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

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied Braces and monthly visits. 
The denial is upheld. 

The patient is a male with a Class I occlusion with appropriate overbite and overjet. He has maxillary and mandibular spacing. He has treatment planned for orthodontics to correct his malocclusion. His health plan has denied the request on the basis that treatment is not medically necessary. The family is appealing this ruling.
At issue is the medical necessity of Braces and monthly visits.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Braces and monthly visits is not medically necessary for this patient.
The patient has some minor spacing. His overbite is appropriate and there is no indication of damage to the incisors. His cephalometric radiograph showed he does not have a traumatic deep bite. There is no indication that there is severe soft tissue damage (or any soft tissue damage) on this patient.  There is no medical reason to correct his malocclusion with braces. While the patient has crowded teeth, there is no 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. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. If his teeth were aligned, it would provide an aesthetic improvement, but it would not create a medical improvement to the patient's health.
Therefore, the requested health service/treatment of Braces and monthly visits is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class III Periodontal Disease

Treatment: D4341 deep gum and root cleaning in all four quadrants

The insurer denied coverage for D4341 deep gum and root cleaning in all four quadrants

The denial is upheld.

Based on the submitted documentation which includes copies of periodontal charting, dental chart notes, panoramic and bitewing radiographs, and insurer correspondence, it appears that this patient presented for evaluation for dental services and periodontal therapy. The dentist reported periodontal chartings indicating 2-5 millimeter generalized periodontal pocketing with focal 6-millimeter depth readings bleeding on probing. The recommended treatment was scaling and root planing in all for maxillary and mandibular quadrants. 

Upon review of the submitted documentation, there is minimal if any loss of alveolar bone height affecting these teeth. Although, there is evidence of radiographic calculus the increased pocket depths likely represent pseudo pocketing due to superficial calculus accumulation and poor oral hygiene. There is minimal significant periodontal probing with no periodontal probing over 6-millimeter depth. The insurer has correctly applied the clinical criteria in denying scaling and root planing services.

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient. The clinical and radiographic documentation does not support or substantiate scaling and root planing services.

The insurer's denial of coverage for the D4341 deep gum and root cleaning in all four quadrants is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diarrhea.
Treatment: Colonoscopy (45380) performed in a hospital (or hospital clinic).
The insurer denied the Colonoscopy (45380) performed in a hospital (or hospital clinic).
The denial is upheld.

The patient is a male patient who underwent a colonoscopy. The patient had undergone a colonoscopy for colon cancer screening and change of bowel habits at a gastrointestinal (GI) endoscopy and surgery center.

No, the proposed treatment, colonoscopy (45380) performed in a hospital (or hospital clinic) was not medically necessary.
The colonoscopy as performed was medically indicated for the evaluation of chronic diarrhea.  The setting at which the care was provided was not medically necessary. There was no cogent medical information provided to support the performance of this service at an on-campus hospital setting. The patient did not have significant medical conditions, an American Society of Anesthesiologists (ASA) class of III, or other conditions such as morbid obesity or severe obstructive sleep apnea (OSA) requiring care at an on-campus service site.

The plan declined the request as follows:
"This service can be approved under the plan clinical criteria in a hospital setting when one of these is met: 1) there are no other places nearby to obtain the service; or 2) the medical status or the procedure needs monitoring that can only be done in a hospital; and if problems occur, the person can only be treated safely in a hospital. The information we have does not show you have any of these problems. For this reason, this request for the procedure to be done in a hospital (or hospital clinic) is denied as not medically necessary."

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The colonoscopy as performed was medically indicated for the evaluation of chronic diarrhea.  The setting at which the care was provided was not medically necessary. There was no cogent medical information provided to support the performance of this service at an on-campus hospital setting. The patient did not have significant medical conditions, an American Society of Anesthesiologists (ASA) class of III, or other conditions such as morbid obesity or severe obstructive sleep apnea requiring care at an on-campus service site.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ectopic Pregnancy. 
Treatment: Inpatient Admission. 

