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

Diagnosis: Right Upper Extremity Cellulitis 
 
Treatment: Inpatient Admission 

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

This is a male patient with a medical history of asthma, a liver disease, and polysubstance abuse including intravenous drugs. He presented to the Emergency Department with complaints of left arm pain and swelling. He was admitted to the hospital for treatment for cellulitis of his left arm. He received intravenous (IV) antibiotics. A chest x-ray was performed with negative results. An x-ray of the left arm was done that revealed no significant tissue or joint abnormalities. He remained afebrile and hemodynamically stable. He signed out against medical advice (AMA). 

According to medical documentation, the patient presented with left upper extremity erythema and pain. Otherwise, he was afebrile and hemodynamically stable. Laboratory results similarly were unremarkable including a normal white blood cell (WBC) count. There was no evidence of a systemic infection and no surgical intervention was required. Moreover, the patient had not failed an outpatient course of antibiotics. As per Stevens et al. (2014) article on the "Practice guidelines for the diagnosis and management of skin and soft tissue infections", outpatient therapy is recommended for patients with cellulitis who do not have systemic inflammatory response syndrome (SIRS), altered mental status, or hemodynamic instability; and hospitalization is recommended if there is concern for deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a severely immunocompromised patient, of it outpatient treatment is failing. Based on the above findings, this patient did not present with clinical signs and symptoms that would necessitate hospitalization for the treatment and management of his cellulitis. 

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

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

Chest Pain
Inpatient hospital

The patient is a female with a history of end stage renal disease (ESRD) on hemodialysis (HD), hypertension (HTN), seizure disorder, and intracranial hemorrhage who presented with palpitations and chest pain. The pain woke her up from sleep and was a constant, burning type pain on the left side of her chest and was associated with shortness of breath and emesis x1. She denied fevers, chills, headache, cough, abdominal pain, or change in bowel habits. She was admitted to rule out a pulmonary embolism.

The health plan's determination is upheld. The inpatient stay was not medically necessary. There was no evidence of myocardial infarction, no documentation that acute intervention of possible unstable angina was indicated, no hemodynamic instability, respiratory distress, pulmonary edema or chest pain indicative or another serious etiology. She was ruled out for pulmonary embolism with a CT angiogram and was considered low risk for pulmonary embolism based on her presentation. She had a potassium of 6.3 on presentation but without clinically significant cardiac arrhythmias and was treated with routine hemodialysis. She was hypertensive on presentation but without evidence of encephalopathy, cerebral or myocardial infarction, intracranial hemorrhage, pulmonary edema, aortic dissection, seizures, acute kidney injury, papilledema, or microangiopathic hemolytic anemia. Her blood pressure was controlled with oral agents in the emergency room. There was no other indication for admission documented. The patient could have been safely and effectively managed at a lower level of care with subsequent transition to outpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Central Nervous System/Neuromuscular disorder
Treatment:  Inpatient hospital

The patient is a male with a history of hypertension who presented to the emergency department (ED) with a headache and elevated blood pressure.  He developed an acute intense frontoparietal headache and stated that he never had a similar headache in the past.  He denied having any focal weakness, photophobia, phonophobia, aura, nausea, vomiting, or recent trauma.  His blood pressure at home was greater than 200/100 with baseline systolic blood pressure (SBP) in the 160s.

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  He had uncontrolled hypertension (hypertensive urgency), but this was not a hypertensive emergency as the patient ruled out for a stroke.  The elevated blood pressure would not have anything to do with a bell's palsy, although, could have been the cause for his headache.  The documentation does not support that his severe headache persisted beyond an observation period of time (i.e 24 hours).  This patient did not meet Milliman Care Guidelines for hypertension, as there was no altered mental status, acute stroke, cerebral hemorrhage, myocardial ischemia, congestive heart failure, aortic dissection, acute renal failure, papilledema, retinal hemorrhage, seizures, or any other end organ damage.  Also, there is no evidence that he required frequent IV anti-hypertensives.  He was ruled out for a stroke and had a stable blood pressure after 24 hours and was, thus, stable for discharge home at that time.  A diagnosis of Bell's palsy does not require an inpatient admission.  A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient hospital

