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

Diagnosis: Urinary tract infections. 
Treatment: Cystourethroscopy with fulguration trigone/bladder neck/prostate/urethra/glands and cystourethroscopy W/Bx (with biopsy) (code 51114 and 52204). 
The insurer denied coverage for cystourethroscopy with fulguration trigone/bladder neck/prostate/urethra/glands and cystourethroscopy W/Bx (code 51114 and 52204). 
The denial is upheld. 

This is an adult woman with history of "embedded" Urinary Tract Infections, Hyperlipidemia (HLD), hypothyroid, peripheral vascular disease (PVD), obesity, hyperglycemia. Patient presented to her physician for follow-up of Urinary Tract Infections (UTI's), and she received a referral to an OON (out of network) physician for further treatment and evaluation. The insurer has denied coverage for cystovueteriscopy with fulguration trigone/bladder, neck/prostate by an OON facility as not medically necessary. 

The appeal by the patient is noted and read in detail. The concept of "embedded UTI" is not familiar to most urologists. Bladder infection is cystitis, either acute or chronic. While some Urinary Tract Infections (UTI's) or cystitis can be caused by retained urine, bladder calculi, bladder tumor or bladder diverticulae, it is not the standard of care to fulgurate the lining of the bladder as a treatment for chronic cystitis. Most urologists have never done such. In some cases of interstitial cystitis, which is not caused by a bacterial infection, a urologist may fulgurate a bladder lesion called a Hunner's ulcer - if one is visualized, as this may help the underlying condition, which is a painful bladder syndrome. The American Urological Society also only recommends fulguration "If Hunner lesions are present, then fulguration (with laser or electrocautery) and/or injection of triamcinolone should be performed. Recommendation (Evidence Strength: Grade C)". 

In addition, the CPT (current procedural terminology) code is 52214 for cysto/fulgration of trigore/bladder neck/prostate/urethra or poniveteral glurels. Embedded Urinary Tract Infection (UTI) is not a term familiar to most urologists and code 52214 is not recognized as a standard of care (SOC) treatment for chronic cystitis. 

The procedure codes 52214, 52214 are not considered medically necessary for this patient. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for cystourethroscopy with fulguration trigone/bladder neck/prostate/urethra/glands and cystourethroscopy W/Bx (code 51114 and 52204), is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Asthma
Treatment: Ventolin HFA (albuterol)
The insurer denied coverage for Ventolin HFA (albuterol).
The denial is upheld.

Patient is an adult who was prescribed Ventolin HFA (albuterol) for treatment of asthma by his primary doctor. Ventolin HFA is not on the preferred formulary list of the insurance company. The preferred list includes Albuterol sulfate (generic Pro Air HFA, Proair HFA, Proair Respiclick)  

No medical records were provided for review. As per some notes, it was stated that this patient complained of palpitations when he used the beta (B) 2 (two) agonists in the preferred list and not when he used Ventolin HFA. No other details were provided nor was the medical record provided for review.

Palpitations are a class effect of all Beta agonists if used frequently so unlikely that Ventolin HFA will not produce it if used in the same frequency as the other inhalers. Tachycardia and palpitations are dose dependent.

Also noted in the request for Ventolin HFA formulary exception was that this patient had worsening of cough and was unable to breathe when he used the inhalers on the preferred list of the insurance company. No other medical documents or medical records provided for review.

Based on above Ventolin HFA cannot be approved. It is essentially the same drug as the alternatives listed.

The formulary drugs are not expected to cause adverse effects. 

It is not known if the formulary drugs were tried, or if the patient did/did not have an adverse reaction or contraindication due to the lack of medical records.

The formulary drug is not expected to be ineffective.

The non- formulary drug is not expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Ventolin HFA (albuterol) is upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease (GERD)
Treatment: LINX Reflux Management System (LINX) Procedure
The insurer denied the LINX procedure.
The health plan's determination is overturned.

The patient is a female who has refractory gastroesophageal reflux disease (GERD). The patient is on Proton-pump inhibitors (PPI's) and Pepcid. The esophagogastroduodenoscopy (EGD) showed a hiatal hernia and the manometry was normal. She had a Demeester score of 29.1. Diagnostic testing showed GERD and hiatal hernia.

