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

Diagnosis: hypothyroidism. 
Treatment: skilled nursing facility stay. 
The insurer denied the skilled nursing facility stay. 
The health plan's determination is upheld. 

This is a case review for a female admitted to a Skilled Nursing Facility (SNF) for the diagnosis of Hypothyroidism, Type II Diabetes Mellitus, Hyperlipidemia, Hypertension, Peripheral Vascular Disease, Lymphedema, Osteoarthritis, and Osteomyelitis. The health plan denied her ongoing stay forward. 
The patient was admitted to the skilled nursing facility. She has a medical history notable for diabetes, hypertension, lymphedema, hyperlipidemia, and obesity. She was admitted for acute care recovery for the diagnoses noted above. She required a third toe amputation. The patient lives at home alone and was expected to return home with home health care after a period of recovery at the skilled nursing facility. 

The requested Skilled Nursing Facility (SNF) Stay was not medically necessary for this patient. 
The patient showed a plateau in her improvement with physical therapy. She was not making meaningful progress towards her goals. Therapy was eventually discontinued after continued evidence of a lack of progress. The plan was correct in their assessment that the patient does not meet the criteria for an ongoing skilled nursing facility stay. She was not able to demonstrate strong rehabilitation potential for medical justification for an ongoing stay. Therefore, the request for an ongoing stay at the skilled nursing facility was not medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Breast cancer.
Treatment:  Radiation Therapy for Breast Cancer: Phase 1:25 fractions (treatment sessions) of proton beam therapy.

The insurer denied coverage for Radiation Therapy for Breast Cancer: Phase 1:25 fractions (treatment sessions) of proton beam therapy.  The denial is upheld.

According to the medical records, the patient is an adult female with history of cT4dN1 ypT2N1a right breast cancer status post (s/p) neoadjuvant systemic therapy followed by surgical resection. The request is for approval of postoperative proton beam radiation therapy.

Proton radiation is not proven to yield superior clinical outcomes in the member's setting. The provider did not supply a proton/photon plan comparison to show that photon radiation is unable to provide adequate safety/precision (the provided plan comparison was for a case control and not specific to this patient). The patient has not received prior radiation to the same area.  She does not have a genetic/comorbid condition that increases her risk for normal tissue sensitivity since the records indicate that her Ehlers Danos syndrome and Lupus are currently inactive.

"Radiation therapy plays an important role in the multidisciplinary management of breast cancer. Recent years have seen improvements in breast cancer survival and a greater appreciation of potential long-term morbidity associated with the dose and volume of irradiated organs. Proton therapy reduces the dose to nontarget structures while optimizing target coverage. However, studies have yet to demonstrate that protons improve upon the treatment outcomes achieved with photon radiation therapy. There remains considerable heterogeneity in proton patient selection and techniques, and the rapid technological advances in the field have the potential to affect evidence evaluation, given the long latency period for breast cancer radiation therapy recurrence and late effects." (Mutter, R. W. et al. 2021).

"The therapeutic options for patients with noninvasive or invasive breast cancer are complex and varied. These National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines for Breast Cancer include recommendations for clinical management of patients with carcinoma in situ, invasive breast cancer, Paget disease, phyllodes tumor, inflammatory breast cancer, and management of breast cancer during pregnancy. The content featured in this issue focuses on the recommendations for overall management of ductal carcinoma in situ and the workup and locoregional management of early stage invasive breast cancer." This article discusses radiotherapy but makes no mention of proton beam. (Gradishar, W. J. et al. 2022). Similarly, the most recent NCCN for breast cancer does not mention use of proton beam. (NCCN V 4.2023)

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Radiation Therapy for Breast Cancer: Phase 1:25 fractions (treatment sessions) of proton beam therapy image guided radiation therapy services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
The patient has a past medical history significant for hypertension who presented to the emergency room with complaints of cough and right lower quadrant pain. 

Vitals on presentation included: Temperature 101.2 Fahrenheit (F), Blood Pressure (BP) 160/108, Pulse (P) 112, Respiratory Rate (RR) 20, oxygen (O2) saturation 99% on Room Air (RA). Laboratory values were notable for the following: White Blood Cell (WBC) Count 14.7, Hemoglobin (Hgb) 15.2, Hematocrit (Hct) 42.6, creatinine 1.10, glucose 116, lactic acid 3.4, creatine phosphokinase (CPK) 1400, and sodium 128.

