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

Diagnosis: Urinary Tract Infection
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a past medical history (PMH) of migraines and constipation who was admitted with complaints of (c/o) right flank pain. The vital signs were notable for a pulse of 100. The physical exam was notable for costovertebral angle (CVA) tenderness and mild distress. Lab work was notable for leukocytosis, a urinalysis (UA) with positive (+) nitrates and pyuria, a urine culture showed positive (+) Escherichia (E). coli growth. Imaging studies included a computed tomography (CT) scan of the abdomen/pelvis (A/P) which showed no acute intra-abdominal or pelvic abnormality. The patient was diagnosed with a urinary tract infection (UTI) and treated with intravenous (IV) antibiotics, intravenous fluids (IVF), and pain control. Infectious disease (ID) evaluated the patient and noted that the patient was not septic on admission. A discharge summary noted that there was no imaging evidence of pyelonephritis and that the right flank pain was most likely musculoskeletal in origin. The patient was discharged in stable condition. At issue is the medical necessity of an 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 right flank pain. The patient was hemodynamically stable, did not have severe acute kidney injury, ascending infection, toxic appearance, unstable vital signs, immunosuppression, urinary obstruction, coexisting urolithiasis, residing in long-term care facility, diabetes mellitus type 2 (DM2), abnormal anatomy, abscess formation, single kidney, or kidney transplant. The patient was evaluated by Infectious Disease and noted that the patient was not septic on admission and while there was consideration of pyelonephritis, the discharging physician noted that the patient's flank pain was most likely secondary to musculoskeletal origin and that the patient had a standard urinary tract infection. Overall, this patient was found to have a UTI and treated with IV antibiotics, with resolution of the patient's symptoms, and these interventions could have been safely and appropriately provided at a lower level of care.
Regarding the provided criteria, the patient did not have hemodynamic instability, altered mental status (AMS), worsening clinical findings despite observation care, pregnancy, kidney transplant, significant uropathy, device-associated infection, ureteral obstruction, impaired bladder emptying, renal abscess, emphysematous pyelonephritis, or acute renal failure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral Palsy
Treatment: Replacement Manual Wheelchair
The insurer denied the replacement manual wheelchair.
The denial is overturned.

The patient is a school-aged male with a medical history of cerebral palsy. A mobility evaluation performed nine months ago indicated that the patient has quadriplegic cerebral palsy as well as neuroscoliosis, seizure disorder, and impaired tone. He is non-ambulatory and dependent for activities of daily living. He is dependent for transfers and requires a lift to perform transfers. The patient's current manual wheelchair is greater than five years old and requires replacement. He was noted to have neuroscoliosis with pelvic asymmetry. There was noted reduced range of motion in the extremities with spasticity. He requires ankle foot orthoses for positioning of his feet and ankles. A face-to-face mobility evaluation was performed by the patient's physician. The patient was noted to have impaired trunk control and spasticity of all extremities. The requested durable medical equipment was denied coverage by the health plan as not medically necessary, including adjustable footrests, rocker back, and a tray. This decision is being appealed.

The requested manual wheelchair and its accessories are medically necessary.

The patient is non-ambulatory and cannot use a cane or walker for assistance with ambulation. He requires a manual wheelchair for mobility and accomplishing daily activities. He has spastic quadriplegic cerebral palsy and cannot transfer or perform pressure relief. Therefore, he requires a manual wheelchair with tilt in space functionality to provide pressure relief and decrease the likelihood of skin breakdown. He requires a new manual wheelchair since his current manual wheelchair is older than five years of age and he has outgrown it. The patient has positioning requirements given his spasticity, neuroscoliosis, and pelvic asymmetry. This requires a manual wheelchair with the appropriate seat cushions and adjustable height back to support his anatomy. He also requires a rocker back given his positioning needs and trunk spasticity. He requires adjustable foot plates to support his lower extremities and these must be able to accommodate his ankle foot orthoses which are necessary to decrease plantar flexion contracture due to his lower extremity spasticity. The coding for the foot restraints has been clarified and these are necessary to restrain the patient's feet in the manual wheelchair.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever and Shortness of Breath (SOB).
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 hypothyroidism and hyperlipidemia. Her presenting complaints were fever, dyspnea and chest pain, along with a sore throat and a runny nose. On arrival to the emergency department the patient's vital signs were, a blood pressure of 125/81, her heart rate was 114, her respiratory rate was 20, and her oxygen saturation was 94 percent (%) on room air. Her physical examination was notable for the presence of moderate respiratory distress and wheezing. Her laboratory studies were notable for positive rhinovirus. Her white blood cell count (WBC) was 10.8 and she had a negative troponin level.