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

The patient is a female with one pregnancy (G1) referred from her physician's office for eight weeks of amenorrhea and ultrasound consistent with five centimeter ectopic pregnancy.  She was admitted to the hospital and taken to the operating room where, under general anesthesia, dilatation and curettage, diagnostic laparoscopy, lysis of adhesions, and salpingectomy were performed without complications.  The patient was taken to the post operative recovery room where she had an uneventful postoperative course and she was discharged to home in good condition. 

The health plan denied the admission.  The prior denial reason was lack of medical necessity for inpatient level of care and based this on plan criteria including continued heavy bleeding, low blood pressure, high heart rate, uncontrolled nausea and vomiting, bladder, bowel, or other damage and cites Milliman Care Guidelines (MCG).  The facility contends that the admission was medically necessary.  The reason for appeal is that there was a high risk of mortality and bleeding from ruptured ectopic pregnancy and that the criteria cited by the health plan were not relevant to this patient's condition because they did not cite ectopic pregnancy. 

No, the proposed inpatient admission was not medically necessary. 

The preoperative, intraoperative, and post operative course of this patient's treatment were entirely uncomplicated.  There were no surgical or anesthetic complications.  Uncomplicated gynecologic laparoscopic surgical procedures can be performed on an ambulatory basis routinely.  Although untreated ruptured ectopic pregnancy can present with life-threatening intraperitoneal bleeding, this was not the case for this patient.  Further, once a definitive surgical procedure is performed and is determined to be hemostatic based on routine postoperative observation there is no need for or benefit from admission and the patient can be safely discharged to home without hospital admission. 

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Myocardial Infarction

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is the case of an adult male that presented to the hospital with chest pain lasting for thirty minutes accompanied by nausea and vomiting. His past medical history was significant for hypercholesterolemia and provoked pulmonary embolism. On further questioning, the patient reported intermittent chest pain over the preceding two weeks. On arrival the pain was 10/10 in severity. On physical exam, vital signs were stable with a blood pressure of 151/91 and a pulse of 66 his body mass index (BMI) was 35.5 and no other significant abnormalities were noted. Electrocardiogram (ECG) revealed anterior Q (interval on ECG) waves with ischemic ST (interval on ECG) abnormalities in the anterior precordial leads. Serum troponin was elevated at 0.9 nanogram/milliliter (ng/ml). Computed tomography angiography (CTA) of the chest revealed no pulmonary embolism and no aortic dissection. The patient was admitted to the coronary care unit (CCU) for further management. Overnight repeat serum troponin was noted to be 6.9 and the patient continued to note 10/10 chest pain. He ultimately underwent cardiac catheterization with percutaneous intervention to a 100% (percent) occlusion of the mid left anterior descending artery. He was treated medically and released three days following presentation.

Risk assessment of patients presenting with chest pain and ST (interval on ECG) changes on ECG as well as negative cardiac enzymes was performed by Sanchis et al. (Reference 3). Using their risk stratification schema, this patient would have a high risk of future myocardial infarction or death within one year.

This patient presented with an acute myocardial infarction and a 100% occlusion of the mid left anterior descending (LAD) coronary artery. His HEART (history, age, ECG, risk factors, troponin) score of six put him in the high-risk category, consistent with a high risk of future cardiac events (1, 2). He was admitted and ultimately noted to have a new hemodynamically significant lesion on cardiac catheterization as well as a change in the left ventricular ejection fraction (LVEF).  Based on his high-risk score using both the HEART and TIMI (thrombolysis in myocardial infarction) risk stratification, acute care hospital admission was medically necessary.

Based on the above, the medical necessity for the inpatient admission is substantiated. 

The health plan did not act reasonably, with sound medical judgement or in the best interest of the patient.