The patient was empirically started on antibiotics (vancomycin and Zosyn) and intravenous (IV) fluids. A Chest X-ray (CXR) showed increased opacity of the left lung base. A computed tomography (CT) scan of abdomen/pelvis was negative. The patient improved clinically, remained afebrile and hemodynamically stable. The patient was discharged to continue outpatient management. 

According to medical records, the patient presented with a fever (101.2 F), tachycardia (heart rate of 112), hypertension, and multiple laboratory abnormalities including elevated WBC, CPK, lactic acid, and low sodium. The patient's CXR was suggestive of pneumonia. Based on the above findings in a high-risk patient with a history of substance abuse, hospital admission was medically necessary for administration of intravenous antibiotics and additional diagnostic evaluation.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient emergency admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

This patient is an adult female with no significant medical history. She presented to the hospital with nausea, vomiting, and abdominal pain. The patient was started on intravenous fluid and pain control. She was given antibiotics and underwent imaging. The patient subsequently left the hospital against medical advice.

The requested health service was not medically necessary.

The requested service would not be considered medically necessary as it would be for the convenience of the patient or the practitioner. Acute inpatient level of care was not the least intensive and/or most appropriate alternative among diagnostic and treatment options. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain, palpitations
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

This is an adult male patient who presented to the hospital complaining of chest pain, palpitations, and shortness of breath on exertion. On arrival, the patient's vital signs were stable: 
blood pressure 152/65 millimeters of mercury (mmHg) and pulse 92 beats per minute (bpm). His physical exam revealed no significant abnormality. A 12-lead electrocardiogram demonstrated normal sinus rhythm without ST or T wave abnormalities. Serum blood testing was significant for a hemoglobin of 7.7 grams per deciliter (g/dl) and mean corpuscular volume (MCV) of 67. The patient was admitted to the hospital where an acute coronary syndrome was ruled out. 
Echocardiogram demonstrated a left ventricular ejection fraction of 55% and no significant valvular abnormalities. The patient was transfused with one unit of blood. Gastroenterology workup demonstrated large, thrombosed hemorrhoids. The patient was ultimately discharged on iron therapy.

The requested health service for inpatient medical admission was medically necessary.

This patient presented with chest pain, palpitations, and dyspnea on exertion and was found to have severe iron deficiency anemia. He required inpatient admission with blood transfusion and endoscopy (2). This patient presented with chest pain, palpitations, and dyspnea on exertion and was found to have severe iron deficiency anemia. Although this patient had a low history, electrocardiogram, age, risk factors, and troponin (HEART) score (1), admission to the hospital was medically necessary to assess for an acute coronary syndrome in the setting of severe anemia. Moreover, the patient had recurrent symptoms of chest pain and dyspnea on exertion and required diagnosis and treatment of anemia. Current guidelines support inpatient admission, transfusion, and endoscopy for patients who present with severe anemia (2).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Upper respiratory infection with known sickle cell disease
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld.

This was a child with known sickle cell disease with a history of fever up to 102 degrees Fahrenheit. This was accompanied by nasal congestion, transient headache, watery eyes, fatigue and decreased oral intake. Other than a heart rate of up to 140, the patient was hemodynamically stable with 100% (percent) oxygen saturation and the physical examination was unremarkable, except for right ear canal erythema, clear rhinorrhea, and mild bilateral anterior cervical lymphadenopathy. The patient was non-toxic and was well hydrated.

A decision was made to admit and administer intravenous (IV) antibiotics, but the record is lacking in any medical decision making (MDM) to support this plan of management. The fever was due to the patient's current upper respiratory infection. There is no evidence in the chart to support a suspicion of an acute sickle cell crisis, chest crisis or sepsis.

Fever in a sickle cell anemia patient does not always warrant inpatient level of care. Current guidelines for management of sickle cell disease, referenced below, support this conclusion. 

According to Emergency Medicine guidelines, https://www.acep.org/sickle-cell/ 
"Consider admission if pain is not well-controlled; patients usually know if their pain has stabilized at a manageable level; Other complications found (e.g., infiltrate on CXR [chest x-ray]; suspect serious or systemic infection); Consider admission for young (<[less than} 1 year) patients, or older patients with fever if they cannot seek care quickly or follow-up with SCD [sickle cell disease] provider the next day; Consider alternative treatment settings for improving but not relieved pain, such as observation units, to allow for a longer duration to treat pain and spare a hospital admission." 