The proposed health service or treatment of the LINX procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This patient has medically refractory GERD. Her Demeester score is 29.1. The patient has tried medical management and hence the LINX device is medically necessary.
As per the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES):
Conclusions:
Longer-term (3-5 years) experience with the LINX Reflux Management System confirms the initial safety profile that led to Food and Drug Administration (FDA) approval of the device. The LINX device has been demonstrated to result in long-term GERD control based on symptomatic outcomes, proton pump inhibitor utilization, and potential hydrogen (pH) studies.
LINX is a reasonable treatment option for appropriately selected patients with GERD who meet indications for antireflux surgery. The LINX procedure is part of the armamentarium in the treatment of GERD. As such, it should be performed by surgeons familiar with the workup and different management alternatives of GERD and not offered in isolation. Implantation of the LINX device should be covered and reimbursed by insurance for appropriate patients who meet the selection criteria as described above.

The health plan's determination is overturned in whole.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease (GERD)
Treatment: LINX Reflux Management System (LINX) Procedure
The insurer denied the LINX procedure.
The health plan's determination is overturned.

This patient is a female with a history of long-standing gastroesophageal reflux disease (GERD) despite medical management with twice a day (BID) Proton-pump inhibitors (PPI) and H2-receptor antagonists (H2 blockers). The endoscopy revealed a small hiatal hernia. The 24-hour potential hydrogen (pH) study revealed an elevated DeMeester score of 29.1 consistent with reflux. Esophageal biopsy did not reveal any evidence of Barrett's esophagus.

The proposed health service or treatment LINX procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This patient has GERD refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic nissen fundoplication and LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons.
LINX is considered a standard surgical treatment for GERD within the medical community and is recommended in updated published guidelines from the Society of Gastrointestinal and Endoscopic Surgeons to be a safe, effective and durable treatment for GERD for mid to long-term outcomes based on published findings. There are only a few exclusions to the treatment of which the patient has none- she is at least 18 years of age and does not have history of prior gastric or bariatric surgery, Barrett's esophagus with dysphagia, body mass index (BMI) of 35 or greater, or hiatal hernia greater than (>) 3 centimeters (cm).

The health plan's determination is overturned in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Braces and Monthly Visits
The insurer denied: Braces and Monthly Visits
The denial is overturned

The patient is an adolescent male. He is noted to have Class I skeletal malocclusion. He has Class II canines with moderate upper and lower crowding. He has a deep bite. The health plan's prior denial of coverage of the requested braces and monthly visits was due to the patient having a handicapping index score of 20. This denial is being appealed.

The braces and monthly visits are medically necessary.

The patient has multiple anterior teeth in crossbite, with gingival attachment loss. Each one of these is an automatic qualifier for treatment, according to the handicapping index scale. This case has medical necessity, and orthodontic treatment with monthly follow up visits are needed to correct the malocclusion.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Home health care

Diagnosis: Alzheimer's disease
Treatment: Consumer Directed Personal Care Assistance Services: 24 Hours per Day, 7 Days per Week (Split Shift) Monday through Sunday - Total of 168 Hours per Week
The insurer denied Consumer Directed Personal Care Assistance Services: 24 Hours per Day, 7 Days per Week (Split Shift) Monday through Sunday - Total of 168 Hours per Week. The health plan's determination is upheld. 

The is a male patient with past medical history of transient ischemic attack (TIA), Alzheimer's disease with behavioral disturbance, hypertension, schizoaffective disorder, diabetes mellitus type 2, macular due to hyperlipidemia, osteoporosis, osteoarthritis, coronary artery disease, gastroesophageal reflux disease (GERD), diabetic retinopathy, insomnia, and urinary incontinence, and bowel incontinence who had been provided 47 hours/week of Consumer Directed Personal Care Assistance Services (CDPAS).

