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

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

The patient is a female. She presented with sharp, piercing right and left chest pain, with palpitations, and dyspnea. She has history of lung cancer, GERD (gastroesophageal reflux disease), hypertension, and hyperlipidemia. She had recently had a lobectomy.

She was mildly anemic, but had negative EKG (electrocardiogram) and enzymes changes for ACS (acute coronary syndrome). She had run out of her BP (blood pressure) medications (metoprolol). Her vital signs were stable. Her exam was normal.

The patient was admitted with atypical chest pain diagnosis. Her pain was similar to her pain post lobectomy. She was restarted on her outpatient medications, and her pain and palpitations were relieved. CT (computed tomography) was negative. The patient was monitored, and she was discharged after one night.

No, the Inpatient admission was not medically necessary.

The most appropriate level of care is always in the best interests of patient care.

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 patient's case, her symptoms were atypical and unlikely to be representative of acute coronary syndrome. Her blood pressure normalized, and her exam and cardiac findings were normal. Her biomarkers and EKG (electrocardiogram) showed no evidence of acute ischemia. The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for ACS (acute coronary syndrome) such as IV (intravenous) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV (intravenous) NTG (nitroglycerin).

The letter of appeal was carefully considered, but it offered no evidence to support an 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 an inpatient level of care in this patient's care. This patient had no evidence of 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 of the 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: Incisional hernia
Treatment: Inpatient hospital admission (procedure codes 49560 and 49568) 
The insurer denied coverage for the inpatient hospital admission (procedure codes 49560 and 49568). 
The denial is overturned. 

This is a male patient who underwent an open ventral hernia repair with bilateral component separation. The patient has a history of a colon perforation with right colon resection and ileostomy placement. The ileostomy was subsequently reversed. The patient has a history of alcohol abuse with withdrawal symptoms/delirium tremens. Two Jackson-Pratt drains were placed. Patient-controlled analgesia was initiated post-operatively. 

Complex hernias have been defined as hernias with signs of incarceration, strangulation, infection, chronic pain, irreducible scrotal hernias, multiple recurrence(s), or a relevant history of lower abdominal surgery or radiation. Although some complex hernias are suitable for ambulatory repair, there is insufficient data to support repair of complex hernias in the ambulatory setting. [1,2] Strangulated hernias should not be repaired in the ambulatory setting. [1]

Per Milliman Care Guidelines (MCG), inpatient admission may be needed for open repair of large, recurrent, incarcerated ventral or incisional hernias. [3] The patient had multiple midline incisional hernias, as well as a hernia at the ileostomy site. The patient had an American Society of Anesthesiologists (ASA) score of 3, which also supports an inpatient admission. Per provided clinical documentation and guidelines, the requested inpatient hospital admission was medically necessary. 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 inpatient hospital admission (procedure codes 49560 and 49568) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cough, wheezing and respiratory distress. 
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission. 
The denial is overturned. 

This patient is a female child who has a history of an admission for wheezing and pneumonia.  There is a history of asthma in her family.  She had a runny nose and developed a cough, wheezing and increased work of breathing 1 day prior to admission.  The mother brought her to the Emergency Room (ER) when she was not improving.

In the ER she was noted to have respiratory distress with retractions, prolonged expiration and evidence of increased work of breathing.  There was nasal flaring and wheezing noted on physical examination.  She was given 3 doses of albuterol and Atrovent followed by intravenous (IV) Decadron and an IV Normal Saline fluid bolus.  Her respiratory distress did not improve and was started on 30% oxygen via high flow nasal cannula at 10 liters.  She was also administered albuterol every hour.  A respiratory viral panel was positive for rhinovirus.  In view of the failure of her wheezing to improve with treatment in the ER the decision was made to admit her with a diagnosis of status asthmaticus for ongoing treatment with albuterol every hour.  

The patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. She has a history of asthma and evidence of persistent increased work of breathing following treatment in the ER.  She did not improve with high flow nasal oxygen at 30% and albuterol administered every hour.  She continued to have an increased respiratory rate and work of breathing.  The presence of nasal flaring and respiratory distress following 3 nebulized treatments with DuoNeb, IV fluids and Decadron indicated ongoing need for albuterol treatments.  When there was ongoing respiratory distress with increased work of breathing, it was appropriate and consistent with the standard of care to admit her to the hospital for ongoing treatment with albuterol every 1 hour.  She was not stable enough to be sent home.  In addition, the patient's mother had reported that there was mold in the home and the social worker noted that there was an active ACS (Administration for Children's Services) case for this child and the mom had indicated that the child had been coughing for one year. 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 inpatient hospital admission is overturned.  Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Emboli. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient was admitted with complaints of (c/o) left rib pain worse with deep breathing. Vital signs were remarkable for a pulse of 105. The physical exam was notable for left lower ribs with tenderness to palpation (TTP). Lab work was remarkable for a positive D-dimer. Computed tomography pulmonary angiography (CTPA) showed bilateral pulmonary emboli. The patient was diagnosed with bilateral pulmonary emboli and was treated with anticoagulation. The patient was discharged in stable condition. At issue is the medical necessity of the inpatient level of care. 

