedure 69930 & L8614) cannot be confirmed.

Yes, based on the information provided, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic pain; dyspareunia
Treatment: Ambulatory Surgery (outpatient procedure 37241)
The insurer denied: Ambulatory Surgery (outpatient procedure 37241)
The denial is overturned

The patient is an adult female with a history of chronic pelvic pain and discomfort. Ovarian vein study revealed she has ovarian vein reflux. Ovarian vein embolization was requested. The health plan's prior denial reason was "criteria from the guideline named ovarian and internal iliac vein embolization was not found in the nationally recognized medical reference called MCG [Milliman Care Guidelines]."

The health plan should cover the requested health service.
Ovarian vein embolization (also known as gonadal vein embolization) is now established as a safe procedure. Recent large population review paper revealed as "Percutaneous embolization for PCS [pelvic congestion syndrome] is an effective method of treatment having a high percentage of symptom improvement (reported in 697 of 762 patients). Studies utilizing a VAS [visual analogue scale] as a quantitative measure of symptom improvement report statistically significant overall symptom improvement comparing posttreatment and pretreatment values with an average decrease of 5.7 within 0 to 10 scale."

The requested health service is more beneficial, as there currently no established treatment for this condition currently.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic pain; dyspareunia
Treatment: Ambulatory Surgery (outpatient procedure 37241)
The insurer denied: Ambulatory Surgery (outpatient procedure 37241)
The denial is overturned

This adult female presents with pelvic pain and dyspareunia. Her symptoms have been present for at least two years, but are worse recently. Both the office notes and the letter from the patient demonstrate that the symptoms are severe enough to affect her normal function. Ultrasound demonstrated left ovarian vein reflux. MR (magnetic resonance) venogram showed bilateral ovarian vein reflux. Venogram and possible ovarian vein embolization was recommended. Coverage was denied by the health plan on the basis that treatment of pelvic venous congestion syndrome (sometimes called "pelvic varicocele disorder") is unproven. The denial is being appealed.

The health plan should cover the requested health service.
The issue in this case is the venography and ovarian vein embolization to treat a patient who presented with pelvic discomfort and dyspareunia. To determine the appropriateness of the procedure, the relevant literature and also this particular patient's findings will be reviewed.

This case centers on the treatment of chronic pelvic congestion syndrome. This entity is uncommon. A variety of treatments have been used in cases of suspected pelvic congestion syndrome, including pain medication, hysterectomy, and ovarian vein ligation. More recently, there have been several studies [1-9] suggesting benefit from ovarian and internal iliac vein embolization. This procedure has been found to be safe. The available clinical literature strongly supports the use of gonadal and internal iliac vein embolization in selected patients.

Based on the available data, one can be confident that some cases of pelvic pain arise from venous congestion in the pelvis. The finding of enlarged variceal pelvic veins is not normal, and it is reasonable to associate these enlarged veins with pelvic pain, based on the similar well-established association in the lower extremities. Furthermore, the treatment of pelvic varices by embolization is a logical, minimally invasive, and safe strategy. The available case series [1-9] of this topic strongly suggest a benefit from embolization. One of these reports [1] describes a randomized trial. The studies which most carefully document pain [3-5] relief show that 55-80% of patients have significant pain relief.

Based on the above information, venogram and possible gonadal vein embolization should not be considered investigational in the treatment of pelvic venous congestion. The treatment is medically appropriate.

The denial letter is based on the health plan policy, which states that the procedure is unproven. However, this viewpoint is not supported by the medical literature, as discussed above.