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

The patient presented to the emergency room (ER) from an orthopedic clinic following an outpatient diagnosis of deep vein thrombosis (DVT) with concern for pulmonary embolism (PE). Past history includes hypertension and anxiety, but no prior clotting disorder. The patient underwent a quadriceps surgery in the affected leg about 5 weeks prior, and took aspirin for DVT prevention for 4 weeks. Records from the ortho office appointment were not provided, but it appears the patient had DVT symptoms and had a Doppler performed which was positive with extensive clot burden. Additionally, the patient was having sharp chest pain, and thus was sent to the Emergency Dept. Vital signs and physical examination were unremarkable, but due to elevated Wells score. A computed tomography angiography (CTA) of the chest was performed and disclosed evidence of a pulmonary embolism. The laboratory findings were benign, and he was admitted to the hospital for further care, in particular an echocardiogram, as well as initiating anticoagulation. Pulmonology was consulted and recommended the above.
The echocardiogram was without any evidence of right heart strain. 

The health plan's determination is overturned. The inpatient admission was medically necessary. In this case the providers felt that an admission was indicated and an echocardiogram was necessary to rule out right heart strain, as there was significant risk of decompensation, which is even more likely with high clot burden such as this patient had. This decision is still within the current standard of care and criteria for medical necessity of an inpatient level of care due to the patient's potential for decompensation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient presented with new onset, multiple episodes of chest pain, suggestive of unstable angina. The patient had multiple risk factors for CAD, including poorly controlled diabetes. She had outpatient work-up including a coronary CTA, which was consistent with severe CAD in LAD and D1 distribution. There was a high index of suspicion for an ACS (acute coronary syndrome), and a cardiac catheterization was performed. Given the presentation, uncontrolled diabetes, as well as clinical suspicion for an acute coronary syndrome/unstable angina, she was not an appropriate candidate for an ED chest pain observation unit. It would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

The patient is a female presenting with a skeletal Class I malocclusion and mild crowding. She has a significant anterior open bite. She is treatment planned for 18-24 months of orthodontics with extraction of teeth 5, 12, 21, and 28 to address the crowding and open bite, but the treatment was denied due to lack of medical necessity.
The subject under review is the medical necessity for the proposed orthodontic treatment.

The health plan's determination is overturned.

Braces, (comprehensive orthodontic treatment) is medically necessary for this patient.Anterior open bite patients are among the most difficult patients to treat. One side effect of an anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients 
 without an open bite. Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite. This patient is treatment planned for extractions, which is less invasive than orthognathic surgery.
Studies have shown that patients with severe malocclusions, including anterior open bite, have significantly lower masticatory and gastrointestinal digestive function than persons with normal occlusion. However, it has also been shown that after orthodontic treatment, there was no difference in masticatory function and gastric emptying between the treated group and the control group with normal occlusion. Given the patients malocclusion and the likelihood of significantly reduced masticatory function and digestive function, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: Braces
The braces are medically necessary. 

The patient has a crossbite between teeth #'s 6 and 27. This crossbite of an anterior tooth with attachment loss is an "automatic qualifier" on the Handicapping Index report. The canines need to be placed in their proper positions so there is no grinding and/or fracturing of the malposed teeth. Also, proper alignment of these teeth will help prevent temporomandibular joint (TMJ) problems over time. This case definitely needs orthodontic treatment, which is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented with a skeletal Class II malocclusion and significant crowding. She has an anterior open bite. She is treatment planned for 24-30 months of orthodontics with extraction of teeth 5, 12, 21, and 28 to address the crowding and open bite. The issue for review is the medical necessity of braces.
The health plan's determination of medical necessity is overturned. Evidence shows that patients with severe malocclusions, including anterior open bite, have significantly lower masticatory and gastrointestinal digestive function than persons with normal occlusion.  However, it has also been shown that after orthodontic treatment, there was no difference in masticatory function and gastric emptying between the treated group and the control group with normal occlusion. Given this patient's malocclusion and the likelihood of significantly reduced masticatory function and digestive function, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Crossbite with clinical attachment loss
Treatment:  Braces
The proposed braces are medically necessary. 

