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

Diagnosis: Cervicalgia
Treatment: Chiropractic Services (Chiropractic Manipulative Treatment)
The health plan denied the requested Chiropractic Manipulative Treatment. 
The health plan's determination is upheld.

The patient presented with "severe neck pain, (cervical) C5 disc herniation, and right arm numbness." The provided records are minimal and not in keeping with the standard of care. There is no clinical discussion or interpretation, and no care plan included in the documentation for review. No diagnostic impression is given; however, the provider does note in a later letter that his diagnosis listing was incomplete. He notes to not define the weight of cervical traction or level of decompression. "Cervical adjustment" does not define technique or levels treated. The patient appears to have treated 14 times then self-dismissed from care.
The patient returned approximately 2 months later with recurrence of symptoms. No re-evaluation is included in the documentation. Visits range from weekly to every 3 weeks. No objective measures of improvement are given - only subjective pain score. The patient again self-dismissed from care. 
At issue is the medical necessity of the Chiropractic Manipulative Treatment.

I uphold in whole the health plan's determination.

As stated, the patient had been receiving ongoing care for the same complaints and diagnoses for more than 4 months with no measured objective improvement being documented. Further, the patient choosing to have care based on subjective complaints does not represent managed care, but palliative treatment. The documentation submitted for review failed to adequately document the care provided or discuss progressing objective improvement with that care.
While it is appreciated that the patient may have had a degree of objective relief with the care provided, medical necessity is based on objective improvement. No objective measures are presented in the treatment notes. The documentation does not support a clear clinical rationale for continued care. In the absence of documented objective improvement, the medical necessity of CMT is not demonstrated in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Traumatic Brain Injury. 
Treatment: Continued Skilled Nursing Stay. 

The insurer denied the Continued Skilled Nursing Stay. 
The denial is overturned. 

The patient is a male with history of Traumatic Brain Injury (TBI) after a self-inflicted gunshot wound (GSW) leading to functional and cognitive decline. He was in acute admission followed by acute inpatient rehabilitation and then transferred to SNF (skilled nursing facility). His relevant past medical history included major depressive disorder, hypertension, hyperlipidemia, alcohol abuse, etc (et cetera). 

Prior to admission, the patient was independent with ADLs (activities of daily living), living with his wife, who works full time. The plan was to discharge him home. 

The patient was admitted to SNF (skilled nursing facility). He required minimum assistance for going up/down platform step, contact-guard for ambulation of 50 feet with verbal cue, standby or contact guard for transfer from bed to wheelchair, transition from supine to sitting position, lower body dressing/bath, toileting, hygiene, transfers, bed mobility, etc (et cetera). 

The patient was unsteady on his feet and a high risk for falls. He was eventually able to improve to independence with most of the activities, able to ambulate 200 feet, etc (et cetera). 

Yes, the Continued Skilled Nursing Stay was medically necessary. 

The patient required minimum assistance for going up/down platform step, contact-guard for ambulation of 50 feet with verbal cue, standby or contact guard for transfer from bed to wheelchair, transition from supine to sitting position, lower body dressing/bath, toileting, hygiene, transfers, bed mobility, etc (et cetera). 

The patient was unsteady on his feet and a high risk for falls. And as of a month after admittance he was able to improve to independence with most of the activities, able to ambulate 200 feet, etc (et cetera). Therefore, continued stay in SNF (skilled nursing facility) was medically necessary, as he had increased fall tendency. Further stay in SNF (skilled nursing facility) was reasonably expected to be health beneficial for the patient, as the patient was prone to falls and prone to further injuries without the continued stay in SNF (skilled nursing facility). 

As stated above, the continued stay in SNF (skilled nursing facility) was medically necessary with clinical evidence showing improvement, but the patient was still unsteady on his feet with increased fall tendency. Further stay in SNF (skilled nursing facility) was reasonably expected to be health beneficial for the patient, and withholding it in whole or in part, would be reasonably expected to affect the patient's health adversely, as the patient was prone to falls and prone to further injuries without the continued stay in SNF (skilled nursing facility).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, Tachycardia, Psychosis. 
Treatment: Full hospital admission. 

The insurer denied coverage for the full hospital admission. 
The denial is upheld. 

This is a female with a history of psychosis. The patient was inpatient on a Psychiatric Unit when she developed tachycardia and elevated blood pressure. The patient was transferred to the Medical Service for evaluation and treatment of hypertension (elevated blood pressure of 190/110) which was accompanied by sinus tachycardia. The patient's electrocardiogram (EKG) revealed sinus tachycardia at rate 116, left axis deviation, and P waves suspicious for biatrial enlargement. 

