Persius/hicric huggingface dataset:
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 a young adult female. The request is for orthodontic benefits. She has a Class III skeletal malocclusion, mild upper and lower crowding and several anterior crossbites. The health plan's prior denial of coverage was due to handicapping index score of 12. The prior denial is being appealed by the health plan.

The requested braces and monthly visits are medically necessary.

The patient has crossbites (reverse bites) of both her lower permanent canines (teeth numbers 22 and 27). When there is/are crossbites of permanent anterior teeth with gingival attachment (gum) loss, this is an "automatic qualifying" event. This patient has two of these events. Orthodontic treatment is medically necessary to correct these problems.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of bipolar disorder, hypertension (HTN), and generalized anxiety disorder (GAD) and was admitted with complaints of (c/o) shortness of breath (SOB) on inspiration. His vital signs were notable for tachycardia of 105 beats per minute. The physical exam was notable for mild distress. Lab work was unremarkable. Imaging studies included a computed tomography (CT) scan of the chest which showed a filling defect in the right lower lobe (RLL) consistent with (c/w) a pulmonary embolism (PE), transthoracic echocardiogram (TTE) without evidence of right heart strain. The patient was diagnosed with a pulmonary embolism and treated with anticoagulation and telemetry. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

No, the hospital stay was not medically necessary at an acute inpatient level of care.
This patient presented to the emergency department (ED) with c/o SOB on inspiration and was found to have a pulmonary embolism. The patient had no history of cancer, heart failure, or chronic lung disease, there was no hypotension, sustained/severe tachycardia, tachypnea, fever, altered mental status (AMS) or hypoxia. The pulmonary embolism severity index (PESI) score was consistent with class 1, which is very low risk, with a 0-1.6 percent (%) 30-day mortality. The simplified pulmonary severity index (sPESI) was also indicative of low-risk. In addition, there was no respiratory distress, hemodynamic instability, recent bleeding, or serious comorbid conditions. Patients with a PESI score less than 65 are very low risk for 30-day mortality (0%), and those with a score less than 85 are low risk for 30-day mortality (1%); patients in these categories can be considered for outpatient management. This patient was monitored and received anticoagulation, which could have been provided safely at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Charge Syndrome
Treatment: Durable Medical Equipment (oxygen equipment E1399 x 5)
The insurer denied coverage for Durable Medical Equipment (oxygen equipment E1399 x 5)
The denial is overturned

This is a pediatric patient with a history of Charge Syndrome, dependent on a 3.5-millimeter (mm) tracheostomy, due to laryngomalacia. The patient is known to have one copy of the CHD7 (Chromodomain Helicase DNA (deoxyribonucleic acid) Binding Protein 7) gene which is consistent with autosomal dominant Charge Syndrome. The patient has not required a ventilator or CPAP (Continuous positive airway pressure) in the home. The patient was found to have mild tracheomalacia, increased secretions and is gastrostomy tube dependent. The patient has not had any visits to the Emergency Room (ER), inpatient hospitalizations or respiratory infections since being discharged from the Neonatal Intensive Care Unit (NICU). The patient continues to have the original size 3.5 mm tracheostomy tube which was placed in the NICU. The patient continues to use a humid vent (humidifier) during the day and is on an oxygen concentrator at 0.5 liters at night. The patient has a home nurse during the night and there have been no nocturnal desaturations reported. The patient is on glycopyrrolate three times per day and a ipratropium/albuterol inhalation solution which is administered by the patient's mother as needed (PRN).

The patient's pulmonologist has recommended that the patient be provided the Airvo heated humidification system for home use to prevent complications. It is appropriate and consistent with the standard of care to provide humidification for children who require nocturnal oxygen and a tracheostomy tube.

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient. The insurer's denial of coverage for the Durable Medical Equipment (oxygen equipment E1399 x 5) is overturned. Medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Neck pain
Treatment: ZTLido patches
The insurer denied ZTLido patches.
The health plan's determination is overturned.

The patient is a male with a history of chronic neck pain. He has been treated with cervical medial branch blocks, ablation, trigger point injections, ibuprofen, ice, transcutaneous electrical nerve stimulation (TENS) unit, anti-inflammatories, chiropractic care and massage. He was recently seen for persisting pain. On exam, there was weakness in the upper extremities with the exception of hand grip strength. There was decreased sensation in the C (cervical) 6 distribution and equal reflexes.