The patient has a crossbite of an individual anterior tooth with clinical attachment loss.  This is an "automatic qualifier" on the handicapping index scale.  This condition needs to be corrected with orthodontic treatment.
Appeal type: Medical necessity
Decision: Upheld

The patient who presented to the emergency department (ED) with a history of progressively worsening abdominal pain. His evaluation included physical exam, labs, and a computed tomography (CT) scan. He was without fever at the time of presentation. Vital signs were normal at the time of presentation. Lab data identified a white blood cell count (WBC) count of 16 K. The CT scan yielded the diagnosis of acute appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was obtained. His past medical history is notable for drug abuse. 

He was admitted the following day and underwent a laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. The operative note describes an acute, non-perforated, appendicitis. He was provided IV fluid and perioperative antibiotics. The vital signs remained normal following surgery. He tolerated a diet and was discharged from the hospital the following day. The health plan denied the inpatient admission as not medically necessary. The health plan's determination is upheld. 

The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient required urgent surgical intervention for acute appendicitis, however, a lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care. There was no documentation of hemodynamic instability, intra- or peri-operative complications, severe pain, or unstable comorbidities. The patient member tolerated oral hydration, diet and medication. His pain was well controlled.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mood disorder
Treatment: Continued inpatient admission 
The continued inpatient admission was not medically necessary.
The patient had made an impulsive suicide attempt while under the influence of alcohol and cocaine. By the dates in question, she had consistently denied suicidality. She was future oriented. She tolerated her medication without difficulties. Her family was supportive. She showed no signs of withdrawal. Nothing in the documentation reviewed indicates that treatment could not have been provided safely and effectively at a less intensive level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Velopharynx (soft palate), Complete Anterior-Posterior Obstruction and Lateral Narrowing; Oropharynx, Lateral Obstruction; Tongue, Complete Anterior-Posterior Obstruction; Epiglottis, Complete Anterior-Posterior Obstruction.

Treatment: Hypoglossal Stimulator

The insurer denied the Hypoglossal Stimulator. The denial was reversed. 

The patient is a middle aged male with a history of severe sleep apnea as documented in early 2018 with Apnea-Hypopnea Index (AHI) = 87.  The patient's inability to utilize continuous positive airway pressure (CPAP) has been documented since late 2017.  His Body Mass Index (BMI) is 33.45. In mid- 2018 the patient underwent a drug induced sleep endoscopy, laryngoscopy, and otolaryngologic examination under anesthesia. The findings were velopharynx (soft palate), complete anterior posterior obstruction and lateral narrowing; oropharynx, lateral obstruction; tongue, complete anterior posterior obstruction; epiglottis, complete anterior posterior obstruction.

The peer reviewed literature 1, 3-16 is abundantly clear concerning the efficacy for patients with a high AHI and the inability to utilize some form of CPAP without concentric collapse of the upper airway.  This is the case with this patient.  The use of hypoglossal nerve stimulation for the treatment of Obstructive Sleep Apnea (OSA) has been approved by the American Academy of Otolaryngology Head and Neck Surgery17 and the International Sleep Society.18. The Food and Drug Administration (FDA) of the United States Department of Health and Human Services has approved the use of hypoglossal stimulation for patients with obstructive sleep apnea but have stated their approval is for patients with an AHI of 15 to 65.19, 20 The patient's AHI of 87 exceeds the upper limit set by the FDA.

The carrier's denial of coverage for hypoglossal stimulator is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overbite and overjet
 
Treatment: Braces

The insurer denied the braces. The denial was upheld.

Although the patient has overbite and overjet, there is slight crowding and no anterior or posterior crossbite or problems with closing his mouth. The patient does not meet HLD Index score of 26 points to substantiate the necessity for braces. Therefore, braces are not medically necessary.