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 left rib pain and was found to have bilateral pulmonary emboli. The patient had no history of cancer, heart failure, or chronic lung disease, there was no hypotension, severe tachycardia, tachypnea, fever, altered mental status (AMS) or hypoxia. The pulmonary embolism severity index (PESI) score was 55, consistent with class I, which is very low risk, with a 0-1.6% 30-day mortality. His simplified pulmonary embolism 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: Appendicitis
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned.

The patient is a boy who presented with abdominal pain in the right lower quadrant consistent with appendicitis. He was well until one day prior to admission when he developed pain in the periumbilical area. He then developed non-bilious non-bloody emesis. He also had decreased appetite. The pain subsequently migrated to the right lower quadrant. He was seen by his pediatrician and was sent to the emergency department for further evaluation.
In the emergency department, he was found to be febrile to 38.2C (Celsius). He was also hypertensive with a blood pressure of 143/67. He was in mild distress and his physical examination revealed pain at McBurney's point and a positive Rovsing sign. He had tenderness in the right lower quadrant. His white blood count was 15 and a computed tomography (CT) scan of the abdomen revealed appendicitis with no perforation. He received acetaminophen and morphine, and was started on maintenance intravenous fluids.

Inpatient stay was medically necessary for this patient. He required prompt intervention that required an inpatient setting for parenteral treatments, surgical intervention, and monitoring.
This is a young boy who presented with significant abdominal pain and was found to have appendicitis. At the time of presentation he was febrile and hypertensive. He required prompt treatment with intravenous fluids and parenteral antibiotics, with surgical intervention to remove the inflamed appendix. He also required medication for pain control. He was promptly taken to the operating room for a laparoscopic appendectomy, and was observed for an appropriate period afterwards to ensure that he was tolerating oral fluids and was afebrile.
The decision-making at the time of admission for this patient was consistent with his young age, the presence of appendicitis with fever and hypertension, and the need for prompt intervention including laparoscopic appendectomy, intravenous fluids, parenteral antibiotics, and pain management along with close monitoring for potential deterioration of clinical status. He was appropriately discharged once he was tolerating fluids and was medically stable.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain. 
Treatment: Nerve Treatment in the Spine. 

The insurer denied Nerve Treatment in the Spine. 
The health plan's determination is upheld. 

This is a male patient diagnosed with low back pain. It was noted that the patient has previously tried and failed physical therapy, epidural steroid injection, medications including gabapentin, Tylenol, and non-steroidal anti-inflammatory drugs (NSAIDs). It was noted the patient's pain is worse in the morning as well as with prolonged activities and nothing has provided significant relief. The treating provider recommended the patient undergo L5 - S1(Lumbar or Sacral) Intracept procedure. 

The Nerve Treatment in the Spine is not medically necessary for this patient. Records indicate the patient has a history of chronic low back pain and has failed conservative treatment including physical therapy, epidural stirred injection, medications including gabapentin, Tylenol, and NSAIDs. There was no physical examination performed. The MRI (Magnetic resonance imaging) does not show Modic changes, which is the condition that this treatment is typically recommended for. 

Studies suggest that, in some patients, the origin of lower back pain (LBP) is the vertebral endplates, with pain transmitted via the basivertebral nerve (BVN). Although some results have been promising, additional studies are needed to establish the safety and efficacy. Per Becker et al, " Ablation of the BVN for the treatment of chronic lumbar back pain significantly improves patients' self-reported outcome early in the follow-up period; the improvement persisted throughout the 1-year study period." However, this is noted to be an industry sponsored study and does not demonstrate long term effects of the procedure beyond one year. Per Fischgrund et al, "Patients treated with RF (radiofrequency) ablation of the BVN for CLBP exhibited significantly greater improvement in ODI (Official Disability Index) at 3 months and a higher responder rate than sham treated controls. BVN ablation represents a potential minimally invasive treatment for the relief of chronic low back pain." Again, there appears to positive initial results, however, the study was fairly small (225 patients with chronic back pain) and there continues to be a lack of long-term studies evaluating long term risks/benefits when compared to other standard means of treatment and further large, high-quality studies are needed. This treatment is not standard of care in the general medical community as there is no evidence that this treatment is safe or effective for chronic back pain. There is a lack of evidence found in the peer-reviewed medical literature supporting this device as effective for the treatment of chronic back pain or establishing this treatment as equal to or superior to that of standard means of treatment for this condition. The procedure is not considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted canine.
Treatment: C8080 Braces And D8670 Monthly Visit x 12.
The insurer denied the C8080 Braces And D8670 Monthly Visit x 12.
The denial is overturned. 

The patient is a female. The request is for orthodontic benefits.

Yes, the braces and monthly visits are medically necessary.