The patient's echocardiography revealed left ventricular hypertrophy with normal systolic function, grade 1 diastolic dysfunction, and estimated right ventricular systolic pressure of 45. The patient was treated with Procardia and metoprolol. The patient remained asymptomatic other than her psychiatric symptoms. 

Based on the review of the patient's medical record and literature, there is no clinical evidence that this patient required the full hospitalization to treat her hypertension or to rule out acute coronary syndrome. The patient's hypertension could have been managed by medical consultation in the Psychiatric Unit after initial treatment and evaluation for acute coronary syndrome in the Emergency Department or at an Observational level of care. 

The health plan acted reasonably with sound medical judgement, and in the best interest of the patient. 

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

Diagnosis: Overjet
Treatment: Braces
The insurer denied the braces. 
The denial is overturned. 

The patient is a female. The request is for coverage for comprehensive Orthodontic treatment.

Clinical exam and records indicate that the patient has a Class II molar relationship on the right side, anterior deep bite, 5mm (millimeter) overjet with damage to soft tissue and moderate crowding.

Yes, the Comprehensive Orthodontic treatment is medically necessary.

Normal overjet is considered 1-3mm (millimeters). The patient presents with a Class II molar relationship and an overjet of 5mm (millimeters) with considerable rotation of tooth #8 that is evident from the intra-oral photos. This can only be corrected with orthodontic treatment. 

The patient has a Class II molar relationship. Her lower first molar is more posterior than the upper molar--this is indicative of the degree that the upper front teeth and jaw are projecting further forward than the lower teeth and jaw.

Any significant overjet beyond the norm puts the patient at risk for increased trauma to the anterior teeth due to the protrusion. The patient is also more prone to sleep apnea, speech impediments and damage to the soft tissue (gums) as indicated in the assessment. This will directly impact the patient's quality of life. Therefore, the Comprehensive Orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gap in crown
Treatment: Crown - porcelain/ceramic tooth #3 
The insurer denied the Crown - porcelain/ceramic tooth #3. 
The denial is upheld. 

The patient is a male requesting benefits for new crown on tooth #3.

No, the Crown - porcelain/ceramic tooth #3 (D2740) is not medically necessary.

The x-rays do not show the crown having an open margin and food trap. There also is no decay seen under the crown which would necessitate a replacement crown. Replacement of the crown is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a male with a known history of diabetes. He who presented with hyperglycemia. At his initial diagnosis of diabetes in the previous year, he was treated with insulin and an oral medication, which he continued for two months. The patient self-discontinued the medications. 

The patient's glucose was 355, and Beta hydroxybutyrate was elevated at 0.51. The urinalysis was negative for ketones. Bicarbonate was 28 and anion gap was normal at 11. pH (potential of hydrogen) was 7.39. White blood count was 3, and platelets were 115. A1c (glycated hemoglobin) was 14.9%. 

The patient was treated with a normal saline bolus. He was started on insulin practice at bedtime, metformin twice a day, and Humalog before breakfast lunch and dinner. The patient is reported to have required carbohydrate counting. The patient was discharged after education. 

Yes, the Inpatient Admission was medically necessary. 

Diabetes education consists of several components, nutritional counseling, self-monitoring of blood glucose and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components [1, 2]. The patient presented with hyperglycemia and ketosis. The patient was previously diagnosed with diabetes and treated with insulin 11 months earlier but had discontinued all treatment and presented with weight loss and hyperglycemia and ketosis, as well as an A1c (glycated hemoglobin) of 14.9 requiring re-initiation of insulin. 

Practice patterns differ depending on the availability of educators, etc (et cetera). Whether a patient gets hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen [3-6]. 

It was deemed that the patient required reinitiation of insulin as well as clearing ketones with hydration. It was appropriate to admit the patient for an acute inpatient admission to figure out the doses of insulin. The acute inpatient admission was health beneficial for the patient and it was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease
Treatment: Acute inpatient admission
The insurer denied coverage for the acute inpatient admission.
The denial is upheld. 

This is a male patient who had a history of hypertension, hyperlipidemia, diabetes mellitus, and coronary artery disease with stents. He presented for planned intervention in the left anterior descending (LAD) distribution for 90-95% proximal LAD, 80-90% mid LAD, 70-80% distal LAD and 80-90% second diagonal (D2) coronary artery disease.  Pre-procedure vital signs included blood pressure (BP) 137/76, heart rate 65, and oxygen saturation 98%, with laboratory test results including creatinine 1.0, hemoglobin 13.8 and white blood cell (WBC) count of 8.3. Electrocardiogram (EKG) was normal. The patient underwent intra-aortic balloon pump assisted drug eluting stents (DES) of the LAD and D2 via femoral approach, with no complications and was admitted after the procedure.  On day 2 of admission, he had a brief episode of near-syncope when out of bed, with BP 98/68 and heart rate 68, which decreased to 30 for 10 seconds, then returned to 65 to 70.  The assessment was a vasovagal/neurocardiogenic event, similar to previous episodes, and he was treated with intravenous fluid. He was discharged to home on day 3 of admission on his home medications for outpatient management.

