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

Diagnosis: Asthma. 
Treatment: Inpatient stay. 

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

The patient is a female with a medical history of hypertension, Vitamin D deficiency and asthma with a documented prior history of intubation. She was admitted for an acute asthma exacerbation with symptoms of shortness of breath and wheezing. She was treated with Duoneb nebulizers, magnesium sulfate and oral Prednisone 60 milligrams (mg). Although she was placed on supplemental oxygen, there is no documentation of hypoxia or hypoxemia and her condition and peak flow improved with observation. 

Based upon the severity of illness, intensity of required therapy and the criteria provided, the inpatient hospital admission was not medically necessary. This patient was admitted for an acute asthma exacerbation with symptoms of shortness of breath and wheezing. In the emergency room, the physician records state that the patient was afebrile, hemodynamically stable, had a respiratory rate of 20 breaths per minute, had an oxygen saturation of 94% on room air, had a normal pulmonary effort and on chest auscultation demonstrated wheezing and rhonchi. She was treated with Duoneb nebulizers, magnesium sulfate and oral Prednisone 60mg. As per the clinical documentation on admission, the patient reported feeling much better, was in no acute distress, she was alert and awake, was hemodynamically stable without cardiac dysrhythmias, had a respiratory rate of 20 breaths per minute, had an oxygen saturation of 100% on 3 liters per minute of supplemental oxygen and had wheezing on auscultation of the chest. She did not have documented hypercapnia or documented hypoxemia. She did not require any ventilatory support, she did not have a sustained respiratory rate >30 breaths per minute or heart rate >140 beats per minute. She had no reported cyanosis or increased work of breathing and her chest x-ray did not demonstrate evidence for acute infiltrates, consolidations, pneumothorax, pleural effusions, or fractures. Her peak flow was 60% of her personal best prior to treatment and 80% of her personal best after observation. Although she was placed on supplemental oxygen, there is no documentation of hypoxia or hypoxemia. Therefore, based on the clinical documentation and Milliman Care Guidelines (MCG) criteria, the inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a patient with multiple medical problems including diabetes, hyperlipidemia, hypertension, diabetic neuropathy, status/post (s/p) left below the knee amputation, who was evaluated for a right foot ulcer. The patient developed an ulcer on the dorsum of his right foot 3 days before with drainage.
The patient was noted to have right forefoot swelling with erythema and purulence and toe gangrenous changes with ulceration on the dorsum of the foot. His provider recommended hospital admission for intravenous (IV) antibiotics and work up of the patient's right foot ulcer.
The patient presented to the emergency department for admission and was admitted with a diagnosis of cellulitis of his right lower extremity. The patient left the hospital against medical advice.
The provider documented that the patient refused lower extremity angiogram and left against medical advice (AMA).
The issue for review is whether the patient's admission was medically necessary.
The admission was medically necessary for this patient.
This is a medically complex patient who presented with a diabetic foot infection and cellulitis requiring hospital admission and intravenous (IV) antibiotic treatment. The patient was at significant risk of developing sepsis, wet gangrene requiring amputation of his foot or leg, and possibly death from sepsis. Therefore, the admission from was medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lower back pain. 
Treatment: Procedure code 64628, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept). 

The insurer denied coverage for procedure code 64628, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept). 

The denial is upheld. 

This is an adult with chronic low back pain. The patient has had epidural steroid injections, medial branch blocks, radiofrequency ablation (RFA) of the medial branches and sacroiliac (SI) joint injections, as well as lumbar discectomies. The patient's magnetic resonance imaging (MRI) shows Modic II changes at L4 (lumbar 4) and L5 (lumbar 5). The request is for RFA of the basivertebral nerves at L4 and L5. 

In sum, the publications to date have been company-sponsored and had methodology flaws. There is no published data on long-term complication rates. 

Urits et al (3) also commented on the need for more research on this promising technique:  "reproducible large RCTs (randomized control trials) are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF (radiofrequency) ablation in the management of CLBP (Chronic low back pain) and improve the quality of life of CLBP patients in the near future." 

There are other evidence-based interventions available to this patient. This procedure is unlikely to be more beneficial than the standard approaches. 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. 

Procedure code 64628, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) has final approval from the appropriate regulatory bodies for this diagnosis. 

It is uncertain if this patient is a good candidate for procedure code 64628, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept). 

Procedure code 64628, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) is not the best available treatment for this patient at this time. 

It is unknown if the adverse risks are increased over standard treatment/services. 

In summary, the denial of procedure code 64628, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right paratracheal mass. 
Treatment: Inpatient hospital admission. 

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

The patient is an adult male who presented to the hospital with complaints of fatigue, weight loss, dizziness and difficulty walking. 