She was admitted to an inpatient level of care where she was treated for viral versus bacterial pneumonia triggering an asthma exacerbation.

The health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient. 

The inpatient stay was not medically necessary. The patient presented with fever, shortness of breath, and wheezing consistent with low-risk pneumonia secondary to viral or bacterial etiologies (later she was found to be rhinovirus positive). This likely triggered a mild-moderate asthma exacerbation.

The patient had an unremarkable chest x-ray and her chest computed tomography (CT) had lingular ground glass opacities. Upon reassessment several hours after emergency department (ED) presentation, the patient was noted to be in continued respiratory distress. She was given steroids and antibiotics. The workup in the ED excluded a pulmonary embolism and acute coronary syndrome. The reassessment in the ED did not note improvement in symptoms but given that time period was only a few hours a period of an observation level of care would have been appropriate to monitor the patient for improvement, intervene quickly to interrupt clinical worsening and to administer therapies such as steroids and nebulizer therapies. Given the patient's lack of hypoxia, severe respiratory distress and abnormal peak flow readings, an observation level care would have been most appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, hypertension, dementia

Treatment: Personal care aide (PCA) services 2-12-hour split shifts, 7 days a week

The insurer denied coverage for personal care aide (PCA) services 2-12-hour split shifts, 7 days a week

The denial is overturned

 
This is an advanced elderly patient with medical problems that include coronary artery disease, hypertension and dementia. She lives alone in a 1-bedroom apartment. The patient is approved for Patient Care Aide (PCA) live-in services, and the request is for PCA services 2-12-hour split shifts, 7 days a week, which is under review.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Moderately Impaired-Decisions consistently poor or unsafe; cues/supervision required at all times." She is totally dependent to maximal assistance for Instrumental Activities of Daily Living (IADL) tasks. She is also totally dependent for bathing, lower body dressing and toilet use. She is frequently incontinent of bladder and infrequently incontinent of bowel. She requires maximal and extensive assistance for upper body dressing and bed mobility, respectively. She is unable to perform transfer activities (locomotion) or ambulate. The patient is essentially bed bound and should be repositioned while in bed approximately every 2 hours particularly since sustaining the recent hip fracture due to a fall and to prevent decubitus ulcers. Based on the records reviewed, the approved live-in PCA is unlikely capable of providing for the patient's functional needs with the ability to consistently obtain an uninterrupted 5 hours of sleep. The patient's declining clinical condition (requiring hospice care), cognitive and functional deficits are at a level or unpredictable as to require the requested PCA services 24 hours a day split shift (two 12-hours shift).  

Based on the above, the insurer's denial must be overturned. 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 personal care aide (PCA) services 2-12-hour split shifts, 7 days a week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right facial palsy
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This case involves a young adult who presented to the emergency department with complaints of right-sided facial droop with 1 hour onset. The patient denied any significant past medical history. The patient did report weakness in the legs as well as headache and dizziness for the past week. Physical examination noted right facial droop and flattening of the right nasolabial fold. Treatment plan was for labs, computed tomography (CT) of the brain, and neurology consultation. Neurology consultation stated there was evidence of right facial palsy on examination. There was no difficulty walking or with speech or vision. Forehead appeared spared, but there was weakness of the right orbicularis oculi suggesting a peripheral cranial nerve VII palsy. Computed tomography (CT) of the head showed no acute abnormality. The patient's condition was suggestive of Bell's palsy. The patient had a National Institutes of Health Stroke Scale (NIHSS) score of 3. The patient was admitted due to clinical signs and symptoms of suspected cerebrovascular accident (CVA). 