Based on the above, the medical necessity for (D8080) braces is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Suspected small for gestational age fetus; variable decelerations on fetal monitor
Treatment:  Inpatient Admission
The insurer denied the Inpatient Admission.  The denial was upheld.

This is a female patient who is 37 weeks and 3 days gestation.  She was referred to the emergency department and was evaluated by obstetrical triage for prolonged monitoring because of suspected small for gestational age fetus and variable decelerations on a fetal monitor.  She has no significant medical history and obstetric history of eight prior pregnancies, including five full-term vaginal deliveries and two spontaneous abortions.  

Doppler velocimetry of the umbilical artery is recommended for monitoring pregnancies with suspected growth restriction.  Delivery prompted by abnormal Doppler ultrasonography reduces the frequency of perinatal death.  Normal Doppler findings are reassuring and thus potentially allow prolongation of pregnancy and reduction in the number of unnecessary pre-term deliveries. 

Neither the patient nor the fetus was in any jeopardy.  There was no bleeding, and vital signs were stable.  The fetal heart rate was reassuring.  There was no evidence of ruptured membranes.  The patient did not have a history of preterm deliveries.

MCG guidelines list the following clinical indications for admission:

a)	The condition requiring premature delivery,
b)	Delivery,
c)	Fetal distress or demise,
d)	Preterm labor and positive fFN,
e)	Significant maternal disease, infection, or comorbidity as cause,
f)	Significant vaginal bleeding or any vaginal bleeding with known placenta previa, vasa previa or placenta accreta,
g)	Continued fetal monitoring,
h)	Tocolytic therapy that requires inpatient care,
i)	Complications of tocolytic treatment.

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

Diagnosis: Substance abuse
 
Treatment: Inpatient detoxification admission, medication, monitoring

The insurer denied continued inpatient detoxification. The denial was reversed.

This female was admitted for inpatient substance detoxification treatment. The patient had withdrawal symptoms including diaphoresis, nausea, agitation, abdominal pain, muscle spasms, chills, cravings, headache, a blood pressure of 132/90 and depression. The patient was using intravenous (IV) heroin up to 3 grams per day. The patient was in current outpatient substance treatment and was unable to remain abstinent. The patient had comorbid diagnoses including Post-traumatic Stress Disorder (PTSD) and mood symptoms. The patient had a 5-day methadone protocol.

The American Psychiatry Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. This was the case with this patient. The patient had past substance inpatient detoxification treatments and was using substances while in outpatient substance treatment. It was not likely the patient could remain abstinent in outpatient substance detoxification treatment. According to the LOCADTR, the patient required 24-hour treatment as the patient needed detoxification medication to modify withdrawal. The patient continued to have withdrawal symptoms with COWS scores of 3 and 5. It was not likely the patient would stop using substances and be treated for detoxification as an outpatient. The patient lacked sober supportive living. The patient was at risk for overdose and severe withdrawal symptoms due to her large amount of heroin use and continued withdrawal symptoms despite detoxification medication.   

Based on the above, the medical necessity for the continued inpatient substance abuse services is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pectus Excavatum 

Treatment: Chest Wall Surgery - CPT code 21743: Reconstructive Repair of Pectus Excavatum or Carinatum; minimally invasive approach (Nuss procedure), with Thoracoscopy

The insurer denied the Chest Wall Surgery - CPT code 21743: Reconstructive Repair of Pectus Excavatum or Carinatum; minimally invasive approach (Nuss procedure), with Thoracoscopy.  The denial was reversed.           

