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

Diagnosis: Gender Dysphoria
Treatment: breast reduction
The insurer denied: breast reduction
The denial is overturned.

The patient is a female to male transgender who requests top surgery. The patient has been living as a male for one year. The patient is not on hormone therapy but plans to start soon. The patient has been chest binding for one year. The patient's mental health professional supports the plan for top surgery. Breast reduction is planned. The subject under review is the medical necessity for the breast reduction surgery for this patient.

The health plan's determination is overturned.

The requested breast reduction is medically necessary for this patient. Per the World Professional Association for Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People" 7th Edition guidelines:
Criteria for Breast/Chest Surgery (One Referral)
Criteria for mastectomy and creation of a male chest in female to male (FtM) patients:
1. Persistent, well-documented gender dysphoria;
2. Capacity to make a fully informed decision and to consent for treatment;
3. Age of majority in a given country (if younger, follow the standard of care [SOC] for children and adolescents);
4. If significant medical or mental health concerns are present, they must be reasonably well controlled.
Hormone therapy is not a prerequisite.
Regarding chest surgery for adolescents, WPATH guidelines are as follows: "Chest surgery in FtoM patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent's specific clinical situation and goals for gender identity expression."
The patient meets these guidelines. The patient has well documented gender dysphoria and has the capacity to make an informed decision. The patient has been chest binding for 12 months. Mental health concerns are managed by the patient's therapist. The patient's psychologist has recommended the mastectomies. The standard of care for adolescent top surgery is met.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma 
Treatment is an inpatient admission.
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient is an adult female who has a history of (H/O) asthma and hypertension (HTN). She presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB) and fever. The patient C/O of productive cough with yellow phlegm. In addition, she complained of myalgia and fatigue.

In the ED the patient's Temperature was 102.3F (Fahrenheit), Heart Rate 150, Respiratory Rate 20, oxygen (O2) saturation 99%. The patient was awake and alert.

Labs revealed white blood cell count (WBC) 7K (thousand), Hb (hemoglobin) 11.8, Electrolytes were within normal limits. The chest x-ray (CXR) revealed no acute infiltrate. Influenza A was positive.

The patient was admitted to hospital for Asthma exacerbation, URI (upper respiratory infection), rule out (R/O) Pneumonia / Influenza. She was treated with intravenous (IV) steroids, bronchodilators and Leukotriene receptor antagonists (LTRA). The patient was also given IV (intravenous) Rocephin and Azithromycin. She was also started on Tamiflu.

The patient remained stable after admission. IV (intravenous) steroids were discontinued, and the patient was switched to oral (PO) Prednisone. She was discharged home the next day.

This patient did not need acute inpatient hospitalization. She could have been placed in observation status while diagnostic testing and treatment were initiated. The observation period could be for up to 48 hours. The patient did not have pneumonia and improved after treatment in ED.

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain
Treatment is an inpatient admission.
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient had previous gastric surgery and presented with abdominal pain, 
vomiting, and diarrhea. He was awaiting gallbladder surgery, but it had not been done. A few months earlier, he had a CAT (computed tomography) scan that showed cholecystitis and gallstone pancreatitis. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. He was diagnosed with gastroenteritis. A CAT scan showed a contracted gallbladder but no stones. The ultrasound showed calculi and sludge but with a normal gallbladder wall and no pericholecystic fluid. 

Clinical indications for admission for Gastroenteritis (MCG (Milliman Care Guidelines) M-170) include having a severe systemic infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting, severe electrolyte abnormalities, or an inability to maintain oral hydration after observation care. The patient did not have these conditions.

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Stone (MCG M-555) include having acute cholecystitis or acute cholangitis. This patient had gallbladder disease but neither the CAT scan or ultrasound showed acute cholecystitis or acute cholangitis. He also did not have hemodynamic instability, common bile duct obstruction, severe dehydration, severe pain, or bacteremia. 

This patient had gallbladder disease which was chronic and did not require any acute interventions at this time. He also had a gastroenteritis. However, IV (intravenous) hydration, PPI (proton pump inhibitor) therapy, and obtaining stool cultures could have been done with observation status. He did not meet MCG criteria for admission for either Gastroenteritis or Gallbladder or Bile Duct Inflammation or Stone. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. The denial is upheld.

