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

Diagnosis: Class I Malocclusion
Treatment: Braces
The insurer denied braces. The health plan's determination is upheld. 

The patient in question is a male with a Class I occlusion. He has minor maxillary spacing and mandibular crowding. Tooth 10 is missing. He is treatment planned for 36 months of orthodontics with rapid palatal expansion and extraction of teeth 5, 21 and 28 to correct his malocclusion. Under review is the medical necessity of braces.

Braces are not medically necessary. While the patient has minor spacing, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Therefore, braces are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Elevated PSA (prostate-specific antigen)
Treatment: Prostate Biopsy (procedure code 55706)
The insurer denied the Prostate Biopsy (procedure code 55706).
The denial is upheld.

The patient is a male. He has history of elevated PSA (prostate-specific antigen) and abnormal MRI (magnetic resonance image).  His provider performed transperineal biopsy.

No, the Prostate Biopsy (procedure code 55706) is not likely to be more beneficial.

TRUS (transrectal ultrasound) biopsy remains the standard for prostate biopsy at this time.  The use of a transperineal approach is reserved for patients with anal stenosis or prior abdominal/perineal surgery, neither of which are present in this patient.  Avoidance of infection is not a justification for using this approach.  Currently, antibiotic prophylaxis is used with fluoroquinolones prior to prostate biopsy and this approach.

A meta-analysis of nine trials found that antibiotic administration prior to prostate biopsy reduces the risk of bacteriuria (risk ratio [RR] 0.25, 95% CI [confidence interval] 0.15-0.42), bacteremia (RR [risk ratio] 0.67, 95% CI [confidence interval] 0.49-0.92), fever (RR [risk ratio] 0.39, 95% CI [confidence interval] 0.23-0.64), urinary tract infection (RR [risk ratio] 0.37, 95% CI [confidence interval] 0.22-0.62), and need for hospitalization (RR [risk ratio] 0.13, 95% CI [confidence interval ]0.03-0.55).  Fluoroquinolone resistance is a concern, and in these situations, options include use of a different antibiotic, or culture prior to the procedure to evaluate for drug resistance.

Therefore, there were other alternative options available to the provider as opposed to the use of a transperineal approach that was used.  The standard of care would be these methods for this otherwise average-risk individual as opposed to a transperineal approach.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Elevated PSA (prostate-specific antigen)
Treatment: Prostate Biopsy (procedure code 55706)
The insurer denied the Prostate Biopsy (procedure code 55706).
The denial is upheld.

The patient is a male with an elevated PSA (prostate-specific antigen). He had a saturation biopsy of the prostate.  A transperineal technique with MRI (magnetic resonance imaging) fusion was used.  He had not had a prior biopsy.  The PSA (prostate-specific antigen) was 5.8.

No, the health plan should not cover the Prostate Biopsy (procedure code 55706).
Transperineal stereotactic template-guided prostate saturation biopsy is considered investigational.

No, the Prostate Biopsy (procedure code 55706) is not likely to be more beneficial.
According to the NCCN (National Comprehensive Cancer Network) Guidelines:

"For high-risk men with negative biopsies, consideration can be given to a saturation biopsy strategy (including transperineal techniques) and/or the use of multiparametric MRI (magnetic resonance imaging) followed by an appropriate biopsy technique based on the results."

The patient had not had a prior negative biopsy.

Therefore, given the above, the Prostate Biopsy (procedure code 55706) is not likely to be more beneficial.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Elevated PSA (prostate-specific antigen)
Treatment: Prostate Biopsy (procedure code 55706)
The insurer denied the Prostate Biopsy (procedure code 55706).
The denial is upheld.

The patient is a male. He has a history of PSA (prostate-specific antigen) increase from 2.2 to 5.8. He has no family history of prostate cancer. He had no prior biopsy. MRI (magnetic resonance imaging) of the pelvis demonstrated no focal restriction lesions suspicious for prostate cancer in the peripheral zone and no suspicious lesions in the transitional zone. The patient had transperineal prostate biopsy with MRI (magnetic resonance imaging) fusion with 12 cores obtained.

