Persius/hicric huggingface dataset:
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Jaw Fracture

Treatment: hospital admission

The insurer denied coverage for hospital admission.

The denial is modified.

This patient suffered a jaw fracture that required treatment. The patient was in a motor vehicle accident (MVA), and suffered a left mandibular angle fracture, which was determined that the patient would need an open reduction internal fixation (ORIF) performed. The patient left against medical advice and was given a prescription for antibiotic, which he did not fill, and then returned four days later, and was admitted for ORIF. The patient was then scheduled to be treated in the hospital setting and undergo general anesthesia with nasal intubation for open reduction and internal fixation. This is an appeal for inpatient overnight hospitalization. The patient also had tooth 17 removed along with a cyst. The patient was discharged.

"With the exception of the nose, mandibular fractures occur twice as frequently as fracture of other facial bones. The importance of the mandible is not only cosmetic; it also functions in biting, chewing, and speaking."1

"The purpose of the treatment of mandibular fractures is to restore proper dental occlusion and stable temporomandibular joint (TMJ) movement as well as the reduction of the displaced fracture."2

"The ability to treat fracture with open reduction (OR) and internal fixation (IF) has dramatically revolutionized the approach to mandible fracture.3 Traditionally, OR/IF has required a period of postoperative mandibular immobilization by rigid maxillomandibular fixation (MMF) for up to 6 weeks for satisfactory healing. Difficulties associated with this period of immobilization include airway problems, poor nutrition, weight loss, poor mouth hygiene, phonation difficulties, insomnia, social inconvenience, patient discomfort, work loss, and difficult in recovering normal-range jaw function. Rigid fixation of mandible fractures allows early mobilization and restoration of jaw function and airway control; improves nutritional status, speech, oral hygiene, and patient comfort; and allows early return to the workplace.4 5" (El-Anwar et al 2015).

The patient required an extensive surgery to include open reduction and internal fixation of a left angle fracture as well as removal of tooth 17 with cyst removal. The patient was nasally intubated under general anesthesia. The surgeon recommended the patient be kept overnight to make sure there were no airway issues as well as pain control, nutritional status and hemostasis were under control.      

Based on the clinical information provided the patient should have been allowed an overnight stay for the day of surgery for one day. This allowed the patient to be followed for airway patency, swelling, fluid status, pain control, nausea and vomiting, and hemostasis. The first two days of admission the records do not support why the patient was in the hospital, or why the surgery was not performed on a given date.

Based on the above, the medical necessity for the hospital admission is partially substantiated. The insurer's denial is modified.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cyclical Vomiting. 
Treatment: Hospital inpatient admission. 

The insurer denied coverage for hospital inpatient admission. 

The denial is upheld. 

The patient had a history of gastritis and presented with 2 days of nausea and vomiting. She was afebrile and the vital signs were stable. Her abdominal exam was benign. There was no leukocytosis. She was diagnosed with cyclical vomiting and given IV (intravenous) hydration, Pepcid, and Zofran. The renal function was normal. An endoscopy was advised but the patient refused it. She was treated by psychiatry for anxiety. After receiving treatment, she was able to tolerate a diet. 

Milliman Care guidelines (MCG) clinical indication for admission for vomiting (M-370) include gastrointestinal obstruction a significant metabolic derangement, hemodynamic inability, severe electrolyte abnormalities, severe pain, acute renal function, and inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had cyclical vomiting possibly related to gastritis. However, IV hydration with potassium replacement Pepcid and Zofran could have been given with observation status. She responded to the treatment and was then able to tolerate a diet. She did not meet MCG criteria for admission for vomiting. An inpatient admission was not medically necessary. 

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

Based on the above, the medical necessity for the hospital inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope. 
Treatment: Hospital admission. 

The insurer denied coverage for hospital admission. 

The denial is upheld. 