This is a female with a history of hypertension, hypothyroidism, and mild tricuspid regurgitation. She has a new onset of atrial fibrillation due to complaints of palpitations and chest pain. She had initial cardiac enzymes, rate controlled with medication and was given anticoagulation while being ruled out for a heart attack. A stress test was ordered. The patient refused the stress test. The rate was controlled and was anticoagulation given with subsequent restoration of sinus rhythm.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient was admitted without hemodynamic compromise, and no evidence of altered mental status, syncope, heart failure, myocardial ischemia or medication toxicity. There was also no need for repeat cardioversion or intravenous medications for an extended period of time. The patient had her rate controlled with medication and was given anticoagulation and ruled out for a myocardial infarction (MI). A stress test was ordered, however, the patient refused. The patient could have been kept in the hospital at a lower level of care and had the appropriate treatment.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient hospital

The patient is a woman with a history of hypertension, hyperlipidemia and diabetes. She presented to the emergency department complaining of palpitations and lightheadedness. Her blood pressure was 139/95 mmHg with a heart rate of 174 beats/minute. An electrocardiogram showed supraventricular tachycardia that did not terminate with vagal maneuvers, but was terminated with one dose of intravenous adenosine. The patient's troponin level was elevated. She was treated with intravenous fluids, aspirin and oral metoprolol and admitted to the hospital. An echocardiogram was performed and showed a normal left ventricular ejection fraction. Myocardial perfusion imaging was performed and showed no evidence of ischemia. The patient was discharged. Coverage for an inpatient admission is at issue.

The health plan's determination is upheld. The inpatient stay was not medically necessary. 

This patient presented with hemodynamically stable paroxysmal supraventricular tachycardia (PSVT). The rhythm was terminated with an intravenous adenosine bolus and the repeat electrocardiogram was unremarkable. While there are no clear guidelines regarding disposition for patients presenting to the emergency department with PSVT, most authors suggest than, in the absence of serious comorbidities, syncope, or rapid pre-excited atrial fibrillation or flutter, hospital admission is not necessary for adults whose PSVT is converted to sinus rhythm without complications. One single-center, retrospective study of patients presenting to emergency department with PSVT found that 71% were discharged home after an average stay of four hours. The 24-hour recurrence rate in those patients was less than 5%. Likewise, data from the National Hospital Ambulatory Medical Care Survey 1993-2003 database revealed a 76% discharge rate for PSVT after evaluation in the emergency department.
While this patient's serum troponin level was mildly elevated, this is common in PSVT. Serum troponin levels have been shown to increase with PSVT, in the absence of coronary stenosis, and it is not recommended that they be checked based on PSVT alone but only when there is reasonable suspicion of acute coronary insufficiency. This woman denied chest pain and had no ischemic electrocardiographic changes. Other than aspirin, she received no treatment for myocardial ischemia, suggesting the suspicion was low. In summary, this single episode of hemodynamically stable PSVT that was terminated with intravenous adenosine did not require an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Digestive System / Gastrointestinal
Inpatient Hospital

The patient is a male who presented to the emergency room with right lower quadrant pain. His white blood cell count was elevated. Computed tomography (CT) scan of the abdomen and pelvis demonstrated early appendicitis. He was given intravenous fluids and antibiotics. He underwent laparoscopic appendectomy that same day. He did well postoperatively and was discharged home the next day.

The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

No, the requested inpatient stay is not medically necessary for this patient. There is no evidence in the provided documentation that the patient received care above what could have been provided at lower level of care. Inpatient care hospitalizations in association with appendicitis/appendectomy are typically reserved for patients complicated by perforation and/or peritonitis, bleeding, wound problems, fistulas, or inability to tolerate oral intake. There is no evidence that high acuity services outside of the surgery were provided to the patient. There were no conditions or problems specific to this patient were identified that would make a level of care below inpatient unsafe.
Appeal type: Medical necessity
Decision: Overturned

This is a male patient with a history of immunocompromised status, intravenous drug use, structural heart defect, and seizure disorder. He presented to the Emergency Department (ED) with complaints of lower extremity swelling with pain and erythema. Laboratory work up was performed that revealed white blood cell (WBC) count of 2.7, hemoglobin 11.0, hematocrit 33.9, creatinine 1.4, and glucose 108. The patient was admitted to the hospital with leg cellulitis. Intravenous (IV) antibiotic were administered empirically. A lower extremity ultrasound was performed with negative results for a deep vein thrombosis (DVT). The patient was medically stable and was discharged home on oral antibiotics.

