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

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 

The insurer denied the inpatient stay. 
The denial is upheld in whole. 

The patient is a male who presented to the emergency department complaining of rapid heart rate and chest pain. His medical history was remarkable for paroxysmal supraventricular tachycardia (PSVT). His blood pressure was 71/53 millimeters of mercury (mmHg) with a heart rate of 195 beats per /minute. An electrocardiogram showed supraventricular tachycardia at 188 beats per /minute with ST segment depression. The tachycardia was terminated with Valsalva maneuver. Post -conversion, the patient's heart rate was 81 beats per /minute with a systolic blood pressure of 110 mmHg. An electrocardiogram showed sinus rhythm without ST segment abnormalities. Chest x-ray was unremarkable. The patient's serum troponin I level was 0.13 nanograms/milliliter (ng/ml) and rose to a peak of .520 ng/ml. The patient was admitted to the hospital. He remained in sinus rhythm. He was seen in consultation by a cardiologist who opined that no evaluation for ischemia was indicated and recommended outpatient follow-up for possible catheter ablation. The patient was discharged. The issue at hand is the medical necessity of inpatient stay.

While there are no established guidelines regarding disposition for patients presenting to the emergency department with PSVT, most authors suggest that, 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 electrocardiogram during tachycardia showed ST segment depression, rate related ST segment changes are frequent and not necessarily indicative of underlying coronary artery disease. His serum troponin levels were elevated. However, cardiac enzymes 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. In this patient, this would have been unlikely. In summary, this single episode of hemodynamically stable PSVT that was terminated with Valsalva maneuver did not require an inpatient admission. 

The health plans determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder. 
Treatment: Autism Related Treatment. 
The insurer denied applied behavior analysis. 
The health plan's decision is overturned.

The patient is a male who has Down syndrome. He underwent surgery for congenital heart disease early in life. He has been diagnosed with autism spectrum disorder by his pediatrician, and also on the basis of two psychological evaluations. This initial evaluation did not acknowledge the patient's diagnosis of Down syndrome.
Limited information was provided regarding the patient's early medical and developmental history. He came into the care of his current foster parents at an early age. He received Early Intervention from that time, together with physical, occupational and speech therapy for 45-minute sessions twice weekly. After aging out of the early intervention program, he attended an Applied Behavior Analysis (ABA) class at a local public school, with an after-school respite program. He is now in a self-contained classroom with 7 students, 1 teacher and 6 aides at a private school for children with developmental disabilities.
A report by his ABA therapy provider describes that he has been receiving ABA therapy with his current provider. He has been recommended to continue to receive 15 hours per week across 5 days at his after-school program and at home.
The patient has significant delays in language and communication. He has made progress with manding for desired items but needs prompts to use full sentences. He has difficulty with behavior regulation and may tantrum if his wants and needs are not met. He struggles with lack of focus, having difficulty completing tasks. His sense of safety is poor, and he tends to elope in the community. He is making progress with socialization, for example sharing toys and exhibiting pretend play, but has difficulty advocating for himself, staying on task, and making appropriate comments to adults.
A psychology evaluation included formal neuropsychological testing. The patient's first language was Yiddish. On the Comprehensive Test of Nonverbal Intelligence 2nd Edition (CTONI-2) his Full-Scale Nonverbal intelligence quotient (IQ) was estimated to be 58, in the mildly intellectually disabled range. On the Weschler Intelligence Scales for Children -5th Edition (WISC-V) his nonverbal IQ was estimated at 45. On the Gilliam Autism Rating Scale 3rd Edition (GARS-3) his Autism Index was 111, indicating that a diagnosis of autism spectrum disorder was very likely. At issue in this review is whether ABA therapy is medically necessary for this patient.

The health plan's determination is overturned.

The requested health service/treatment of Applied Behavior Analysis is medically necessary for this patient, to address his autistic features, including difficulty with social interaction, delayed language and communication, and safety issues including a tendency to elope when in the community.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole.

The patient is a previously healthy female who presented to the hospital emergency department (ED) with a history of progressively worsening abdominal pain of 2-days duration. Her evaluation included physical exam, computed tomography (CT) scan, and labs. She was afebrile at the time of presentation. The heart rate was normal at 68 beats per minute at presentation. The abdomen was tender in the right lower quadrant. Her lab data identified a normal white blood cell (WBC) count of 6.0. The CT scan showed a dilated fluid filled appendix. Her evaluation yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. A surgical consultation was requested. She was admitted to the hospital.
The patient was provided IV fluid and antibiotics. She underwent a laparoscopic appendectomy with findings of appendicitis. Surgery was performed without complication. Her diet was advanced and pain management was converted to oral medications. She was discharged home.
At issue is the medical necessity of the Inpatient Stay.