This patient has a past medical history of hypertension and diabetes mellitus and presented to the hospital following an episode of syncope.  She was feeling lightheaded all morning and while eating breakfast felt worse and lost consciousness. She was caught by her daughter and did not sustain any trauma.  Upon arrival to the emergency department (ED) vital signs were stable (Blood Pressure 188/84, and Pulse 70 beats per minute (bpm)). No abnormal findings were noted on physical examination.  Electrocardiogram (ECG) revealed normal sinus rhythm with left ventricular hypertrophy and non-specific T (intervals on ECG) wave abnormalities.  The patient was admitted to the hospital for observation and treatment. Echocardiogram revealed a preserved left ventricular ejection fraction (LVEF). Serum blood testing revealed normal renal function and a mild elevation in troponin (0.024 ng/ml [nanogram per milliliter). Toxicology screen was negative for drugs of abuse.  The patient was treated with her home medications for hypertension (nifedipine and hydralazine) with good response. The patient signed out against medical advice the following day. 

According to the European Society of Cardiology, this patient was a low risk patient for future morbidity and mortality. (Reference 1) In a study of individuals presenting to the emergency room, patients that were low risk or intermediate risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing. (Reference 2).  In this case, the patient  falls into a low risk category and could be managed a lower level of care. In conclusion admission to the hospital was not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for the hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right Foot Cellulitis/Aiibscess

Treatment hospital admission

The insurer denied coverage for hospital admission

The denial is overturned

The patient is an adult female with past medical history significant for pituitary microadenoma and obesity who presented to the Emergency Department with complaints of fever and pain her right foot.  Vitals on presentation included: Temperature 101.2 Fahrenheit, Blood Pressure 115/67, Pulse 127, Respiratory Rate 20, Oxygen (O2) saturations 98% (percent) on Room Air. Laboratory results included the following: White blood cell (WBC)22.2, Hemoglobin (HGB)-10.7, Hematocrit (HCT)-35.3, creatinine-0.67, glucose-105.

The patient was admitted to the hospital for a right foot cellulitis/abscess. She was empirically started on antibiotics (vancomycin). X-ray of the foot was negative for fracture, trauma, or bony erosions. All cultures were negative. The patient remained afebrile and hemodynamically stable. She was discharged on oral antibiotics to continue outpatient management.

According to documentation, the patient presented with a right foot abscess. She had fever (101.2 F), tachycardia (HR-127), and laboratory results were notable for an elevated WBC (22.2). Based on above findings, the patient met criteria for acute inpatient care for administration of intravenous antibiotics and wound care.  

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

The insurer's denial of coverage for the hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia Universalis

Treatment Xeljanz

The insurer denied coverage for Xeljanz

The denial is upheld.

The patient is an adult male with a diagnosis of alopecia universalis. According to the appeal letter, the patient has failed therapy with topical, intralesional and oral steroids. No documentation is provided to demonstrate which actual steroid or non-steroid medications the patient has previously tried, at what dosage, or the results of these treatments. Similarly, no medical documentation is provided regarding the length of time the patient has been treated with these medications. The provider is requesting Xeljanz.

The patient has not failed or been shown to have a contraindication to numerous non-systemic therapies known to possibly improve alopecia universalis, including light therapy, squaric acid, diphencyprone (DPCP), calcipotriene, and anthralin. Although case reports have demonstrated possible efficacy of Xeljanz for alopecia areata and related conditions, further studies are needed to demonstrate the long-term efficacy and safety of Xeljanz. It is noted that the Food and Drug Administration (FDA) released a statement finding increased risk of deep vein thrombosis and pulmonary embolism in patients enrolled in a phase 4 clinical trial of Xeljanz at a dosage of 10 milligrams (mg) twice a day (BID). (1) 

The standard of care for treatment of alopecia universalis would necessitate an attempt to use the above-mentioned options for the treatment of alopecia universalis. The patient has not failed or been shown to have a contraindication to numerous therapies known to possibly improve his condition. 

Based on the documentation submitted, Xeljanz was not considered medically necessary treatment for the patient's condition.

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

The insurer's denial of coverage for Xeljanz is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pressure. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male. He presented with chest pressure x 2. He had history of hypertension and CAD (coronary artery disease). He has previous MI (myocardial infarction) and PCI (percutaneous coronary intervention). 

In hospital, the patient was admitted to telemetry, where he received optimal medications and a monitor patch. He was discharged with diagnosis of unspecified chest pain. 

No, the Inpatient admission was not medically necessary. 

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. 