No, the health plan should not cover the Prostate Biopsy (procedure code 55706).
The requested procedure transperineal biopsy of the prostate is an alternative to transrectal ultrasound biopsy of the prostate. Studies have demonstrated that this procedure can be performed in the office setting. The NCCN (National Comprehensive Cancer Network) guidelines note that transperinal biopsy of the prostate is an option to transrectal ultrasound biopsy of the prostate but notes, "A definitive study comparing a more limited transperineal biopsy versus conventional transrectal biopsy has not been performed."

This patient had a more limited transperineal biopsy and not a saturation biopsy. There is a growing body of literature supporting the role of transperineal prostate biopsy in the outpatient setting with local anesthesia. There is lack of documentation to support routine limited transperineal prostate biopsy under anesthesia as this patient had.

The medical records provided indicate that the patient is undergoing an initial prostate biopsy, the provider does not identify any contraindications to transrectal biopsy. The provider performed a more limited transperineal biopsy under general anesthesia.

No, the Prostate Biopsy (procedure code 55706) is not likely to be more beneficial.
The NCCN (National Comprehensive Cancer Network) guidelines on early detection of prostate cancer notes, "a definitive study comparing a more limited transperineal [as this patient had] versus conventional transrectal biopsy has not been performed." Thus, it cannot be concluded that the requested service is likely to be more beneficial.

In addition, a meta-analysis comparing transrectal and transperineal biopsy for detection of prostate cancer revealed no significant differences in the prostate cancer detection rate for transperineal and transrectal prostate biopsy. With regard to pain relief and additional anesthesia, transrectal prostate biopsy was relatively preferred compared to transperineal.  The study analysis indicated that the profile of complications between the transrectal and transperineal biopsy techniques were equivalent.
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.  

The patient has a history of Asthma.  She presented to the Emergency Department (ED) with complaint of increasing shortness of breath (SOB) over the past week.  The patient reported using her rescue inhaler very frequently.  The patient's home medications included Symbicort and Albuterol.  Vital signs (V/S) at presentation were temperature (T) 37.2C, heart rate (HR) 115, respiratory rate (RR)18, BP 138/88 and oxygen (O2) saturations 89 percent (%) on room air (RA).  The patient was in no acute distress (NAD).  She was noted to have expiratory and inspiratory wheezes on lung exam.  

The patient was treated with intravenous (IV) steroids, bronchodilator (BD) via nebulizers, magnesium, and intravenous (IV) fluids.  After treatment in the ED, the patient's O2 saturations improved to the mid-90's.  Admission labs revealed white blood cell (WBC) count 9.5, hemoglobin (Hb) 14.8, electrolytes were within normal limits (WNL) and Troponin was negative.  Chest x-ray showed no acute infiltrates.  Electrocardiogram (EKG) showed no acute ST-T (intervals on EKG) Changes.  The patient was admitted to the hospital for Asthma Exacerbation. 

As per History & Physical (H&P), the patient was afebrile and hemodynamically (HD) stable.  O2 saturations were 95% and HR 92.  The patient was in no acute distress.  Lungs were described as clear.  The patient was alert and oriented to person, place, and time.  Peak expiratory flow (PEF) was 375, baseline 450. 

The patient was continued on oral (PO) Prednisone, Duo Nebs and Singulair.  The patient remained stable on PO meds after admission.  She remained afebrile.  PEF improved to 450.  The patient was discharged home on oral medications with outpatient follow-up with Pulmonology.  

The patient did not need acute inpatient hospitalization.  She could have been placed on Observation status (which could be for up to 48 hours) while diagnostic testing and treatment were initiated.  The patient was afebrile and hemodynamically (HD) stable.  O2 saturations had improved after treatment in the ED.  The patient had normal WBC at admission.  Procalcitonin (PCT) was normal.  Chest x-ray showed no pneumonia or pneumothorax (PTX).  The patient was ambulatory and tolerating PO.  PEF was close to baseline.  The patient was treated with PO meds after admission.  

She could have been discharged home on oral (PO) medications after a period in observation with close follow-up in an outpatient setting after discharge.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.  

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

Diagnosis: Muscular Dystrophy
Treatment: Emflaza Pre-service
The insurer denied the Emflaza Pre-service.
The denial is overturned.