The patient has an impacted lower right canine. When extraction is not indicated, this is an "automatic qualifier," according to the handicapping index scale. It is very important to have the patient's canines in their proper position to allow the rest of the teeth to occlude properly during the chewing cycle. The lower right canine needs orthodontic treatment to position it properly. This case has medical necessity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class 3 skeletal tendency, anterior cross-bite,upper and lower crowding, negative overjet.
Treatment: C8080 Braces And D8670 Monthly Visit x 12 And D8680 Retainer, Pre-service.
The insurer denied the C8080 Braces And D8670 Monthly Visit x 12 And D8680 Retainer, Pre-service.
The denial is overturned. 

The patient is a male. The request is for dental benefits for orthodontic treatment, monthly visits and a retainer.

The patient presents with a class 3 skeletal tendency, anterior cross-bite (indicated on HLD [Handicapping Labio-Lingual Deviation] index ), upper and lower crowding, negative overjet (2mm [millimeters]).

Standard orthodontic records were created.

Yes, the proposed treatment of orthodontic therapy(braces), monthly visits and retainer is medically necessary.
This patient presents with a severe anterior crossbite that is very evident from the photos and the x-rays. This is demonstrated particularly in the photos where anterior teeth #s 7, 9 and 10 (upper right lateral incisor, upper left central incisor and the upper left lateral incisor respectively) are seen to be in cross-bite.

Cross-bite is when the upper teeth fall inside or lingual to the lower teeth. Typically, in normal occlusion, the teeth positions are reversed.

This tooth position will affect the patient's ability to speak and chew effectively, and to maintain good oral hygiene. This would thus lead to additional dental problems, such as gum disease and tooth decay.

Therefore, given the above, the Braces, Monthly Visits, and Retainer are medically necessary.

Given the severity of the cross-bite, if left un-treated, the complications of decreased proper function as it relates to chewing, speech and poor oral hygiene will only lead to a compromised oral dentition in the patient's future.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (overjet, overbite and ectopic eruption). 
Treatment: Comprehensive orthodontic treatment (braces) and periodic orthodontic treatment.
The insurer denied coverage for comprehensive orthodontic treatment (braces) and periodic orthodontic treatment.
The denial is upheld. 

This is a female child who presented for evaluation for orthodontic care. The Orthodontist identified several clinical findings including overjet, overbite and ectopic eruption and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 9 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements having attained a score of 9 points on the HLD index. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating Orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 9 points to justify orthodontic care. This reviewer concurs with the index completed by both the Orthodontist and the insurer attaining a total of 9 points on the HLD index (2 points overjet, 2 points overbite, 3 points ectopic eruption, and 2 points labiolingual spread) which is below the threshold of 26 points to support orthodontic care. Of note in this case, is that the patient's own Orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.
 
Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies.

Each of the peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

The clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval.

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

The insurer's denial of coverage for comprehensive orthodontic treatment (braces) and periodic orthodontic treatment is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left knee pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient is a female. She presented with left knee pain. She was admitted to the hospital for an elective total knee arthroplasty. The procedure was non-complicated. She was discharged.

No, the Inpatient admission was not medically necessary.
The medical record demonstrated a non-complicated post-surgical course. There were no comorbidities or underlying medical conditions to warrant additional service.

The records showed that the patient's vital signs were stable. There was no evidence of fever. The wound was without problem. There was no evidence of infection. The laboratory tests were satisfactory. There was no evidence of bleeding. The patient was able to tolerate oral pain medication with satisfactory VAS (Visual Analogue Scale) scores. PT (physical therapy) services were provided with associated ancillary support.

Given the above findings, the medical necessity of the acute care level of admission and service provided is not substantiated. The patient's treatment could have been given at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Arthroscopic Surgery.
Treatment: Assistant Surgeon Services. 

The insurer denied the Assistant Surgeon Services. 
The denial is upheld. 

This is a female with lateral compartment degeneration to her right knee. She had previously undergone an anterior cruciate ligament (ACL) reconstruction. She had valgus deformity and progressive deterioration. Her physician performed several reconstruction procedures. Arthroscopic surgery was performed consisting of micro fracture and chondroplasty. Bone marrow aspirate concentrate (BMAC) was harvested. An osteotomy to the distal femur was performed with application of a plate.  The physician utilized the assistance of a physician assistant (PA) and a physician (27495/29879). 

No, the proposed assistant surgeon was not medically necessary. 

The physician utilized the assistance of a physician assistant (PA) and a physician for Current Procedural Terminology (CPT) codes 27495/29879. There was no need for the service of the physician assistant; the records show he is a physician assistant (PA), not a Doctor of Medicine (MD). The records show another physician was present. The records and reports do not document medical justification for the use of two assistants. There were no extenuating circumstances to substantiate the service as another physician was clearly present.  The procedure was complex and unusual. It would be of benefit to have a second pair of hands for the osteotomy portion of the operation. The micro fracture and chondroplasty were not complex nor extensive. The physician would hold the arthroscope and perform the chondral procedures. There would thus be no reason to require a second assistant for the 27495/29879.