In this case, the patient's symptoms were atypical and unlikely to be representative of acute coronary syndrome. The patient's exam and cardiac findings were normal (BP [blood pressure] normalized). Biomarkers and EKG (electrocardiogram) showed no evidence of acute ischemia ("abnormal EKG [electrocardiogram]" was unchanged from previous). CXR (chest x-ray) was normal. The physicians' treatment did not reflect any serious concerns that the presenting cardiac condition represented an acute event.  Orders did not include medical therapy for ACS (acute coronary syndrome) such as IV (intravenous) heparin, high dose beta blockers or IV (intravenous) NTG (nitroglycerin).  Discharge diagnosis was chest pain, unspecified. 

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. 

There was no "complex" care that required inpatient level of care in this patient's case. The statement that this patient could not be managed safely in a lower level of care is not supported by this clinical presentation or treatment. 

This patient had no evidence of active CAD (coronary artery disease). In fact, all tests showed absence of ischemia.  While there was always a potential for an adverse event, one did not happen, and no actual treatment was added. 

Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS (acute coronary syndrome) present. 

All testing and therapy that were provided would have been appropriate, safe and guidelines-consistent in a lower level of care. Thus, inpatient level of care was not medically necessary. 

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite. 
Treatment: D8080 Braces, Pre-service. 

The insurer denied the D8080 Braces. 
The denial is overturned. 

The patient is a female.  The request is for dental benefits for orthodontic treatment (braces).  The patient presents with a class I molar relationship, severe upper and lower arch crowding, anterior crossbite with gingival attachment loss, impacted upper left UL5 (upper left 2nd premolar), and posterior crossbite on left. 

Orthodontic records have been made - x-rays, photos; completed clinical consultation. 

The health plan denied the claim because the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) index needed to approve orthodontic treatment.  The provider appealed based on the multiple diagnoses, particularly the anterior crossbite with gingival attachment loss as this is an automatic qualifier for orthodontic treatment per the Handicapping Labio-Lingual Deviation (HLD) index. 

Yes, the proposed treatment of orthodontic therapy (braces) is medically necessary. 
The patient presents with several dental malalignment conditions; severe crowding in both the upper and lower arches, an impacted upper left second premolar, anterior crossbite with gingival attachment loss lower left canine. These conditions are all supported in the x-rays and photos submitted. 

This malalignment has the ability to affect the quality of the patient's speech, chewing and ability to maintain proper hygiene. The potential complications can give rise to inflammation of the gums and  eventually gum disease. 

Given the severity of these conditions, the lack of orthodontic intervention will leave the patient at risk for further shifting of the teeth and deterioration of the patient's overall dentition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Lower Back Pain

Treatment: the total disc arthroplasty described by code 22857 at lumbar bone five to sacral bone one (L [lumbar] 5-S [sacral] 1) and one inpatient bed day

The insurer denied coverage for the total disc arthroplasty described by code 22857 at lumbar bone five to sacral bone one (L5-S1) and one inpatient bed day

The denial is overturned

This is the case of an adult male patient with a past medical history of chronic lower back pain. The patient had a visit with an orthopedic spine surgeon.  According to the visit notes, the patient presented with a history of low back pain, which had increased in the months prior to the office visit. The impression was lumbar disc generation L5-S1; and low back pain with radiation to bilateral gluteal. 

The patient has isolated disease without known contraindication to the procedure. The management of localized degenerative disc disease is either a fusion or arthroplasty. The choice is dependent upon patient and physician factors. In this clinical case, the surgeon is a recognized expert in the field of total disc arthroplasty. His results are known (ie. author of one of the references). His experience and application of the technique would be the best for this patient.

The scientific literature reports improvement in health outcome. There are several references which support its use. There are long term outcomes on many patients with noted improvement. There are Policy recommendations by National Organizations who recognized the lumbar disc replacement as effective and an accepted type of treatment for lumbar disc disease. 

Approval had been granted several years ago. 

If one is taking into consideration comparison to anterior lumbar fusion (ALIF), the approach is the same. Complications of hardware require extensive revision to both types of procedures. It is difficult to remove a failed artificial disc replacement (ADR) but likewise difficult to remove a failed cage. 

The requested service is likely to be more beneficial than a fusion (ie based upon patient selection and level of experience/expertise of treating physician).