Consumer Directed Personal Care Assistance Services: 24 Hours per Day, 7 Days per Week (Split Shift) Monday through Sunday - Total of 168 Hours per Week are not medically necessary for this patient.
There is no documentation of overnight care needs such as frequent toileting or the necessity for turning and repositioning every 2 hours. There are no overnight care logs provided documenting overnight care needs. Although the patient has dementia with psychosis and behavioral disturbances, including insomnia, there is no documentation of overnight care needs that would not allow a PCA (personal care assistant) 5 hours of uninterrupted sleep. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services 24 Hours per Day, 7 Days per Week (Split Shift) Monday through Sunday - Total of 168 Hours per Week are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Kidney Stones.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

The member presented with flank pain and was diagnosed with kidney stones. She underwent cystoscopy with a retrograde pyelogram and ureteral stent insertion. She was discharged in 24 hours.

A systematic review and meta-analysis including 23 randomized controlled trials (2458 patients) found that outpatient therapy in addition to medical expulsive therapy (with alpha blocker) to Extracorporeal shock wave lithotripsy (ESWL) in ambulatory settings in patients with renal or ureteral stones improved expulsion rates, reduced time to stone clearance, and reduced pain. Meta-analyses of randomized controlled studies have found that use of an alpha blocker as an outpatient is associated with shorter times to stone passage and lower risks of surgical intervention. 

A multisite prospective study of 2759 adult patients (mean age 41 years) with suspected nephrolithiasis found that most were discharged home from the emergency department, and only 9% required hospitalization.
 
Analysis of a national database that included over 3.6 million visits to the emergency department for renal or ureteral stones found that 12% of patients required inpatient admission.

Inpatient admission was not medically necessary per evidence-based literature and lower level of care is more appropriate.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sepsis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

The patient presented to the emergency department (ED) with fever, a positive pregnancy test and bleeding. The patient was admitted with a diagnosis of complete versus incomplete abortion with superimposed septic abortion. The patient was started on intravenous (IV) antibiotics. An infectious disease consult was obtained which recommended 48 hours of IV antibiotics.

Septic abortion refers to any abortion, spontaneous or induced, that is complicated by uterine infection, including endometritis. Septic abortion can progress rapidly and be lethal. Therefore, any patient who presents with abdominal/pelvic pain, uterine tenderness, and fever in the setting of pregnancy loss, termination, or recent pregnancy should be evaluated quickly. Once recognized, the general approach includes empiric broad-spectrum IV antibiotics, IV fluid support, and surgical evacuation of the uterus if needed.

Duration of antibiotic treatment varies based on the patient's hemodynamic stability, clinical response, and culture results, particularly blood culture information. Minimum criteria for stopping intravenous antibiotics include complete control of the infection's source, and significant patient clinical improvement. Patients may then be switched to oral medication to complete 10 to 14 days of additional treatment.

Based on the above, this patient's admission was medically necessary. Once the patient was afebrile and clinically improved, the patient was discharged home. This is consistent with standard of care.

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

The inpatient admission is considered medically necessary for this patient.

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

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

Diagnosis: Abdominal pain and alcohol abuse
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult male with history of alcohol abuse with frequent admissions for abdominal pain and alcohol abuse, including three weeks prior. The patient presented with three days of abdominal pain and was found to have alcoholic ketosis. He was hypertensive and tachycardic. He was noted to have alcoholic ketoacidosis, and was hydrated, given Zofran, Ativan and thiamine, and monitored for alcohol withdrawal. On Day #2, the patient's pain had improved, there was no vomiting, and his Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score for alcohol withdrawal was 0. He tolerated a diet. He was continued on Zofran, Ativan and thiamine, and remained stable and was discharged on Day #4.

The acute inpatient hospital stay was not medically necessary.

The health plan denied the acute inpatient stay as there was no evidence that the patient has met the Milliman Care Guidelines Abdominal Pain, Undiagnosed. The patient was essentially inebriated on admission. He had no evidence of abnormal vital signs (blood pressure, heart rate, or breathing rate that persisted despite appropriate treatment). The patient did not have severe pain requiring inpatient management; he did not have peritoneal signs, prolonged nothing by mouth (NPO) status or inability to maintain oral hydration persisting after outpatient care. On Day #2, the patient was tolerating oral intake without abdominal pain or vomiting, was feeling better on oral medication and had a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score of 0. He was medically stable for discharge, and acute inpatient hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Confusion
Treatment: Increase in personal care services 24 Hours a day, 7 Days a week-(Split-Shift), for a total of 168 hours 
The insurer denied: Increase in personal care services 24 Hours a day, 7 Days a week-(Split-Shift), for a total of 168 hours 
The denial is: Upheld