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

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient.
The patient presented to the ED and underwent an uncomplicated appendectomy procedure. The post-surgical course was performed without adverse incident. The patient responded favorably to this treatment and the hospitalization was uncomplicated. The patient was previously healthy, and her vital signs were consistently normal. The progress notes document clinical stability without complication during the period of monitoring. The submitted clinical documentation does not support the need for inpatient admission for this patient.
Generally accepted medical standards indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications, the treatment of appendicitis can be provided without an inpatient level of care. In this case the patient tolerated oral hydration, diet and medication, and surgical treatment.
Therefore, the requested health service/treatment of Inpatient Stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied dental implants. 
The denial is upheld.

The patient is a female who presented to the office her dental provider for evaluation and treatment of teeth #2, 3, 4, 5, 14, 15, 18, 19, 20, 28, 29, 30 and 31. Included for review are previous letters of appeal and denial, panoramic radiographic images from an unknown date. Previous denials have been on the basis that there was no documentation provided to evidence why implant placement was the only viable option and why a fixed partial denture was not an option. The subject under review is the medical necessity for the requested implants.

The health plan's determination is upheld.

The requested implants are not medically necessary for this patient. Based on the documentation provided, the treating dentist did not provide any rationale, diagnosis, nor support for the desired treatment. Based on the documents provided for review there is no support for the current treatment plan and there is not any medical necessity for implants in sites # 2, 3, 4, 5, 14, 15, 18, 19, 20, 28, 29, 30 and 31.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Complex Regional Pain Syndrome (CRPS).

Treatment: Procedure code 64555 - Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (Sprint Peripheral Nerve Stimulation [PNS]).

The insurer denied coverage for procedure code 64555 - Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (Sprint Peripheral Nerve Stimulation).  The denial is upheld.

This patient has Complex Regional Pain Syndrome (CRPS) affecting his Left leg.  He is taking Nortriptyline, Tizanidine, Nucynta, Ketamine infusions and medical marijuana. He has tried physical therapy (PT) and a home exercise program.  He has had Dorsal root ganglion placement at left L(lumbar)5-S1 and also at left L3-L4.  He has not had Spinal Cord Stimulation (SCS), Intra-thecal medication trials or surgical sympathectomy.  The request is for placement of the Sprint PNS at two separate nerves.

The Sprint PNS System has received Food and Drug administration (FDA) clearance and is indicated for up to 60 days in the back and/or extremities for symptomatic relief of chronic intractable pain, postsurgical and post-traumatic acute pain, post-traumatic pain, and post-operative pain.  It is not FDA approved for CRPS.

Mainkar et al. (1) reported on a small case series using Sprint PNS including one patient with CRPS: "The case series presents 11 cases of PNS of the proximal spinal nerve. Seven patients, including a majority of the patients with lumbar radiculopathy, had analgesia during PNS. Four patients, all of whom targeted the cervical or thoracic spinal nerves, did not receive analgesia from PNS."

They Concluded:

"PNS [peripheral nervous stimulation] of the proximal spinal nerve may be an effective modality to treat dermatomal pain in patients who are not candidates for other therapies that require access to the epidural space. This technique was used to successfully treat lumbar radiculopathy, post-herpetic neuralgia, and complex regional pain syndrome."

Similarly, the "variable evidence" for using PNS to treat CRPS is highlighted by Shin et al. (2) "Substantial yet variable evidence to support peripheral nerve stimulation and intravenous therapies. It is imperative that interventional treatment is individualized, with an emphasis placed on improving quality of life and function."

There are several evidence-based therapies that are available for this patient.  This approach is not likely to be more beneficial than standard treatments. The risks are not yet fully documented. 

The insurer's denial of coverage for procedure code 64555 - Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (Sprint Peripheral Nerve Stimulation) is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Short bowel syndrome and ulceration. 
Treatment: Entyvio. 

The insurer is denied coverage for Entyvio. 

The denial is overturned. 

This male patient has a history of prematurity, Crohn's Disease, short bowel syndrome, growth delay and growth hormone deficiency. 

An article titled "Vedolizumab Therapy in Severe Pediatric Inflammatory Bowel Disease (IBD) concludes that a marked number of subjects achieved clinical response in the first 6 weeks. This improvement increased further by week 22 despite the severity of disease in the cohort. 

A Retrospective Multi-Centre Experience from Pediatric lBD Porto Group of ESPGHAN concludes conclusion was that Vedolizumab was safe and effective in this cohort of pediatric refractory IBD. 

This patient has severe Crohn's disease with short bowel and structuring. Vedolizumab has been shown in the medical literature to be effective. Anti-TNF agents have been shown to have an increased risk of malignancy in children. Given the severity of this patient's disease, using Vedolizumab is appropriate. 