According to the review of the medical records provided, the patient's condition progressed despite outpatient management with oral antibiotics. The patient's laboratory results showed leukopenia (WBC count of 2.7), and elevated creatinine of 1.4. These abnormal findings were concerning for this patient with immunocompromised status and active substance abuse. This patient was at high risk for developing a life-threatening complication, especially considering that this patient's symptoms progressed and did not improve with outpatient treatment with antibiotics. The records indicated that the patient was on Ampicillin prior to arriving to the hospital.

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 the inpatient hospital admission is reversed. The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Left Sided Tonsillar Mass
Treatment: Outpatient Proton Bean Therapy Treatments (Codes 77263, 77300, 77331, 77427, 77301, G6002, 77014, 77336, 77523, 77334, 77525, 77370, 77530, 77520, 77333, 77470, 77387, 77522)
The insurer denied the Outpatient Proton Bean Therapy Treatments (Codes 77263, 77300, 77331, 77427, 77301, G6002, 77014, 77336, 77523, 77334, 77525, 77370, 77530, 77520, 77333, 77470, 77387, 77522).
The denial is upheld.

The health plan should not cover the proposed treatment with proton beam therapy (PBT), as it is considered investigational in this patient's clinical scenario. 

The requested PBT is not known to be more beneficial than standard therapy for this case.  

The patient is a gentleman with locally advanced left oropharyngeal cancer referred for combined chemoradiotherapy. 

Proton beam radiotherapy can be controlled with greater precision than x-ray radiotherapy.

This means that more energy goes into destroying the tumor and less radiation is delivered to the surrounding healthy tissue. For this reason, proton therapy is particularly good for treating tumors near healthy organs, including head and neck tumors. 

More than 60,000 Americans are diagnosed annually with head and neck cancer. When treating head and neck tumors, it is critical to protect the delicate organs that surround the tumor. Proton therapy can potentially reduce damage to salivary glands, spinal cord, and other organs near the head and neck tumors, thereby reducing the likelihood of side effects such as dry mouth, nerve damage, and osteoradionecrosis. Secondary malignancies are also less likely with proton beam therapy.

Long term clinical evidence to support the use of proton therapy in this case in terms of safety and efficacy has not been well-established. Peer-reviewed medical articles pertaining to this case to justify the use of proton therapy are few and retrospective in nature. Standard radiotherapy with photon either 3D or IMRT (intensity-modulated radiation therapy) for this case would still be considered the standard approach. Even though technically the proposed treatment is dosimetrically superior to photon therapy, this has not been shown to translate to a clinical advantage.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epilepsy
Treatment: Epidiolex
The insurer denied the Epidiolex.  The denial is overturned.

The treatment with Epidiolex is medically necessary.

The patient is a female with seizures. Assessment was listed as Leigh's disease, seizure, dystonia, and Lennox-Gastaut syndrome. According to an office visit report and letter by pediatric neurologist (MD), the patient has complex seizures, including tonic seizures with secondary generalization. According to the MD, the patient was doing better on Epidiolex with reduction of seizure events as well as functional improvement, including improved cognitive functioning, speech, communication, and alertness and that the MD could see this on exam. Other medications included topiramate.   The MD recommended that the Epidiolex dosage be increased. 

The patient has intractable epilepsy related to a severe mitochondrial/metabolic condition (Leigh syndrome). The patient has multiple neurological impairments including dystonia and epilepsy. The patient's epilepsy was described, in the provider's note, as being in keeping with Lennox Gastaut syndrome. The patient failed Topamax, a medicine indicated for Lennox Gastaut syndrome. Epidiolex is approved by FDA for Lennox-Gastaut syndrome. Therefore, this treatment is medically necessary. 