A request was made for ZTLido patches. A formulary exception is indicated in this case.

A recent letter from the patient states that he has tried the plan's formulary medication of Lidoderm patches. They are ineffective, will not adhere to his skin and when he uses tape to position the patch it has caused him skin rashes.

The records provided clearly outline the failure of relief from the Lidoderm patches. The ZTlido Patch has been approved by health authorities for the treatment of post-herpetic neuralgia in a number of countries, and studies present some degree of evidence of its efficacy and safety in postsurgical pain, diabetic peripheral neuropathy, carpal tunnel syndrome, chronic neck/lower back pain and osteoarthritis. Topical lidocaine may be a great alternative alone or in addition to systemic drugs and non-pharmacological approaches for an optimized pain management and in multimodal analgesia. Topically applied agents with analgesic properties can target peripheral nociceptive pathways while minimizing absorption into the plasma that leads to potential systemic adverse effects. Clinical trials have found 5% lidocaine patches to be effective and well tolerated with a minimal risk of toxicity or drug-drug interactions. With this patch formulation, the penetration of lidocaine into the skin produces an analgesic effect without producing a complete sensory block.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Surgical procedure on the stomach
The insurer denied a surgical procedure on the stomach.
The health plan's determination is overturned.

The patient is a man who is seeking surgical treatment for the condition of morbid obesity. The patient has a current body mass index (BMI) of 59 kg/m2 (kilograms/meter squared) with weight related comorbid health condition of diabetes.

The requested surgical procedure on the stomach is medically necessary for this patient.

In this case, the proposed procedure is a medically necessary treatment for the documented condition of medically complicated super morbid obesity with a BMI of 59 and is supported by the most recent guidelines published by the American Society for Metabolic and Bariatric Surgery.

This patient has the diagnosis of super morbid obesity with a BMI in excess of 50 and comorbid health condition of diabetes. He has successfully completed a comprehensive multidisciplinary bariatric evaluation with medical, mental health, nutritional, and surgical evaluations. There is no medical or mental health contraindication to the proposed procedure for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep vein thrombosis
Treatment: Full hospital admission
The insurer denied coverage for the full hospital admission.
The denial is upheld.

The patient has a history of deep vein thrombosis (DVT), admitted to the Emergency Department (ED) for numbness and tingling in left lower extremity. She had been immobilized for three weeks for an orthopedic issue. She had an epidural for pain the previous week. 

While heparin is an option, the patient could have been started on oral anticoagulation, which does not require an admission. Her DVT was not complicated or of high risk. Xarelto (varoxaban, a factor Xa inhibitor) is the first oral anti-coagulant approved for anti-coagulation in 60 years, since Warfarin (coumadin) was approved. A variety of parenteral options are available; however, the oral route is preferred by many physicians and patients. In 2012, the United States Food and Drug Administration (FDA) expanded the approved use of Xarelto (rivaroxaban) to include treating DVT or pulmonary embolism (PE), and to reduce the risk of recurrent DVT and PE following initial treatment. Previously Xarelto was only approved for reduction of risk of stroke and systemic embolism in Nonvalvular Atrial Fibrillation.      

Full admission was not medically necessary. An oral anticoagulant, such as Xarelto, which was, in fact, used on discharge, would have obviated the need to an admit, had it been administered initially.

XARELTO is a factor Xa inhibitor indicated:

- to reduce the risk of stroke and systemic embolism in patients with
nonvalvular atrial fibrillation (1.1)
- for the treatment of DVT, PE, and for the reduction in the risk of recurrence of DVT and of PE
(1.2, 1.3, 1.4)
- for the prophylaxis of DVT, which may lead to PE in patients
undergoing knee or hip replacement surgery". (Xarelto Package Insert)

"DVT is the formation or presence of a thrombus in the deep veins. DVT occurs mostly in the lower extremities and to a lesser extent in the upper extremities. PE is an obstruction of the pulmonary artery or its branches by a thrombus (sometimes due to fat or air). The most likely source of thrombus in pulmonary arteries is an embolization from deep veins of the legs. This occurs in one-third of patients with DVT. Prevention of DVT thereby decreases the incidence of PE, a serious and life-threatening condition.