On presentation the patient was afebrile, Heart Rate 74, Respiratory Rate 16, oxygen (O2) saturation 100% (percent) at room air. The patient was in no acute distress (NAD) and lungs were clear. Cardiovascular systems (CVS) S (sinus) 1 S2 were normal. The abdomen was soft and non-tender (NT). No cyanosis, clubbing or edema was noted. The patient was alert and oriented times 3 (A X O X 3). 

Labs revealed a white blood cell (WBC) count 3.1K (thousand), Hb (hemoglobin) 10.7, and Na+ (sodium) 127. 

Chest x-rays (CXR) revealed a right paratracheal mass. The patient was admitted for hyponatremia and right paratracheal mass investigation. 

The patient's temperature spiked to 101.2 degrees F (Fahrenheit) on day two. The patient was pan-cultured and seen by Infectious Disease (ID). A computed tomography (CT) Chest and Abdomen revealed extensive mediastinal adenopathy and a lung mass. The patient also had intra-abdominal lymphadenopathy. The patient was seen by Pulmonary and Neurology specialties. A head CT was negative. 

ID opinion was that the patient's fever was likely noninfectious, secondary to underlying malignancy. If malignancy was ruled out, antibiotics (Abx) could be started.

Pulmonary and Oncology also evaluated this patient and consensus was that this patient has a lymphoreticular malignancy/Lymphoma.

The patient was medically cleared for discharge with biopsy in an outpatient setting. This patient had multiple medical issues including difficulty walking, dizziness, hyponatremia, pancytopenia and in addition developed fever. The admission was appropriate. This patient was then scheduled for biopsy in the outpatient setting for his lung mass and mediastinal and abdominal adenopathy.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Encounter for Dental Evaluation-broken tooth. 

Treatment: Crown on tooth number 8.

The insurer denied coverage for crown on tooth number 8.

The denial is upheld.

Upon review of the documentation provided which includes copies of one undated 
periapical radiograph, and insurer correspondence, it appears that this patient presented to the dentist for care involving tooth #8. The treating dentist recommended a full coverage crown for #8. The insurer has denied these services stating there is no clinical or radiographic evidence, such a traumatic injury or decay, provided to support the necessity of this service. The documentation is insufficient to approve treatment, and therefore the service does not meet medical necessity criteria. 

It appears that there is no evidence of fracture or other pathology specifically affecting #8 based on the image provided for review. There does not appear to be any radiographic evidence of caries. The radiograph does not substantiate the requested dental service. 

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

The insurer's denial of coverage for a crown on tooth number 8 is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I occlusion
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 with 5 millimeter (mm) overbite and 5mm overjet. He has maxillary spacing and moderate mandibular crowding. He is treatment planned for braces to correct his malocclusion. This is under review.

Braces are not medically necessary. While the patient has crowded mandibular teeth, 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 to correct if not addressed in adolescence. This patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is 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. For these reasons, braces are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal Reflux Disease (GERD)
Treatment: proposed service code 43210 (esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed)
The insurer denied coverage for proposed service code 43210 esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed).
The denial is overturned.

The patient has a history of gastroesophageal reflux disease (GERD) with heartburn and nocturnal choking. The patient has been treated with a proton pump inhibitor (PPI). Diagnostic workup including endoscopy and manometry. A previous Bravo study demonstrated reflux. The physician is recommending a transoral incisionless fundoplication (TIF) anti-reflux procedure. 

The American Society of Gastrointestinal Endoscopy (ASGE) has published a guideline on the role of endoscopy in managing GERD. The paper states that the TIF procedure was approved by the Food and Drug Administration (FDA). It reports that 15 studies and 550 procedures found improved GERD health quality of life scores after the procedure. Three randomized trials with at least 6 months follow-up found that TIF was more effective than high dose PPI therapy in eliminating troublesome regurgitation or extraesophageal symptoms of GERD.

Healio Gastroenterology has an article titled, " Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) provides strong recommendation for endoluminal GERD therapies." The SAGES performed a systematic literature review. The review found that compared to PPI treatment, TIF was clearly demonstrated to be more effective in controlling GERD symptoms 6 months after the procedure. The scientific evidence in the peer-reviewed literature supports the use of the TIF procedure. The procedure has FDA approval. The patient is a good candidate because the symptoms continued while on PPI therapy. There are many procedures available for the treatment of GERD. However, this procedure has been shown to be both effective and safe. In view of the patient's chronic symptoms of GERD, doing a minimally invasive procedure such as TIF is appropriate.

In summary, the denial of proposed service code 43210 (esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed) and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Basilar Joint Arthritis. 
Treatment: Orthopedic surgical services (arthroscopy or arthroscopically assisted surgery, wrist). 

The insurer denied coverage for orthopedic surgical services (arthroscopy or arthroscopically assisted surgery, wrist). 
The denial is overturned. 