Neurology progress note noted facial asymmetry with cranial nerve VII palsy. Treatment plan was for medication management, physical therapy for facial palsy, and magnetic resonance imaging (MRI). Neurology progress note indicated MRI of the brain revealed no acute intracranial pathology. It was noted the patient could be discharged home with follow-up with neurology in 1 week. Discharge summary reported principal problem on admission was right facial palsy. The patient was discharged to home in good condition. 

There were no significant findings to support admission versus completion of diagnostic workup in the ER (emergency room) or under observation status. Inpatient admission was not supported given lack of findings concerning for CVA and/or need for ongoing monitoring after diagnosis.

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 acute hospital care is not substantiated.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: chest pain
Treatment: inpatient stay
The insurer denied the inpatient stay. 

The health plan's determination is overturned. 

This man presented to the emergency department (ED) complaining of two days of intermittent chest pain. He had been seen in a different facility and was found to have an abnormal electrocardiogram and a serum troponin level of 0.07 that increased to 0.115. His medical history was remarkable for anxiety, depression, and gastroesophageal reflux disease. In the ED, his blood pressure was 122/76 with a heart rate of 78 beats/minute. His room air oxygen saturation was 99% (percent). An electrocardiogram showed sinus rhythm with biphasic T waves in the anterior leads. The patient was treated with aspirin and a statin and admitted to the hospital with acute coronary syndrome. 

Based on the documentation provided, an inpatient level of care was medically necessary.
This patient presented with chest pain, an abnormal electrocardiogram, and an elevated serum troponin level with a significant delta troponin. Thus, he met accepted criteria for a diagnosis of non-ST segment elevation myocardial infarction (NSTEMI). Given the risks for adverse outcomes, including heart failure, shock, malignant arrhythmias and death, inpatient admission is the standard of care for patients with NSTEMI.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic constipation.
Treatment: Linzess 290MCG (micrograms) OR (oral) Caps.
The insurer denied: Linzess 290MCG (micrograms) OR (oral) Caps.
The denial is upheld.

The patient is an adult female with history of chronic constipation, IBS-C (irritable bowel syndrome with constipation). An appeal letter is indicating that the patient tried and failed multiple agents, such as Colace, Dulcolax, MiraLAX, Librax, Lactulose, and dicyclomine.
The patient's provider ordered Linzess on clinic visit, with good response. The health plan denied coverage due to lack of prior trial with Amitiza, which is the health plan's preferred medication. Per the correspondence, Lublprostohe (Amitiza) should be tried and was authorized.
The denial is being appealed, and the provider is requesting continuation of Linzess.

The requested Linzess is not medically necessary.

There is no high-quality literature to support the use of Linzess over Amitiza. According to the American College of Gastroenterology (ACG) Clinical Guideline: Management of Irritable Bowel Syndrome in 2021, both Lublprostone (Amitiza) and Linaclotide (Linzess) are recommended for management of global IBS-C (irritable bowel syndrome with constipation) symptoms.
"We recommend the use of chloride channel activators (Lubiprostone) to treat global IBS-C symptoms. Strong recommendation; moderate quality of evidence."
"We recommend the use of guanylate cyclase activators (linaclotide and plecanatide) to treat global IBS-C [irritable bowel syndrome with constipation] symptoms. Strong recommendation; high quality of evidence."
Thus, based on the current guidelines, Linzess and Amitiza are evidenced to be equally effective. 
One cannot be considered medically necessary over the other.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain
Treatment: Intracept procedure
The health plan denied the requested health service/treatment of Intracept procedure as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with a history of low back pain. The pain began over 5 years ago. Prior treatments have included a back brace, home exercises, therapy, and medications. The pain continues to be severe, ranging from 7 out of 10 to 10 out of 10. The pain impacts her activities of daily living (ADLs). Magnetic resonance imaging (MRI) of the lumbar (L) spine reported Modic changes with disc space at L3. It is noted that the patient has vertebrogenic changes.