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation and atrial flutter

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission 

The denial is upheld

This is the case of an adult woman that presented to the hospital for elective redo catheter ablation of atrial fibrillation and atrial flutter. Past medical history was significant for hypertension and obesity. The patient underwent uncomplicated left atrial catheter ablation and was discharged the following day. 

This patient presented to the hospital for an elective electrophysiologic (EP) study and ablation. According to hospital records, the ablation was successfully performed without complication. Observation following ablation was unremarkable and no post-operative issues were noted. The patient was discharged home the following day. In this case, there were no clinical reasons for hospital admission and the patient could safely be managed at a lower level of care. In two multicenter registry studies looking at healthcare utilization after EP study catheter ablation, more than 80% of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity. (Reference 1) Bartoletti demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day. (Reference 2) In a report involving over 6000 patients, same day discharge following catheter ablation of atrial fibrillation was found to be safe and comparable to outcomes in patients that were observed overnight. (Reference 3) In conclusion, acute inpatient admission was not medically necessary in this case.  

The health plan did act reasonably and with sound medical judgment and 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: Medical necessity
Decision: Overturned

Diagnosis:  Class III skeletal malocclusion, crowding, crossbite.
Treatment:  Braces and Monthly Visit.

The insurer denied: Braces and Monthly Visit.  The denial is overturned.

The patient is an adolescent male. The request is for orthodontic treatment (benefits) and monthly follow up visits. The patient has a Class III skeletal malocclusion with moderate upper crowding and severe lower crowding. He has an anterior crossbite of a permanent tooth with gingival recession. The prior denial by the health plan was due to a handicapping score being nine.

The proposed braces and monthly visit are medically necessary.

The patient has a permanent lower anterior tooth in crossbite (reverse bite). There also is gingival recession with attachment (gum) loss. With his malocclusion causing his anterior teeth to be edge to edge, this will put excessive pressure on this tooth in crossbite and will cause the gum problem to get worse. Orthodontic treatment is needed to correct the malocclusion, and the follow up visits are needed to make sure progress goes properly. Having an anterior tooth in crossbite with attachment loss is also an "automatic qualifier" for benefits.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hip infection.
Treatment:  Inpatient stay.
 
The insurer denied the inpatient stay.  The health plan's determination is overturned. 

This is a male patient admitted for a right hip prosthetic joint infection.
Per the admission history and physical, the patient has a past medical history of diabetes mellitus, gastroparesis, obesity, and osteoarthritis status post right total hip replacement. The current hemoglobin A1c is 6.1. The provider reports the patient is being urgently admitted giving concern for right hip prosthetic joint infection. 

The inpatient admission was medically necessary for this patient.

The provided documentation indicates the patient was urgently admitted for revision hip arthroplasty for the treatment of a prosthetic joint infection. Prior to admission, he had increased hip pain and swelling, fever, and abnormal labs consistent with prosthetic joint infection. The pathology report for the operative tissue samples confirmed evidence of an ongoing hip joint infection. The patient required infectious disease consultation, intravenous antibiotics, and peripherally inserted central catheter (PICC) line placement. As noted in the referenced article from StatPearls, management of prosthetic joint infections necessitates a multidisciplinary team approach, and treatment often includes a combination of medical treatment and surgery.

As noted in the reference article from the Journal of Arthroplasty, the vast majority of revision total hip arthroplasty patients need inpatient criteria and concerns exist for the safety of early discharge and access to care for these complex patients. A search of the medical literature does not yield results supporting the management of prosthetic joint infections under observation level of care or outpatient level of care. Given the complex nature of study joint infections, inpatient treatment is the standard of care.  

Therefore, the requested inpatient hospital admission was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension	
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission
The denial is upheld
 
This patient is an adult that presented to the hospital complaining of shortness of breath and weakness. Past medical history was significant for hypertension and chronic kidney disease. Upon arrival the patient was noted to be hypertensive with a blood pressure (BP) of 187/113. His pulse was 77. No abnormal findings were noted on physical examination. A 12-lead electrocardiogram demonstrated normal sinus rhythm without ischemic abnormalities. Serum blood testing revealed acute renal insufficiency with a creatinine of 4.7 and a Blood urea nitrogen (BUN) of 41. The patient was treated with oral amlodipine and hydralazine and plans were made for admission to the hospital. The patient ultimately signed out against medical advice from the emergency department. 