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

Diagnosis: Acute Myocardial Infarction

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is the case of an adult male that presented to the hospital with chest pain lasting for thirty minutes accompanied by nausea and vomiting. His past medical history was significant for hypercholesterolemia and provoked pulmonary embolism. On further questioning, the patient reported intermittent chest pain over the preceding two weeks. On arrival the pain was 10/10 in severity. On physical exam, vital signs were stable with a blood pressure of 151/91 and a pulse of 66 his body mass index (BMI) was 35.5 and no other significant abnormalities were noted. Electrocardiogram (ECG) revealed anterior Q (interval on ECG) waves with ischemic ST (interval on ECG) abnormalities in the anterior precordial leads. Serum troponin was elevated at 0.9 nanogram/milliliter (ng/ml). Computed tomography angiography (CTA) of the chest revealed no pulmonary embolism and no aortic dissection. The patient was admitted to the coronary care unit (CCU) for further management. Overnight repeat serum troponin was noted to be 6.9 and the patient continued to note 10/10 chest pain. He ultimately underwent cardiac catheterization with percutaneous intervention to a 100% (percent) occlusion of the mid left anterior descending artery. He was treated medically and released three days following presentation.

Risk assessment of patients presenting with chest pain and ST (interval on ECG) changes on ECG as well as negative cardiac enzymes was performed by Sanchis et al. (Reference 3). Using their risk stratification schema, this patient would have a high risk of future myocardial infarction or death within one year.

This patient presented with an acute myocardial infarction and a 100% occlusion of the mid left anterior descending (LAD) coronary artery. His HEART (history, age, ECG, risk factors, troponin) score of six put him in the high-risk category, consistent with a high risk of future cardiac events (1, 2). He was admitted and ultimately noted to have a new hemodynamically significant lesion on cardiac catheterization as well as a change in the left ventricular ejection fraction (LVEF).  Based on his high-risk score using both the HEART and TIMI (thrombolysis in myocardial infarction) risk stratification, acute care hospital admission was medically necessary.

Based on the above, the medical necessity for the inpatient admission is/ is not substantiated. 

The health plan did not act reasonably, with sound medical judgement or in the best interest of the patient.

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

Diagnosis: amyotrophic lateral sclerosis (ALS)
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This patient is a male with a history of diabetes and amyotrophic lateral sclerosis (ALS) who was admitted to the hospital at the request of his PCP (primary care provider) due to need for further evaluation. He had recently been treated at another hospital for neuromuscular weakness that was complicated by an aspiration pneumonia, retention of urine and a urinary tract infection (UTI). He had been hospitalized and ultimately discharged home on a ventilator and a foley as well as 24 hour care. It is noted that an attempted void trial was done with low output so a new foley was inserted. There was significant resistance noted and the patient had hematuria and he was noted to begin developing fevers as high as 101.9 as well as chills along with cloudy urine. He was noted to be afebrile but had large leukocyte esterase, white blood cells (WBC) and bacteria on a urine study. He was started on Rocephin and placed in Intensive Care Unit (ICU) due to concern for sepsis and an acute increase in his secretions and need for more frequent suctioning. He was able to void through a condom catheter and secretions had decreased.

The inpatient admission was not medically necessary. The requested services did not require care at an acute inpatient level of care. 
The documentation included does not demonstrate hypotension, ongoing bleeding, persistent elevations of temperature that did not respond to observation, decreased respiratory control or hypoxemia that was worse than the patient's baseline. The patient did require care in the hospital setting, but this could have been accomplished at a lower level and did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Missing teeth
Treatment: D6010 Implant Placement Tooth 2,3,4.5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, 30, 31 and D7951 Sinus Placement Augmentation, Pre-service
The insurer denied the D6010 Implant Placement Tooth 2,3,4.5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, 30, 31 and D7951 Sinus Placement Augmentation, Pre-service
The denial is upheld

The patient is a male requesting multiple implants placed (in both upper and lower arches) as well as sinus augmentation. The prior denial is for lack of medical necessity that would exclude other treatment options.

No, the requested health service is not medically necessary.
There is no documentation presented explaining why a full upper denture and a lower partial denture would not be a treatment option. If a full upper denture and a partial lower denture would work, there would be no need for the implants. Without a narrative explaining why this treatment option would not work, medical necessity for the requested health service cannot be established.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Without adequate explanation of why the more simple treatment of dentures would not work for this patient, the request is not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Immunologic Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Rituxan. 
The health plan's denial is overturned.