At issue is the medical necessity of the requested health service/treatment of Intracept procedure.

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

The requested health service/treatment of Intracept procedure is not medically necessary for this patient. There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment; however, there is lack of data to recommend this procedure as a treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care. Given the above, the requested health service/treatment of Intracept procedure is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Symptomatic lower extremity varicose veins and venous insufficiency
Treatment: Left leg venous closure with stab avulsion phlebectomy.
The health plan denied the requested left leg venous closure with stab avulsion phlebectomy as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with symptomatic lower extremity varicose veins and venous insufficiency, who underwent radiofrequency ablation of the right great saphenous vein and stab avulsion phlebectomy of the right leg.
An ultrasound of the bilateral lower extremities demonstrated reflux in the bilateral great saphenous veins. The patient was seen in follow up after her treatment. The patient was noted to have experienced significant relief of her right leg symptoms since her treatment and wishes to have treatment of her left leg.
The patient's right leg was noted to be healing well. She was noted to have varicose veins in the left leg. She was recommended treatment of her left leg varicose veins and venous insufficiency by radiofrequency ablation and stab avulsion phlebectomy.
At issue is the medical necessity of the requested health service/treatment of Ambulatory Surgery (left leg venous closure with stab avulsion phlebectomy).
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of Ambulatory Surgery (left leg venous closure with stab avulsion phlebectomy) is medically necessary for this patient.
Radiofrequency ablation of the left great saphenous vein and stab avulsion phlebectomy of the left lower extremity is medically necessary in this patient with symptomatic left lower extremity varicose veins and venous insufficiency. Radiofrequency ablation of the great saphenous vein is the standard of care for the treatment of lower extremity venous insufficiency. Stab phlebectomy is the standard of care for the treatment of symptomatic lower extremity varicose veins.
The patient will benefit from the treatment. Therefore, the requested health service/treatment of Ambulatory Surgery (left leg venous closure with stab avulsion phlebectomy) is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and nausea
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female who presented to the emergency department with complaints of abdominal pain and nausea. The patient's physical exam demonstrated abdominal tenderness. The patient's white blood cell (WBC) count was 17, and computed tomography showed an eight-millimeter inflamed appendix. Her heart rate was normal, and she was afebrile. The patient was taken to the operating room for laparoscopic appendectomy. She was discharged home the same day after surgery.

The proposed inpatient hospital admission was not medically necessary.

The inpatient admission for this case of uncomplicated appendicitis is not medically necessary. 

The documentation provided shows that there is no need for inpatient admission as the patient had an uncomplicated case of appendicitis. Her vitals remained stable, and she was afebrile. She had transient episodes of hypotension that per the documentation were treated with intravenous fluids. There is no documentation that this patient needed any additional fluids after her surgical procedure or monitoring for her hypotension. The patient's laboratory values that demonstrated abnormalities include her white blood cell (WBC) count and bicarbonate; these were not trended and the patient was discharged home after her procedure. 

Standard of care for treatment for uncomplicated appendicitis which this patient had can be treated at an outpatient level of care. This has been proven in the literature. 

Given the clinical improvement, and lack of support for inpatient admission, the inpatient admission is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: D8080 braces and D8670 monthly visit x 12. 

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12.
The denial is overturned. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified deep impinging overbite, and anterior impactions. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index choosing the automatically qualifying conditions of deep impinging overbite with severe soft tissue damage and impacted permanent anterior where extraction is not indicated on the HLD index. 

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, and 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 completed the HLD index, choosing the deep impinging criterion and impacted permanent anterior criterion to justify orthodontic care. The clinical circumstance meets these criteria for approval of care. 

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. 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 health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for D8080 braces and D8670 monthly visit x 12 is overturned. Medical Necessity is substantiated.