The carrier's denial of the total disc arthroplasty described by code 22857 at lumbar bone five to sacral bone one (L5-S1) and one inpatient bed day should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD)

Treatment: Spiriva Respimat 1.25 micrograms (mcg)

The insurer denied coverage for Spiriva Respimat 1.25 micrograms (mcg).

The denial is overturned.

The patient has a history of chronic obstructive pulmonary disease (COPD) (Chronic Bronchitis). The patient's past medical history (PMH) is significant for 45 years of smoking half a pack of cigarettes per day. The patient had pulmonary function tests (PFT) forced volume capacity (FVC) 3.20/79% (percent), forced expiratory volume (FEV1) 2.32/73%, ratio 72%, significant bronchodilation responsiveness (BDR) noted.

The patient carries a diagnosis of COPD, predominantly chronic bronchitis. 

The patient's maintenance medications consist of a long-acting muscarinic antagonist (LAMA) and short-acting beta two agonist (B2) [bronchodilator] PRN (as needed).

This patient appears to be stable on this regimen. There are no alternative formulations of a LAMA in the formulary. The medications mentioned are combinations of long-acting beta2-agonists and inhaled corticosteroids (LABA/ICS) or LABA/ICS/LAMA.

This patient is only on LAMA and occasional as needed bronchodilator for rescue. Since there is no substitute for only a LAMA Spiriva Respimat is medically necessary. The health plan did not act reasonably with sound medical judgment.

The insurer's denial of coverage for Spiriva Respimat 1.25 micrograms (mcg) for the treatment of asthma and chronic obstructive pulmonary disease (COPD) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Wheezing
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient is a female with a history including hydradenitis and moderate persistent asthma with prior admissions. She presented with wheezing, shortness of breath and chest pain. She occasionally takes Advair. She was admitted but left AMA (against medical advice). She also complains of painful right lower extremity abscess and swelling of lymph nodes in pubic area.

The patient's vital signs were as follows: Temperature 98.1, pulse 107, respiration rate 18, blood pressure 124/75, and pulse oximetry 100%. Her exam was remarkable for diffuse wheezing; swelling and tenderness over medial malleolus of right leg with redness and fluctuant; and chronic rash. The patient's labs revealed the following: WBC (white blood count) 16.5, H/H (hemoglobin/hematocrit) 12.8/40.4, Plt (platelets) 312, Na (sodium) 141, K (potassium) 3.4, BUN/Cr (blood urea nitrogen/creatinine) 12/.85. Her chest x-ray revealed NAD (no active disease).

The patient was admitted. Plan of care included albuterol every 3 hours, oral steroids, Advair, and antibiotics for abscess and presumptive PID (pelvic inflammatory disease). Treatment was continued through hospital stay with plan for discharge after 48 hours of IV (intravenous) antibiotics for PID (pelvic inflammatory disease). The patient left AMA (against medical advice).

No, the Inpatient admission was not medically necessary.
This patient with multiple medical conditions and a history of hospitalizations with leaving AMA (against medical advice) was admitted after presenting with a complaint of worsening asthma and swelling of pelvic lymph nodes. The patient was hemodynamically stable and afebrile. She had normal oxygenation. She did not have altered mental status. She did not require supplemental oxygen or ventilatory support. She was admitted for treatment of asthma as well as PID (pelvic inflammatory disease). She remained clinically stable during hospital stay and signed out AMA (against medical advice). The patient did not have respiratory distress. She did not have systemic infection and she had not failed treatment at a lesser level of care. The inpatient admission from was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: acute motor axonal neuropathy (AMAN)
Treatment: Home Health Care, Skilled Nursing Infusion Visits 20
The insurer denied Home Health Care, Skilled Nursing Infusion Visits 20
The denial is upheld.

No, the requested Home Health Care, Skilled Nursing Infusion Visits 20 are not medically necessary.
There is no documented reason as to why the patient cannot receive these treatments at an outpatient infusion center. There is no compelling reason to support that infusions need to be done in the home. Pre-treatment medications do not preclude infusion in the outpatient setting. Alleged immunocompromised stated does not preclude infusion at an outpatient level of care. It is standard of care to provide this service at an outpatient infusion center.

There is no documented reason as to why the patient cannot be treated at an outpatient level of care.