The patient is a male with Duchenne muscular dystrophy (DMD). He has been treated with Emflaza. This was denied coverage as the patient has not tried and failed and does not have a contraindication to treatment with prednisone.

Yes, the proposed treatment with Emflaza is medically necessary.
There are high quality clinical trials supporting the preferential use and superiority of Emflaza relative to the preferred agent prednisone. 

Meta-analysis (McDonald et al.) concluded that Deflazacort-treated patients experienced significantly lower functional decline over 48 weeks compared to prednisone treated patients. 

Moreover,  Shieh et al.'s conclusion suggests greater preservation of six-minute walking distance (6MWD) and four-stair climb with deflazacort versus prednisone/prednisolone with less adverse events in the deflazacort group.

There is data to support the preferential use and superiority of Emflaza relative to the preferred agent prednisone.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite.
Treatment: D8080 Braces, Pre-service.
The insurer denied the D8080 Braces, Pre-service.
The denial is overturned. 

The patient is a male requesting dental benefits for orthodontic treatment (braces).  Per the records, the patient presents with severe Class II, Division II, severe 100% overbite, 2-4 millimeter overjet, upper and lower crowding, and upper and lower incisors detorqued.

Yes, the proposed treatment of orthodontic therapy (braces) is medically necessary.
The patient presents with a 100% overbite -- where the anterior lower front teeth are entirely covered by the upper front teeth. In this scenario, the biting edge of the lower front teeth tend to bite into the gums of the upper front teeth.  A severe overbite like this can lead to gum recession. This can also eventually lead to gum disease, tooth loss and difficulty with speech and chewing.

Severe overbites if not treated tend to become worse over time and with age. Possibility of strained muscles of the jaw and can lead to jaw pain.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heavy Vaginal Bleeding, Dizziness And Shortness Of Breath.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with a diagnosis of uterine fibroids and anemia. On presentation, she was found to have a hemoglobin of 5.7. She was transfused with 1 unit PRBCs (packed red blood cells) and transferred to Brookdale for a higher level of care.

The patient was admitted with a diagnosis of symptomatic anemia for transfusion and potential hysterectomy.  The patient remained clinically stable. She was given 2 units of packed RBCs (red blood cells), and her repeat hemoglobin was 8.  Her symptoms of lightheadedness resolved.  Repeat hematocrit after transfusion has remained stable.  The patient signed out AMA (against medical advice) and left the hospital.

No, while the blood transfusion was appropriate, the Inpatient admission was not medically necessary.
This patient was symptomatic. In addition, she fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8g/dl (grams per deciliter). As such, transfusion was appropriate.

In this day and age, transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home). So the need for transfusion is not a reason for admission.

The transfusion was started at the originating facility. The transfusion could have been completed at a lower level of care without the need for admission. Following transfusion, the patient could have been monitored, her CBC (complete blood count) repeated and then discharged home with a follow-up within 24 hours with her primary physician or gynecologist. Nothing was done in the hospital that could not have been done as an outpatient.

The clinical indications for inpatient care for patients with anemia include active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope. The patient was stable and did not have any of the above indications for admission.

Based on all of the above, admission was not medically necessary. The patient could have been treated at the observation level of care.

The health plan's decision was appropriate, as the inpatient admission was not needed to manage this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal Abscess. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male who presented with rectal abscess and 10/10 constant throbbing pain. The patient had a history of incision and drainage (I&D) with a seton placement. Vital signs were unremarkable. White blood cell count (WBC) was 13.3. A computed tomography (CT) scan demonstrated left perirectal abscess with soft tissue tract extending to the subcutaneous soft tissues of the left buttock. The patient appears to have been admitted after midnight. The patient was set up for incision and drainage of peri rectal abscess. The patient was given Cipro and Flagyl. The procedure was performed without complications in the afternoon. The patient was kept overnight and discharged the next morning. 

The inpatient stay was not medically necessary. The patient was identified to have a rectal abscess which was drained surgically, and the patient did well after the procedure. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental Health. 
Treatment: Mental health Residential. 
The insurer denied mental health residential treatment. 
The denial is upheld.