The patient is a male with dermatomyositis (DM) and polymyositis (PM) with inflammatory airway disease (creatine kinase [CK] 6270, elevated aldolase, anti-nuclear antibody [ANA] 1:1280). The patient has had previous treatment with prednisone. The issue in this case is Rituxan is being denied by the health plan. The subject under review is whether Rituxan is clinically appropriate for this patient's condition.

Yes, Rituxan is clinically appropriate for the patient's condition. Rituxan, which targets CD20-positive cells, is used to treat DM and PM in severe, recurrent, or resistant DM and PM. It's often used in clinical practice for DM and PM and there is ample data that supports its use. A study published in Arthritis Rheum concluded that "83% of adult and juvenile myositis patients with refractory disease met the definition of improvement (DOI)". Another study published in Rheumatology found that "Rituximab is an effective treatment in refractory inflammatory myopathies, showing a decrease in creatine phosphokinase (CPK) and lactate dehydrogenase (LDH), an increase in muscle strength and improvement in scores of disease activity, general health, functional ability and health related quality of life with sustained effect during a median of 27.1 months of follow-up". Finally, another study in Arthritis Rheum concluded that "DM patients treated with rituximab provided sufficiently encouraging results to justify a more formal evaluation of the value of B cell depletion therapy in the treatment of DM."
The patient has severe DM and PM with lung involvement. A letter from the patient's provided was reviewed. Given the severe nature of his condition, Rituxan is medically appropriate at this time and there is ample data supporting its use.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld. 

The patient is a female with a past medical history significant for non-ischemic cardiomyopathy, history of the mitral valve and tricuspid valve repair, laryngeal cancer in remission, history of premature ventricular contractions (PVCs), and anxiety and depression who presented to the emergency department for evaluation of dyspnea and palpitations that had been going on for several days. 

The patient noticed occasional chest tightness and some dizziness associated with palpitations. It was noted that her symptoms often correlated with her menstrual cycle. It was also mentioned that the patient had a history of chronic hypokalemia, for which she took a daily dose of potassium supplements. 
When evaluated in the emergency department, the patient had no symptoms. At the same time, the patient stated that she had a near-syncope while in the waiting room.
At the time of the initial evaluation, the patient was afebrile. Blood pressure was 132/61, heart rate was 88 beats per minute (bpm), respiratory rate was 18 breaths/minute, oxygen saturation was 98% on room air. 
The electrophysiologist reviewed the electrocardiogram (EKG) and stated that the patient was in normal sinus rhythm. It was recommended to monitor the patient's telemetry for 24 hours after initiation of Flecainide, and if stable, recommend outpatient follow-up with EP (electrophysiology). 
The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld. 

The inpatient stay was not medically necessary for this patient. 

Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. Ventricular premature beats (VPB) are single ventricular impulses caused by reentry within the ventricle or abnormal automaticity of ventricular cells. They are extremely common in both healthy patients and patients with heart disorders. VPB may be asymptomatic or cause palpitations. Diagnosis is by electrocardiography. Treatment is usually not required. 
In patients with a structural heart disorder, treatment is controversial even though frequent ventricular premature beats (greater than [>] 10/minute) correlate with increased mortality because no studies have shown that pharmacologic suppression reduces mortality. 
Ablation is offered only if symptoms are intolerable or if the VPBs are very frequent and, by inducing interventricular dyssynchrony, induce heart failure. 
In this particular case, the patient was in normal sinus rhythm and had no signs of hemodynamic instability, heart failure, altered mental status, myocardial ischemia, hypoxemia, syncope, persistent dyspnea, persistent chest pain. 
Therefore, it was reasonable to admit this patient for monitoring, however, overall, this patient remained in stable clinical condition and had no acute decompensated conditions requiring intervention at the acute inpatient level of care.