There is no evidence that this patient required an inpatient level of care following his planned left heart catheterization and staged percutaneous coronary artery intervention.  Post-procedure monitoring and management could have been performed at an observation level of care. The health care plan acted reasonably, with sound medical judgment and in the best interest of the patient.

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

Diagnosis: Glioblastoma
Treatment: Lynparza (olaparib)
The insurer denied the Lynparza (olaparib). 
The denial is upheld. 

The patient is a male with anaplastic oligodendroglioma transformed to GBM (glioblastoma multiforme). His physician has proposed therapy with olaparib based on NGS (next generation sequencing) panel testing.

No, the treatment with Lynparza (olaparib) is not medically necessary.

There is no evidence to support olaparib to treat GBM at this time. Case reports and a proposed study are not considered acceptable evidence of efficacy. The NCCN (National Comprehensive Cancer Network) does not support the use of olaparib as therapy for GBM, and there is no published literature from well-conducted clinical trials demonstrating that this is of benefit. The SHIVA (Molecularly targeted therapy based on tumour molecular profiling versus conventional therapy for advanced cancer) study has shown that the use of molecular diagnostics as the sole basis for therapy selection does not lead to improved clinical outcomes in advanced cancer.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Diclofenac Epolamine 1.3% Patch. 
The denial was upheld in whole.

The patient is a female who is noted to have a history of chronic back pain. It was noted that according to the chart notes prior use of meloxicam caused gastrointestinal (G.I.) distress. Pharmacy claims confirm there have been previous trials with acetaminophen, ibuprofen, Meloxicam, and diclofenac 1% gel. Records provided indicate that the patient's treating physician prescribed diclofenac Epolamine 1.3% patch (Flector Patch). The request was denied as to approve this medication the diagnosis must be consistent with the United States Food and Drug Administration (FDA) product labeling and criteria was not met because this medication is not indicated or FDA approved for the treatment of chronic low back pain. It was noted that there are alternative medications on the preferred drug list such as Nabumetone, Etodolac, ibuprofen, naproxen, Piroxicam, Celecoxib, or diclofenac sodium tablets. It was also noted that diclofenac 1.5% topical solution, and diclofenac 1% gel and Voltaren arthritis pain gel (this is an over-the-counter product covered with a prescription) are also on the preferred drug list (formulary). The application for review states that the patient has acute pain, not chronic pain. The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Diclofenac Epolamine 1.3% Patch (Flector Patch) is not medically necessary for this patient. Records provided indicate the patient has chronic back pain and has previously tried and failed several nonsteroidal anti-inflammatory drugs as well as diclofenac 1% gel. The patient was prescribed topical Diclofenac Epolamine 1.3% patch (Flector Patch), however, the patient does not have an FDA approved indication for use of this topical patch which is FDA approved and indicated for acute sprains, strains, and contusion. The progress note provided clearly indicates that the patient has had "lower back pain for many years." Although it was reported that the patient recently had an increase in symptoms related to lifting, this is not an acute condition, but rather an exacerbation of a chronic condition. There are multiple alternative medications on the preferred formulary list described above that can be trialed. Medical necessity is not established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental Problems.
Treatment:  White Glass with High Gold Content Crown, Tooth 30.

The insurer denied White Glass with High Gold Content Crown, Tooth 30.  The health plan's determination is overturned. 

The patient is a female, who presents for evaluation and treatment of tooth #30.  Provided for review are previous letters of appeal and denial, narratives from the patient, bite-wing radiographic images, multiple pages of claim forms and ledgers, health plan language, and clinical notes.  In question is the medical necessity of the treatment of porcelain fused to high noble metal crown (D2750) for tooth #30.  Previous denials have been on the basis that the tooth, #30, has a current full coverage crown and that the radiographs do not show evidence of decay on the tooth to warrant a new restoration.

The White Glass with High Gold Content Crown, Tooth 30 is medically necessary for this tooth due to the open contact and food impaction.  From the provided notes, there is no decay existent on the tooth or around the crown margins of #30.  From the radiographic documentation provided there is no decay on the tooth or around the crown margins of #30.  However, the clinical notes do document that there is an open contact, which is supported by the radiographic documentation.  As such, the presence of an open contact must be addressed as it allows for food impaction and subsequent decay, periodontal, and peri-implant disease.  As either the implant restoration or the tooth restoration could both be addressed to change the contact being missing, the decision to replace #30 is medically necessary, as it will also improve the margin on the distal of the tooth, which was open on the pre-treatment radiograph.  Hence, in order to prevent the impaction of food due to an open contact, it is medically necessary to change the contact between #30 and 31, which is best addressed with placing a single porcelain fused to high noble metal crown (D2750) for tooth #30 which is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal Pain. 
Treatment:  Inpatient stay.