The patient is a male with history of attention deficit disorder combined type, generalized anxiety disorder, specific phobias, and oppositional defiant disorder. He was also felt to have misuse of substance and features of conduct disorder and personality disorder. His psychiatrist recommended admission to Residential Treatment for his increasing symptoms. The following review is evaluating the medical necessity of residential treatment.

The health plan's determination is upheld.

Residential treatment was not medically necessary. The patient was not noted to be manic, psychotic, or a danger to himself. He did not require 24/7 supervision and his outpatient psychiatrist specifically stated that his main "issues were behavioral, social and dynamic." It appears he has failed outpatient level of care but there is no evidence of other levels of care that were explored or trialed (Kober et al., 2017). He did not meet criteria for residential treatment based on Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII) criteria. There was evidence that patient had a supportive family that were engaged and willing to assist patient with treatment. In addition, patient was not noted to be at an imminent risk of self-harm and there was no evidence of a history of self-harm behaviors. Given the above, residential care was not the least restrictive means for treatment and was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary intervention.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male with a past medical history significant for HTN (hypertension), DM (diabetes mellitus) type 2, dyslipidemia, CAD (coronary artery disease), status post prior CABG (coronary artery bypass graft) with failed bypass grafts and subsequent PCI (percutaneous coronary intervention) of LAD (left anterior descending), and moderate to severe aortic valve stenosis. He presented for an elective PCI (percutaneous coronary intervention) of left circumflex artery (LCX) and OM (obtuse marginal) branch.

The procedure was unsuccessful, with the operator unable to cross the lesion in the OM1 (obtuse marginal 1) branch, complicated by distal vessel dissection with the coronary wire. As per catheterization report the operator was unable to enter the true lumen distally, and after stenting the proximal LCX (left circumflex), the intervention on the distal lesion was abandoned. The patient had dual access for this CTO (chronic total occlusion) procedure, with the groin access closed with a Perclose device and the radial access closed with a radial TR (transradial) band.

The patient was admitted for close monitoring in the inpatient setting. He was discharged home the next day with a plan for outpatient follow-up.

Yes, the Inpatient admission was medically necessary.

This patient with multiple cardiac comorbidities, including significant valvular disease, severe premature coronary disease with complex anatomy, failed surgical revascularization with CABG (coronary artery bypass graft) and required complex coronary intervention of chronic total occlusion lesion in OM1 (obtuse marginal branch 1), with dual access. The procedure was complicated by distal vessel dissection and inability of the operator to re-enter the true lumen of the vessel. Patients such as this one were excluded from the studies of outpatient PCI (percutaneous coronary intervention).

Given the complex coronary anatomy and interventional procedure, multiple comorbidities, as well as coronary vascular complication, it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diaphoresis, lightheadedness and nausea.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male.  At the time of admission to the hospital, he had a past medical history significant for hypertension, dyslipidemia, thyroid disease, chronic lymphedema, chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD) status post multi vessel percutaneous coronary intervention (PCI).  

The patient presented for evaluation due to an episode of diaphoresis, lightheadedness and nausea, which was non-exertional. The patient was hemodynamically stable. Electrocardiogram (ECG) revealed normal sinus rhythm with no acute ischemic changes. Cardiac enzymes were negative. The patient was admitted to rule out acute coronary syndrome (ACS). He was seen in consultation by cardiologist and his symptoms were determined to be atypical. He was discharged home with a plan for outpatient stress test.

No, the proposed inpatient admission was not medically necessary.

The patient presented with atypical symptoms, including diaphoresis and nausea and was worked up for acute coronary syndrome (ACS). There were no acute electrocardiogram (ECG) change or increase in cardiac biomarkers. Acute myocardial infarction was ruled out by cardiac troponin, which were negative. There was no evidence of acute coronary syndrome, acute myocardial infarct (MI), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. The patient was evaluated by a cardiologist, with a finding of atypical symptoms and discharged with plan for outpatient stress test. There were no plans for inpatient stress testing of angiography. Therefore, the medical necessity of the inpatient admission could not be established and the necessary services could have been provided at a lower level of care.