A hypertensive emergency is defined as BP > (greater than) 180/120 with target organ damage. This patient had a history of chronic kidney disease and the serum creatinine was slightly elevated above baseline. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing the consequence of rapid BP correction. No intravenous agents were initiated, and the patient was managed with oral medications. The patient signed out against medical advice prior to hospital admission. The BP was noted to respond to oral medication while in the emergency department (ED). 

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 hospital services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intestinal obstruction and abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient presented with abdominal pain and vomiting. The patient was afebrile, and the vital signs were stable. The patient felt better after drinking the oral contrast for the Computed Tomography (CT) scan. The patient initially had mild abdominal distention which then improved by the time of admission. There was no abdominal rebound or guarding. There was no leukocytosis. A CT scan showed distention of small intestinal loops. The patient was treated with nasogastric suction. On the second hospital day the patient had a bowel movement. A repeat CT scan done which showed no intestinal obstruction and decreased bowel dilatation. 

Clinical indications for admission per Milliman Care Guidelines (MCG) Intestinal Obstruction (MCG M-210) include having signs and symptoms of bowel obstruction that are severe or persistent. Severe indications include feculent vomiting, hypotension, severe electrolyte abnormalities, bowel ischemia, and bowel perforation. This patient did not have severe symptoms and improved rapidly with nasogastric suction. 

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after treatment with observation care, bacteremia, and the need for a procedure that cannot be done on an ambulatory basis. The patient did not have these conditions. 

This patient had abdominal pain and a dilated small intestine on the initial CT scan. The patient was treated with intravenous (IV) fluids, nasogastric suction, and the patient rapidly improved. The follow up CT scan did not show evidence of intestinal obstruction. The patient could have been treated with observation status. The patient did not meet MCG criteria for admission for either Intestinal Obstruction or Undiagnosed Abdominal Pain. An inpatient hospitalization was 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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental decay

Treatment: root canal, post & core and crown for tooth #11

The insurer denied coverage for root canal, post & core and crown for tooth #11

The denial is overturned.

 
This patient has treatment planned for a root canal and post core and crown on number 11. The Panorex shows a few other deeply decayed teeth including 14 and 30. Tooth 11 has deep dental decay. The requested service has been denied on Tooth 11 due to normal bone levels and the surrounding teeth intact.

Tooth #11 is in need of restoration. There is dental decay on this tooth. The treatment plan recommended for a root canal and post core and crown is an appropriate and standard of care treatment plan. This tooth is easily restorable and has normal bone levels and intact surrounding dentition. The tooth #11 has dental decay and a root canal post core and crown will restore this tooth fully. This tooth has the longest root in the mouth and is a necessary tooth for function and a balanced occlusion. The recommended treatment, root canal, post & core and crown for tooth #11 follows the standard of care and is medically necessary for this patient at this time.

"Management of carious lesions depends on the extent, severity, and stage of dental caries. If the lesion is in the initial stage and remineralization is possible, preventive treatment should be considered, such as the application of fluoride gel, varnishes, pit, and fissure sealant. If caries have a marked involvement of hard tissues but is asymptomatic with no pulpal involvement, caries excavation and restoration of the involved tooth surfaces is an option with the different restorative materials based on location in the dental arch. For example, if the carious lesion is in the esthetic segment, tooth-colored restoration should be done. If it is in the posterior portion where it has to bear the heavy masticatory load, restoration can use silver amalgam. If the lesion is active and has involved both enamel and dentin with a close approximation to pulpal tissue, indirect pulp capping is optimal. If the lesion is progressive and has involved the enamel, dentin, and pulpal tissue, root canal treatment merits consideration, followed by extra-coronal restoration" (Rathee, M., & Sapra, A., 2021).

"At the earlier stage of decay, a tooth may be treated with restorations, which are typically made of dental amalgam, resin (composite), glass ionomer, porcelain, or gold. When the bacteria have invaded the pulp, a dental restoration will not treat the pain and infection. Root canal therapy is needed to remove the infected tissues in the pulp chamber and root canals." (Heng C., 2016).                                                         

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 root canal, post & core and crown for tooth #11 services is substantiated.