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

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral Gastroenteritis. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient was a toddler with a past medical history notable for concussion/head trauma that presented to the Emergency Department for assessment and management of fever associated with intermittent nausea, non-bloody, non-bilious vomiting and non-bloody, watery diarrhea (with milk intake). The patient was eating less than usual, had decreased activity, nasal congestion, rhinorrhea and cough. She continued to have wet diapers. There was no associated GI (gastrointestinal) bleeding, pain, known weight loss, sick contacts or dysuria. Of note, the patient had been seen with a similar complaint. The patient's vitals on arrival were notable for heart rate 132, temperature 37 degrees Celsius, respiratory rate 30 and room air oxygen saturation of 99% (percent). Admitting weight was 14.4 kilograms. Admitting laboratories were notable for sodium 137, potassium hemolyzed, bicarbonate 24, blood urea nitrogen 14, creatinine 0.51, glucose 78, white blood cell 4.4 without left shift, hemoglobin 12.8 and platelets 353. No imaging was performed. She vomited once after coughing overnight. Her intravenous fluids were stopped.  She tolerated oral intake since presentation and throughout the admission. No repeat laboratories were performed. No antiemetics or antibiotics were repeated after the single doses given in the Emergency Department. She was discharged home for outpatient follow-up with a heart rate of 120. 
 
This toddler appears to have a viral gastroenteritis (upper respiratory tract symptoms, self-limited intermittent vomiting and loose stools that resolved before presentation) and minimal dehydration that resolved by the time of admission to the inpatient setting. She did not appear significantly dehydrated on presentation and was never at risk for hypovolemia as suggested in the appeal. 
  
The documentation of this child's appearance and vitals would indicate minimal to mild dehydration on presentation that resolved with intravenous resuscitation prior to the decision to admit. Her laboratory abnormalities were not critical and would be expected to correct with time (neutrophil count). Ceftriaxone could have been administered with follow-up of cultures as an outpatient after a period of observation. After admission, she was observed with both intravenous and oral fluids given, and safely discharged on oral fluids with outpatient follow-up shortly after admission. Oral rehydration with or without solids could have been administered as an outpatient after demonstration of the ability to rehydrate enterally in the Emergency Department. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pupillary Miosis. 
Treatment: Current procedural terminology (CPT) code 66982, eye surgery to remove cataract from the eye with the use of special equipment or dye. Left Side - 1 Visit, CPT code 66984, Eye surgery to remove cataract from the eye. Left Side - 1 Visit. 

The insurer denied coverage for current procedural terminology (CPT) code 66982, eye surgery to remove cataract from the eye with the use of special equipment or dye. Left Side - 1 Visit, CPT code 66984, Eye surgery to remove cataract from the eye. Left Side - 1 Visit. 

The denial is overturned. 

This is an adult with a history of cataract, dry eye syndrome, hypertension and diabetes Type II. The patient presented to the physician's office for a dry eye syndrome follow up
visual acuities were 20/60 in the right eye (OD) and 20/150 in the left eye (OS).  Exam showed 3+ nuclear sclerosis cataracts (NSC) in both eyes (OU).  Visual acuities were 20/60 OD and 20/150 OS.  Manifest refraction showed visual acuities of 20/40 OD and 20/60 OS.  Exam showed 3+ NSC OU.

The patient presented with a chief complaint of blurry vision reporting trouble recognizing faces and reading small print.  Visual acuities were 20/60 OD and 20/100 OS.  Brightness acuity testing showed visual acuities of 20/150 OD and 20/400 OS.  Exam showed nuclear sclerosis cataracts in both eyes (OU).  The patient was noted to have pupillary miosis so the plan was to have a complex case with iris stretching. 

CPT 66982 eye surgery to remove cataract from the eye with the use of special equipment or dye. Left Side - 1 Visit, CPT code 66984, Eye surgery to remove cataract from the eye. Left Side is medically necessary.  The patient was noted to have small pupils (poor dilation of pupils), which would require a more complex procedure requiring iris stretching during cataract surgery.  The iris needs to be stretched and manually dilated in order to gain access to the cataract for removal and for safety during surgery. 