The patient has Lennox Gastaut syndrome and has failed Topamax, a medicine indicated for Lennox Gastaut syndrome. Therefore, Epidiolex is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Cancer
Home Health Care

The patient is a female with past medical history of advanced stage soft palate squamous cell carcinoma, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, hyperlipidemia, spinal stenosis and severe malnutrition who underwent bilateral radical tonsillectomy, near soft palatectomy and dissection. The patient has a gastrostomy tube and requires bolus feeding twice a day and kangaroo feedings while continuing oral intake as tolerated with pureed diet. The patient was being set up for chemotherapy and radiation treatment. The patient had home health services to assist with medical needs, including gastrostomy tube care. The patient had assessment tool for PCA services Consumer Directed Personal Assistance Program (CDPAP) and was approved 42 hours/week. The patient had assessment tool performed again with an increase in assistance for tasks of managing medication (supervision to total), shopping (maximum to total), transportation (extensive to maximum), equipment management (n/a to total), personal hygiene (extensive to maximum), dressing upper extremity (extensive to maximum), locomotion (maximum to total), toilet use (limited to maximum), bed mobility (limited to maximum) and eating (independent to total). Following the assessment the patient was approved for PCA services (CDPAP) 52.5 hours/week. The patient's primary care physician (PCP) subsequently completed a physician's order for personal care/consumer directed personal assistance services noting the patient was weak and fatigued, was not able to lift or do strenuous tasks, needed help crushing pills for percutaneous endoscopic gastrostomy (PEG) tube, needed help with bathing, cleaning, shopping and food preparation. The patient would need transportation to frequent radiation treatments and doctor's appointments. The patient's physician filed an appeal to the approved PCA service (CDPAP) hours of 52.5 hours/week to increase to 10 hours/day, 7 days/week to total 70 hours per week.

The health plan's determination is overturned.

The patient had significant change in her medical status with recent extensive oropharyngeal surgery for squamous cell cancer and subsequent diagnosis of metastatic disease requiring chemotherapy and planned radiation therapy. The patient now has gastrostomy tube but also is prescribed pureed foods. The patient also required more help with walking and locomotion due to weakness and fatigue. The patient would need more than assessed assistance with meal preparation and eating (due to pureed food preparation and gastrostomy tube feeding) as well as medication management as her medications now needed to be crushed for gastrostomy tube administration. The patient needs more than assessed assistance with transportation, walking and locomotion due to frequent appointments for chemotherapy, radiation and necessary follow up with doctor appointments. Therefore, the additional hours are medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Infertility
Treatment: IVF and embryo transfer
The embryo transfer was medically necessary; however, the IVF was not medically necessary.

The patient is a female with a diagnosis of infertility.  The patient has undergone an IVF (in vitro fertilization) cycle with physician A earlier, which resulted in a chemical pregnancy.  No details about this cycle are available. 

The patient underwent another IVF cycle with physician B with ICSI (intracytoplasmic sperm injection) and PGS (preimplantation genetic screening).  She had five euploid embryos.  One embryo was transferred.  She had two more frozen embryo transfers (no clinical documentation was submitted about how many embryos were transferred).  None resulted in a live birth. 

The patient is requesting coverage for the embryo transfer cycle that took place between the dates of service under review.

This patient has a diagnosis of infertility and is eligible for infertility treatments.  The patient underwent an IVF cycle that resulted in five euploid embryos.  The next step according to standard of care is to proceed with a frozen embryo transfer.  The patient had three consecutive frozen embryo transfers performed using the euploid embryos from her IVF cycle.  Since she did not conceive after the first transfer, a second transfer was necessary, and since she did not conceive after the second transfer, a third transfer was also necessary.

Note that the patient did not undergo any additional IVF cycles while she had frozen embryos.  She was managed according to the ASRM (American Society for Reproductive Medicine) recommendations, which are to use her frozen embryos prior to undergoing another IVF cycle. 

Therefore, since there are frozen embryos still available, the embryo transfer is medically necessary.  A frozen embryo transfer is the standard of care in this patient's case.
However, IVF would not be indicated at this time.

Note: there was no documentation that IVF was performed on these dates of service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion, Class II canines 

Treatment: Orthodontic braces (code D8080) and monthly visits 

The insurer denied coverage for orthodontic braces (code D8080) and monthly visits. The denial is reversed. 

This patient is a female who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to Class I malocclusion, Class II canines, maxillary spacing and mandibular crowding, excessive overjet and anterior crossbite with gingival attachment loss (mandibular right canine). The Orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 18 points on review by internal reviewers. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

It is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 

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

Based on the above, the medical necessity for the orthodontic braces (code D8080) and monthly visits is substantiated.  The insurer's denial is reversed.