This is a case review for a female with medical history notable for frequent falls. The patient was approved 47 hours per week of personal care services. The patient and her care team requested an increase to 24 hours per day (2-12 hour split-shift), 7 days per week (168 hours per week), and this request was partially denied by the insurance company; they did approve an increase to 56 hours per week. This denial is the subject under review.
The patient's daughter provided a letter of support for this appeal. The letter states that the patient has fallen several times while attempting to toilet in the middle of the night. She also tries to leave the house in the nighttime when there is no aide there. She is very forgetful. The patient's daughter states that they cannot provide the overnight care her mother requires.
There are no letters of medical necessity provided as part of this appeal.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented to person only; she was very forgetful with episodes of confusion and not able to care for herself in the event of an emergency. For her Instrumental activities of daily living (IADLs), she requires total dependence for meal preparation, housework, and shopping. She requires extensive assistance for finances, medications, and phone use. For her activities of daily living (ADLs), she requires maximal assistance for bathing. She requires extensive assistance for hygiene, dressing, walking, locomotion, toilet transfer, toilet use, and bed mobility. Multiple falls over the preceding 3 months were noted. Gait is "slow, unstable, requires hands on assistance." She also requires assistance with all transfers. She is frequently incontinent of urine and uses liners. Skin is intact. A task tool associated with the UAS recommended 61 hours to address her personal care needs.

The requested health service of Increase in personal care services 24 Hours a day, 7 Days a week-(Split-Shift), for a total of 168 hours has not been demonstrated to be medically necessary for this patient.
Split shift 24-hour services are approvable when patients have demonstrable personal care needs that can be expected to occur every 2-3 hours around the clock. This patient does not have any evidence of overnight needs such as turning and repositioning or incontinence care overnight. The request stated that the increase in services would be for help with wandering behaviors which would qualify as safety monitoring and supervision; these are not allowable personal care tasks in the absence of another personal care need. Therefore, there is no clearly established medical necessity for split-shift services.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Displaced supracondylar fracture
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This is the case of a patient with no significant past medical history. The patient presented to the Emergency Department (ED) due to a mechanical fall onto the left arm. An x-ray was done and a displaced supracondylar fracture was diagnosed. The patient was admitted for surgery. The patient had a left supracondylar humerus closed reduction and percutaneous pinning (CRPP). Once the patient was stable, the patient was discharged home.

The medical record shows an isolated orthopedic injury managed in a timely and appropriate manner. The infant underwent a CRPP with an operative time of 16 minutes. There was no blood loss. There were no post-surgical complications. The vital signs were stable. There were no changes to neuromuscular status. There was no need for additional imaging nor other subspecialty consultation. These findings do not substantiate necessity of inpatient hospital admission. Observation would be most applicable considering clinical status.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Occlusal wear.
Treatment: Crowns over teeth numbers 21, 22, 23, 24, 25, 26, 27, 29, 30, and 31.

The insurer denied coverage for crowns over teeth numbers 21, 22, 23, 24, 25, 26, 27, 29, 30, and 31.  The denial is upheld.
 
Upon review of the documentation provided, which includes copies of one undated full mouth series radiographs, multiple pretreatment intraoral clinical photographs, narrative letter from the dentist, and insurer correspondence, it appears that this patient presented for comprehensive dental care. The treating dentist recommended full coverage crowns for teeth #21- 31 with the exception of #28, due to occlusal wear, and preexisting large direct placement restorations #30 and #31. The insurer has denied these services, stating that there is no clinical/radiographic evidence, such as 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. 

The objective documentation provided for review are copies of full mouth series radiographs and clinical photographs. There are no other dental treatment records provided for review. It appears that there is some occlusal wear but no other pathology specifically affecting these teeth based on the images provided for review. There does not appear to be any radiographic evidence of caries. The radiographs and clinical photos do not substantiate the requested dental services, and therefore they are deemed not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for crowns over teeth numbers 21, 22, 23, 24, 25, 26, 27, 29, 30, and 31 is not substantiated.