This is the case of an adult female with a history of basilar joint degenerative joint disease on the right, osteopenia, colonic adenoma, acanthamoeba keratitis, corneal ulcer of the right eye, and hypothyroidism. The patient was seen by Orthopedic Surgeon on multiple occasions for pain in the right basal joint. A physical exam revealed tenderness to palpation at the right basilar joint. Diagnostic imaging demonstrated a small osteophyte. Steroid injections did not provide significant relief and the patient still maintained pain and tenderness. The patient underwent basilar joint arthroscopy with thermal collagen shrinkage, joint debridement of hematoma, and arthroplasty on the right. 

The medical record was consistent for the diagnosis of basilar joint arthritis. A pain generator was defined. A course of conservative treatment was provided. The procedure completed by the physician is recognized by the practicing medical community as effective. It is important to note the term arthroplasty was generalized. The physician removed osteophytes and debrided the joint. He did use a thermocoagulation device to shrink ligaments. He placed a pin. He did not perform an open procedure and did not perform a typical arthroplasty procedure of tendon transfer, interposition placement of device or other reconstruction. All procedures were arthroscopic, and the term "arthroplasty" should not be used. 

A search of literature with key words "thermal shrinkage and thumb" were used. There were references as this type of treatment being utilized and accepted. It is important to note thermal shrinkage procedures to other body sites is not recognized as standard of care (Knee). Thermal shrinkage with osteophyte removal and pin fixation has been shown to be effective in the management of basilar joint arthritis. 

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 the orthopedic surgical services (arthroscopy or arthroscopically assisted surgery, wrist) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep Impinging Overbite. 
Treatment: D8080 braces and D8670 monthly visits. 

The insurer denied coverage for D8080 braces and D8670 monthly visits. 

The denial is overturned. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, deep impinging overbite, ectopic eruption, and anterior crowding. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index choosing the automatically qualifying condition of deep impinging overbite with severe soft tissue damage and attaining 26 total points on the second portion of the index. 

Upon review of the submitted documentation 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, an HLD 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 completes both the first and the second portions of the index choosing the deep impinging criterion and also arriving at 26 points to justify orthodontic care. The clinical circumstance does not meet the first criterion of the automatically qualifying condition, but this reviewer concurs with the second portion of the index completed by the orthodontist which attains 26 points and meets the threshold of 26 points to support orthodontic care. 

Regarding the validity of the HLD index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. 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. 

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visits is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
Treatment: Full Hospital Admission
The insurer denied coverage for full hospital admission.
The denial is upheld.

This is an adult that presented to the hospital for elective cardiac resynchronization implantable cardiac defibrillator insertion. Past medical history was significant for non-ischemic systolic congestive heart failure, diabetes mellitus, and prostate cancer. Electrocardiogram revealed PR (interval on EKG [electrocardiogram]) interval prolongation and left bundle branch block. Prophylactic Implantable Cardioverter Defibrillator (ICD) was recommended. The patient underwent uncomplicated cardiac resynchronization therapy (CRT) ICD implantation and was discharged the following day.

Several studies referenced have demonstrated that following uncomplicated ICD implantation same day discharge is safe and feasible (Reference 1-3). 

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

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

Diagnosis: Severe Osteoporosis. 
Treatment: Evenity. 

The insurer denied coverage for Evenity. 
The denial is overturned. 

According to the medical records, the patient is an adult female with diagnoses of age-related osteoporosis without current pathological fracture, breast cancer (status post chemotherapy and radiation therapy). This is a patient with family history of osteoporosis with fractures. A DEXA (dual x-ray absorptiometry) scan showed lowest T score (bone density measurement) of -4.0 at the left femoral neck. Rheumatology specialist is requesting treatment with Evenity. 

The requested non formulary drug would be more effective than the formulary drugs. This patient has severe osteoporosis (T score -4.0). She would benefit from an anabolic agent like Evenity. As such the medication should be approved with standard duration for a few months. 

"In a phase II trial in postmenopausal women, all doses of a monoclonal anti-sclerostin antibody (romosozumab) increased bone density at the LS (least squares), total hip, and femoral neck. In this one-year trial, 419 postmenopausal women with low bone mass (T-score between -2.0 and -3.5 at the LS, total hip, or femoral neck) were randomly assigned to subcutaneous romosozumab (variable dosing once monthly or once every three months), an active comparator (oral alendronate, 70 mg weekly, or subcutaneous teriparatide, 20 mcg (micrograms) daily), or placebo injections (monthly or every three months). The greatest increase in LS bone density was seen in the group receiving romosozumab 210 mg monthly (11.3 percent compared with 4.1 and 7.1 percent in the alendronate and teriparatide groups, respectively). There was a transient increase in bone formation markers and a more sustained decrease in bone resorption markers, a pattern that has not been seen among available osteoporosis therapies." (Genant, et al., 2016). 

The insurer's denial of coverage for Formulary Exception for Evenity is overturned.