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 current procedural terminology (CPT) code 66982, eye surgery to remove cataract from the eye with the use of special equipment or dye. Left Side - 1 Visit, CPT code 66984, Eye surgery to remove cataract from the eye. Left Side - 1 Visit services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

The patient presented to the hospital for cardiac catheterization after presenting with symptoms of chest pain and dyspnea on exertion. He had a past medical history of ischemic heart disease, heart failure with reduced left ventricular (LV) ejection fraction (15% [percent]), hypertension, diabetes mellitus, and lymphoma. Previous cardiac catheterization revealed a left main artery stenosis and right coronary artery in-stent re-stenosis. Impella assisted revascularization was performed. This consisted of atherectomy and stenting to the proximal and distal right coronary artery and percutaneous intervention to the left main coronary artery and proximal left circumflex artery. Proximal common femoral percutaneous coronary intervention (PCI) was also performed. The patient was admitted to the coronary care unit (CCU) for monitoring and post-operative care. The patient had no complications overnight and was discharged the following day.

Several investigators have studied the safety of same day discharge following percutaneous intervention. Patients requiring circulatory support, multivessel revascularization and left main coronary artery revascularization were classified as high risk and could not be managed at a lower level of care (Reference 1-4). Current expert consensus from the Society of Cardiovascular Angiography and Interventions support treatment at a higher level of care (Reference 4). The patient could not have been managed at a lower level of care.

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

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

Diagnosis: Impacted canine (maxillary left canine-tooth #11). 
Treatment: D8080 Braces, D8670 Monthly Visit. 
The insurer denied the D8080 Braces, D8670 Monthly Visit. 
The denial is overturned. 

The patient is an adolescent female. The request is for orthodontic treatment (braces) and monthly visits. Per the Provider's dental clinical exam--the patient has an impacted canine (maxillary left canine-tooth #11). 

The health plan denied the claim because the patient did not score a 26, the score necessary for orthodontic treatment approval on the Handicapping Labio-Lingual Deviation (HLD) Index Report. The Provider appealed the case based on the diagnosis of an impacted canine, an automatic qualifier for orthodontic treatment (braces) per the Handicapping Labio-Lingual Deviation (HLD) Index Report. 

The proposed treatment of orthodontic therapy (braces) and monthly visits are medically necessary. 

As supported by the x-rays submitted, the maxillary left canine is impacted with no visible space to allow for normal eruption. This will require orthodontic intervention to bring this tooth into occlusion. 

Per the Handicapping Labio-Lingual Deviation Index Report - impacted permanent anterior teeth where extraction is not indicated is an automatic qualifier for orthodontic therapy (braces).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism.
Treatment: Full Hospital Admission.
The insurer denied coverage for full hospital admission.
The denial is upheld.

This patient is an adult male with a history of prior deep vein thrombosis (DVT). Recent Rotator Cuff surgery days prior. He presented to the emergency department (ED) with shortness of breath (SOB) for 2 days. Vital signs at presentation were Temperature 98.5 degrees Fahrenheit, Heart Rate 92, Respiratory Rate 22, Blood Pressure 146/95 mm Hg (millimeters of mercury), and oxygen saturation 93 % (percent) on room air (RA). The patient was in no acute distress, not using accessory muscles, no jugular venous distention and the lungs were clear. His abdomen was soft, and the patient was alert and oriented to person, place and time with a non-focal neuro exam. Labs: White Blood Cells (WBC) 8.3, Hemoglobin (Hb) 14.7, Electrolytes within normal limits. Electrocardiogram (EKG) was normal sinus rhythm with no acute ST-T (interval on EKG) changes, echocardiogram normal, No right heart strain. Computed tomography (CT) Angio (angiography) of chest showed a right lung pulmonary embolus (PE). No saddle embolus. No right heart strain.

The patient was admitted to hospital for pulmonary embolism and started on Heparin drip initially. Pulmonary and Hematology consulted and recommended to continue same and transition to oral medication for long term anticoagulation. Deep vein thrombosis study of lower extremities was negative. The patient had another type of deep vein thrombosis (DVT) study, which revealed right axillary and right brachial vein DVT.