The insurer denied the Inpatient stay.  The determination is upheld.

The patient presented to the emergency room (ER) with right lower abdominal pain with nausea and vomiting.  The pain initially started as umbilical pain before settling in the right lower quadrant.  Vital signs were within normal limits.  The patient had pain at McBurney's point on examination.  The white blood cell count (WBC) was 17.  A computed tomography (CT) scan demonstrated a 1.3 centimeter (cm) appendix with minimal associated fat stranding concerning for early acute appendicitis.  The patient was hospitalized and kept nothing by mouth (NPO) and was given intravenous (IV) fluids.  At issue is the medical necessity of an inpatient stay.

The requested health service of inpatient hospital admission is not medically necessary for the patient.

The patient was hospitalized and monitored overnight and had quick resolution of her symptoms.  It became clear that the patient did not have acute appendicitis by the first morning after hospital admission.  Her WBC was 8.05 and had resolved to this without the use of antibiotics.  Her doctors felt this was likely due to her irritable bowel syndrome (IBS) with a component of gastroenteritis but that there was a low likelihood of this being from appendicitis.  Her abdominal pain had resolved.  She had no diarrhea or nausea/vomiting.  The patient continued to do well and was started on a clear liquid diet.  The patient continued to do well and was discharged home.

The patient did not demonstrate significant systemic illness, ongoing significant vomiting, dehydration, hemodynamic instability, severe pain outside of initial evaluation in the emergency department, signs of intestinal obstruction or peritonitis, or bacteremia.  There is no evidence that additional complex testing or therapy were performed.  There is no evidence that a complicating event occurred during her hospitalization that required a higher level of care.  There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care.  The documentation does not suggest that the patient's care could not have been performed at a lower level care. 

The patient had a quick resolution of the symptoms that resulted in her hospitalization and did not utilize high acuity services during her stay.  The provided documentation does not support the medical necessity of an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Abnormal Heart Rhythm.
Treatment:  Inpatient admission.

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

The patient, a male, has a past medical history significant for HTN (hypertension), diabetes Type 2, CAD (coronary artery disease), CHF (congestive heart failure), atrial fibrillation on Sotalol, and morbid obesity.  He presented to the ER (emergency room) with complaints of shortness of breath and bilateral edema, orthopnea and PND (Paroxysmal Nocturnal Dyspnea). 

The patient was hypertensive with uncontrolled heart rate. Patient had adequate oxygen saturation.  His BNP (brain natriuretic peptide) was elevated at 833.  ECG (electrocardiogram) revealed atrial flutter with variable AV (atrioventricular) block at 126 bpm (beats per minute).  Chest X-ray revealed hazy ground glass opacities. 

The patient was treated with IV (intravenous) Lasix and IV (intravenous) Cardizem boluses.  Cardizem IV (intravenous) drip was started as well.  Patient was admitted for CHF (congestive heart failure) exacerbation and uncontrolled atrial fibrillation.  He was seen in consultation by cardiology and diuresis was continued with Lasix. 

2D (two dimensional) echocardiogram was obtained, revealing low normal LV (left ventricle) function, with LVH (left ventricular hypertrophy), mild MR (mitral regurgitation), and he was diagnosed with diastolic CHF (congestive heart failure). 

The patient's Sotalol was discontinued, and he was treated with Coreg and diltiazem.  He subsequently converted to NSR (normal sinus rhythm), and Cardizem was stopped.  Once stable, the patient was discharged home with a plan for outpatient follow-up.

Yes, the Inpatient Admission was medically necessary.

The patient presented with symptoms of acute CHF (congestive heart failure) exacerbation in the setting of uncontrolled atrial fibrillation/flutter.  Patient had evidence of fluid overload on clinical exam, chest X-ray and laboratory data.  BNP (brain natriuretic peptide) was significantly elevated.  He required treatment with IV (intravenous) diuretic.  In addition, the patient's arrhythmia was not controlled with IV (intravenous) diltiazem boluses in the ED (emergency department), and he required initiation of IV (intravenous) diltiazem drip.  His antiarrhythmic - Sotalol was discontinued, and his medical regimen for AF (atrial fibrillation) management was changed.  Given this presentation, acute CHF (congestive heart failure), uncontrolled atrial fibrillation, requiring IV (intravenous) drip for heart rate management, as well as multiple risk factors, co-morbid conditions, it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and, therefore, the requested inpatient admission was medically necessary in this clinical setting.