This case involves a young male who had a significant excavatum deformity.  The patient had a moderate to deep symmetrical pectus excavatum involving the lower aspect of the sternum.  The patient was seen for a second opinion concerning his Pectus Excavatum Deformity.  The patient does appear to be somewhat traumatized from the pectus deformity.  The patient had gone through a significant growth spurt in the last year and his sternum had become significantly more depressed as he has grown.  He is athletic, and reports that he becomes easily winded and short of breath with exercise; he appeared to be symptomatic of exercise intolerance.  The patient's work-up has included a CT scan of the chest which revealed an obvious compression of the right heart by the sternum, a pulmonary function test that showed to be abnormal with a FVC of 70%, contact allergy testing, and an evaluation by a cardiologist.  The correction index was noted to be 20.  On examination, a deep shape symmetrical defect with a minimal costal flare was noted.  Due to his barrel-shaped thorax the Holter index does not adequately assess the severity of the defect.  The patient was to undergo surgical repair.

The symptoms, the abnormal PFT's and the radiographic findings all support medical necessity. 

The carrier's denial of coverage for chest wall surgery- CPT code 21743 is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shingles
Treatment:Acyclovir 5%

Summary:

The patient is a female with shingles whose use of Acyclovir 5% is being evaluated for medical necessity.  As the patient was already going to receive the oral valacyclovir (a pro-drug of acyclovir), which is the drug of choice for this condition (1,2), there was no indication for the topical medicine. There are no studies showing that a combination of oral and topical treatment is better than oral. In summary, this combination has not been studied and is not part of any guidelines. Therefore, it was not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

This is a patient who is under consideration for hydroxyprogesterone caproate for incompetence of the cervix. She is noted to have a prior history for loop electrosurgical excision procedure (LEEP)  and also had a dilation and evacuation at 23 weeks. The patient is under consideration for hydroxyprogesterone caproate 250 milligrams (mg) intramuscular (IM) injections weekly. The health plan's determination is upheld.
In this case, the patient is under consideration for hydroxyprogesterone caproate injections weekly for the prevention of preterm birth. She has a prior history of LEEP and a prior history of cervical shortening with a twin pregnancy that underwent termination of pregnancy. In this case, there is no recommendation or effectiveness established for the use of hydroxyprogesterone caproate for prevention of preterm birth in this setting. The population that would benefit from the use of hydroxyprogesterone caproate injections for the prevention of preterm birth would be those with a "prior spontaneous preterm birth (PTB) of a singleton pregnancy". This patient is noted to have a prior full term delivery of a singleton gestation and a termination of pregnancy for a twin gestation with cervical dilation. There is no history of a prior spontaneous preterm delivery of a singleton gestation. Thus, the patient would not be a candidate for hydroxyprogesterone caproate injections for the prevention of preterm birth in this presentation as this has not been proven as effective in prevention of preterm birth in the setting presented.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting, diarrhea, fever
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of five years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications.

This young male child presented with refractory diarrhea and vomiting, with laboratory evidence of dehydration (metabolic acidosis). He failed a fluid challenge in the ED despite treatment with Zofran. However, he was overall hemodynamically stable, with good perfusion, and no evidence of sepsis or severe dehydration. He did not require acute inpatient management, and he could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
Following this patient's ED evaluation, she was clinically stable. It was suspected that her symptoms were due to a TIA. Despite this, she had a normal neurologic exam. No treatment had been given for the patient's elevated blood pressure. She was awake and alert, with normal mental status. A CT scan had ruled out a cerebral bleed. Blood work was normal. The admission note for this patient indicates that her plan of care would include a neurology consultation. An ultrasound of the carotid arteries was ordered. No treatment for hypertension was planned except giving the patient her home medications. At the time this patient was kept in the hospital, it would have been reasonable to believe that this limited plan of care could be accomplished for a stable patient with a very short stay in the hospital. For this reason, an inpatient admission was not medically necessary.

The patient had no severity of illness to justify an inpatient admission. She had no neurologic deficit on exam. She had no lab abnormality. Her blood pressure, while elevated, was being treated with oral medication. There was no intensity of services required for the patient to justify an inpatient admission. The patient would be seen by a neurologist. She would have a carotid ultrasound performed.

In conclusion, the patient was clinically stable following her ED evaluation. A limited plan of care was anticipated for. An inpatient admission was not medically necessary for this patient.