This patient remained stable after admission. Remained afebrile and hemodynamically stable, and not hypoxic on room air. He was tolerating food and fluids and in no acute distress. He was switched to oral Xarelto and discharged home. This could have been accomplished in observation setting.

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

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Issues - Overbite and Overjet.
Treatment: D8080 braces, D8680 retainer, D8670 monthly visit.

The insurer denied the D8080 braces, D8680 retainer, D8670 monthly visit.  The health plan's determination is overturned. 

The patient in question is a male. He has a Class II Division 1 malocclusion with spacing and protrusive maxillary incisors. He has a 9 millimeter (mm) overjet. He is treatment planned for orthodontics (braces) to correct the spacing and protrusion.

Braces are medically necessary for this patient. Teeth # (number) 8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. There is strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. Orthodontics will make these teeth significantly less protrusive. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+mm overjet, which this patient has. For these reasons, braces are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholelithiasis and choledocholithiasis. 
Treatment: Inpatient hospital stay. 

The insurer denied the inpatient hospital stay. 
The determination is overturned. 

The patient is one month postpartum and presented with cholelithiasis and choledocholithiasis. She was admitted for intravenous (IV) antibiotics, pain control, gastroenterology (GI) consultation, magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP) and planned cholecystectomy. She underwent the MRCP and then an ERCP with stone extraction and sphincterotomy. This was followed by a robotic cholecystectomy with unexpected intraoperative bleeding and Jackson-Pratt (JP) drain placement. She was improved and discharged home. At issue is the medical necessity of an inpatient level of care. 

This is a medically necessary inpatient stay. This patient required an acute inpatient level of care due to the choledocholithiasis, which is inherently more complicated than simple cholelithiasis. The existence of stones within the common bile duct risks cholangitis which can lead to rapid decompensation and even mortality. It is critical to intervene immediately if choledocholithiasis is either suspected or identified. The team acted with the standard of care by confirming the diagnosis and performing a therapeutic ERCP. Following ERCP, patients are at risk for developing complications such as bleeding or pancreatitis and thus those patients require extra monitoring for that. This patient then received the ultimate definitive treatment, cholecystectomy, which was complicated by intraoperative bleeding. When a patient is admitted for choledocholithiasis, rarely can a discharge within a short time frame such as 2 midnights or 48 hours occur. This is because of the multiple procedures that are necessary. This patient received a more expedited course than often happens, as the ERCP was able to be done on the operating table just prior to surgery. However, the patient still required inpatient care for 3 days. It is routine practice to admit patient's with choledocholithiasis to the inpatient setting and failure to do so would have been inconsistent with standard practice.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Bilateral Occipital Neuralgia and Intractable Chronic Migraine with Chronic Post-Traumatic Headache.
Treatment: Pain Management Injections (64405 (quantity 2) and 64400 (quantity 2)).
The insurer denied coverage for Pain Management Injections (64405 (quantity 2) and 64400 (quantity 2)).
The health plan's determination is overturned in part.

The patient is a male who is diagnosed with bilateral occipital neuralgia and chronic migraine. Treatment with bilateral occipital nerve blocks (current procedural terminology (CPT) 64405) and bilateral trigeminal nerve blocks (CPT 64400) is the subject of this review. 

CPT 64405 (quantity 2) or greater occipital nerve blocks are medically necessary for the treatment of the member's condition, occipital neuralgia. The nerve blocks are considered to be both diagnostic and therapeutic for this condition. Occipital nerve blocks with a local anesthetic and corticosteroids provides a safe, simple and effective treatment method for the patient with occipital neuralgia. The procedure is recognized by neurologists and pain management specialists as a standard treatment for this condition.

CPT 64400 (quantity 2) or original nerve blocks are not medically necessary. These injections are not a treatment for occipital neuralgia and are not a well-established therapy for treatment of other headache disorders such as chronic migraine or post-traumatic headache. These injections have not been shown to have a dural therapeutic effect. A subcommittee of the American Headache Society does not recognize these injections as medically indicated for treatment of migraine or occipital neuralgia.
The requested health service/treatment of pain injections is medically necessary in part for this patient.