Lab parameters were within normal limits except for a mild elevation of aspartate aminotransferase (AST) of 93.

While it was clinically appropriate to assess for possible bacteremia given homozygous sickle cell disease, and administer a dose of Ceftriaxone, the patient did not meet any criteria for a higher level of care and could have been followed up as an outpatient.

The reviewer agrees with the insurer that there was no hemodynamic, pulmonary, neurological, or metabolic reason to treat the patient at an acute level of care, the patient could have been treated at an observational level. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: D8080 Braces
The insurer denied: D8080 Braces
The denial is overturned.

This patient is a teenage male. The request is for orthodontic benefits. The patient has moderate upper and mild lower crowding. He has a posterior right side crossbite. The prior denial was due to a handicapping index scale of 13. 

The requested health service is medically necessary.

The patient has an over-retained upper left primary canine, meaning the baby canine is still present where the adult canine should be. He also has a transposed upper left canine that is out of position in the spot of the upper premolar. The canine is way out of the arch, into the cheek, which will be a major food trap and caries risk. Also, without the canine in its proper position, there can be no "canine guidance" during the chewing cycle. This is when the lower canine glides along the upper canine in a fashion that allows the other teeth to disarticulate. With no canine guidance, all the posterior teeth will grind together and over time will be traumatized by either fracturing and/or loosening. Orthodontic treatment is needed to correct this patient's malocclusion and get his upper left permanent canine in its proper position. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck pain
Treatment: Trigger Point Injections (20553 x1)
The insurer denied: Trigger Point Injections (20553 x1)
The denial is overturned.

The patient is an adult female with neck pain for many years. She has tried over three months of non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and activity modification as well as home exercise without relief. Her pain is a 5/10 and
prevents ability to perform activities of daily living. It is noted the patient has never had invasive procedures for the neck or back previously. Trigger points are identified on exam in the cervical paraspinal muscles, splenius capitis, and trapezius muscle. The patient was diagnosed with myofascial pain, and trigger point injections were performed. Request for trigger point injections was denied as it has been more than 12 months since the first injection.

The requested health service is medically necessary.

According to the policy as well as medical community standards of care and published literature, trigger point injections are medically necessary for the following indications: 
"A. Diagnosis/stabilization of trigger points with injections of corticosteroids and/or local anesthetics at the trigger point, all of the following: 
1. The member/enrollee has local pain symptoms in the neck, shoulder and/or back that have persisted for more than 3 months causing tenderness and/or weakness, restricting motion and/or causing referred pain when compressed; (met) 
2. The member/enrollee has failed greater than or equal to 3 weeks of conventional multidisciplinary medical therapy including all of the following: (met) 
a. Chiropractic, physical therapy, or prescribed home exercise program or the member/enrollee is unable to tolerate such therapy and the injection is intended as a bridge to therapy; (met) 
b. Non-steroidal anti-inflammatory drug (NSAID), unless contraindicated or not tolerated; (met) 
c. Activity modification; (met) 
3. Trigger points have been identified by palpation; (met) 
4. Trigger points are located in a few discrete areas and are not associated with widespread areas of muscle tenderness (as with fibromyalgia); (met) 
5. Injections are not used as sole method of treatment, rather are intended for pain relief to facilitate mobilization to allow non-invasive modalities, e.g., physical therapy and other alternate therapies that address muscle strengthening, flexibility, and functional restoration. (met) 
Up to 2 sets of injections at least 7 days apart may be given for diagnosis and stabilization for the same trigger point. When a given body region is injected, it will be considered as one injection service no matter how many injections are given. (n/a)"
The patient meets the standards of care for medical necessity. The notes provided do not indicate the patient has been receiving injections for more than 12 months or that the patient has ever had these injections previously. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Overturned



Diagnosis: Impacted canines 
Treatment: Braces/monthly visits
The insurer denied braces/monthly visits.
The health plan's determination is overturned. 

The patient in question is a female with four impacted canines (teeth 6, 11, 22, and 27). All of these teeth are completely blocked out and will be unable to erupt without orthodontic intervention. She presents with a skeletal Class I malocclusion and severe crowding. She is treatment planned for Braces and Monthly Visits to address the crowding and impacted teeth.