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 Entyvio is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department complaining of chest pain and dyspnea. His medical history was remarkable for a stroke, pulmonary embolism and deep vein thrombosis. His blood pressure was 144/89 millimeters of mercury (mmHg) with a heart rate of 92 beats/minute. His respiratory rate was 20 breaths/minute with a room air oxygen saturation of 99%. An electrocardiogram was normal, as were the patient's serum troponin level and chest x-ray. He was treated with aspirin and acetaminophen. He then complained of epigastric pain and was treated with an antacid, famotidine and Carafate. Chest computed tomography (CT) angiography showed no evidence of pulmonary embolism. The patient was admitted to the hospital to rule out acute coronary syndrome. He intermittently complained of chest and epigastric pain. His serum troponin level remained normal. His liver function tests and pancreatic enzyme levels were normal. An echocardiogram showed normal left ventricular systolic function and grade I diastolic dysfunction. He had mild epigastric pain and tenderness. He was discharged with plans for outpatient esophagogastroduodenoscopy. The medical necessity for an inpatient admission is at issue.

Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient presented with chest pain and was admitted to the hospital for monitoring and serial cardiac troponin levels to rule out acute coronary syndrome. He was hemodynamically stable, with normal cardiac biomarkers, and a normal electrocardiogram. There is no indication in the records provided that other potentially life-threatening diagnoses were considered likely. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE)/ American College of Chest Physicians (CHEST), Society for Academic Emergency Medicine (SAEM), Society of Cardiovascular Computed Tomography (SCCT), and Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain.
The patient also complained of epigastric pain. However, the records do not indicate that there was concern for a serious acute abdominal process and outpatient evaluation was recommended. This patient's epigastric pain did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) 
Treatment: Privigen 
The insurer denied the Privigen. 
The denial is overturned. 

The patient is a male with chronic inflammatory demyelinating polyneuropathy (CIDP). His provider would like to prescribe Privigen (intravenous immune globulin) 90 grams divided over two days, every two weeks for six months for this condition. The justification for this is that the patient has a wearing off effect after 16 days. This request was previously denied as the patient was not noted to have a positive outcome with intravenous immune globulin (IVIG), which he was receiving every three weeks. The records indicate that Gamunex was previously approved as it met the medical necessity criteria. 

Yes, the proposed Privigen is medically necessary. 

Use of IVIG is the standard of care in treating CIDP. Based on the ICE [Immune Globulin Intravenous (IGIV) For Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)] trial, European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) clinical practice guidelines for the management of CIDP recommend that IVIG be administered as an initial loading dose of 2 grams/kilogram of body weight, followed by maintenance infusions of 1 gram/kilogram every three weeks. IVIG has been determined to be effective for this patient. However, he has wearing off after 16 days and therefore the two week frequency is medically necessary. A study by Allen, et al has shown that 60% of patients needed IVIG at an interval of every fourteen (14) days. 

The patient has a confirmed diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP). Treatment with intravenous immune globulin (IVIG) is the standard of care. The request was denied as the patient was not having a positive response to the IVIG being given every three weeks, however, there is data that many patients need IVIG more frequently. For this reason, it is medically necessary to give IVIG more frequently than every three weeks.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior crossbite with gingival attachment loss skeletal Class I

Treatment: Insertion of braces and adjustment of braces

The insurer denied coverage for insertion of braces and adjustment of braces.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to and anterior crossbite with gingival attachment loss skeletal Class I, maxillary and mandibular crowding, among other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (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, to support orthodontic necessity. 

It is evident that the patient exhibits a 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 not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet criteria to support orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 11 points (1 overjet, 1 overbite, 5 mandibular protrusion, 3 ectopic eruption, 1 labiolingual spread).

Based on the above, the medical necessity for the insertion of braces and adjustment of braces is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left total knee replacement

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admission.

The denial is upheld. 

This female patient has a history of coronary artery disease, chronic diastolic heart failure, obesity, rheumatoid arthritis, right lower leg deep vein thrombosis (DVT), sinus tachycardia, osteoarthritis of both knees.

The records show a non-complicated post-surgical course. A primary total knee arthroplasty was completed. The patient had no issues with pain and was able to tolerate oral medications. Her vital signs were stable. She did not have fever nor signs of infection. Her wound was clean. She did not have blood loss nor require a drain. Her hematocrit was stable. She was able to progress with physical therapy as of post operative day #1. She did not require treatment for an underlying medical condition. Her reported obesity showed a body mass index (BMI) of 31 which did not limit her mobilization nor progress.  

The records did not demonstrate an extenuating circumstance to substantiate admission and length of stay as per Milliman Care Guidelines. There was no condition which could be viewed as an exception.

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

The carrier's denial of coverage for inpatient admission is upheld.  The medical necessity is not substantiated.