Braces and Monthly Visits are medically necessary for this patient. 
If left untreated, the damage that will likely occur to the patient's teeth will be more time consuming and costly to correct than the patient's existing orthodontic problem. Complications of impacted canines include potential root resorption and devitalization of the adjacent lateral incisors. For this reason, the requested orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I occlusion
Treatment: braces
The insurer denied braces
The health plan's determination is upheld. 

The patient in question is a female with a Class I occlusion with 5 millimeter (mm) overbite and 1 mm overjet. She has mild maxillary and mandibular crowding. Treatment is planned for braces to correct her malocclusion. 

Braces are not medically necessary for this patient.
The patient has crowding but no teeth are impacted. Her overbite is deep but there is no indication of damage to the incisors in the photographs. Her cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient.
While the patient has crowding, there is no detectable anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient has a 1mm overjet which does not affect oral health related quality of life. If her teeth were aligned it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Class II Occlusion
Treatment: Braces, Monthly Visits, and Retainer 
The insurer denied Braces, Monthly Visits, and Retainer 
The health plan's determination is overturned. 

The patient in question is a young female with a buccal (reverse) crossbite on teeth # (number) 4 and #5. She has maxillary and mandibular crowding. She presents with a Class II malocclusion. 

Braces, Monthly Visits, and Retainer are medically necessary for this patient.
Because teeth 4 and 5 are in buccal crossbite, they have no antagonist. As a result, it is extremely likely that these teeth will over-erupt. Once this overeruption occurs, it is very difficult to treat. Buccal crossbite (also known as scissor-bite in the literature) can also negatively affect mandibular growth and should be treated as early as possible to eliminate the potential growth disturbance.
If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For these reasons, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: vomiting
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This case involves a man with diabetes mellitus who was admitted to the hospital with coffee-ground emesis. He also complained of left-sided chest pain. Symptoms started after an alcohol binge drinking episode and cocaine use. 

The inpatient hospital admission was not medically necessary.
The patient has nonspecific chest pain, with adynamic cardiac enzymes, due to cocaine use. The echocardiogram had no regional wall motion abnormalities, but the ejection fraction was depressed. There is no indication whether this is a new finding or an acute decrease in the ejection fraction. Based on electrocardiogram (EKG) and cardiac enzymes, there is no clear evidence of acute coronary syndrome. Cocaine-induced troponin leak is a common finding and does not correlate with obstructive coronary disease. There is no evidence of diabetic ketoacidosis on the chemistry panel. The patient's hemoglobin was stable, and there was no further evidence of gastrointestinal bleeding. The patient remained hemodynamically stable throughout the hospital stay and improved within 24 hours, so he left the hospital against medical advice (AMA) to go to work.
There is no evidence that the patient's condition could not be managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: weakness.
Treatment: inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a female with a history of metastatic right-sided inflammatory breast cancer with metastases to the liver, lymph nodes, and most recently to the cerebellum associated with obstructive hydrocephalus, necessitating treatment with steroids and radiation therapy, who presented to the Urgent Care Center with multiple electrolyte abnormalities. At that time, she was undergoing chemotherapy with Carboplatin-Trastuzumab.
In addition to electrolyte abnormalities, the patient had severely abnormal liver function tests. Despite adhering to prescribed dietary and supplemental regimens since her recent discharge, she experienced a few episodes of diarrhea, which she managed with Imodium. She denied nausea, vomiting, abdominal pain, chest pain, shortness of breath, or any other acute complaints. However, she noted a progressive yellowing of her eyes over the last couple of days.

The inpatient hospital admission on the dates in question was not medically necessary.
During this period of time, the patient remained afebrile and hemodynamically stable. The patient did not require treatment with intravenous antibiotics since the course of antibiotics was finished by that time. The patient was feeling well generally and had no new complaints.
She underwent two additional chemotherapy treatments, which she tolerated very well. In general, these treatments could be administered as an outpatient. The patient received treatment with oral corticosteroids and did not require long-term treatment with intravenous corticosteroids. She worked with physical and occupational therapy due to physical deconditioning and debility and was waiting for placement at subacute rehab.
The review of the medical records clearly demonstrated that neither the severity of the patient's condition nor the complexity of services provided rose at the acute inpatient level of care.