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

Diagnosis: Abdominal Pain with Vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male who presented to the emergency department with diffuse abdominal pain and associated nausea and vomiting which had started earlier that day. He has had multiple bowel resections with the most recent being approximately five years ago. His medical history is positive for heroin abuse in the past with his last dose of Methadone yesterday. 

The patient's exam in the emergency department documents the patient to be afebrile with stable vital signs. His abdomen is noted to be distended but soft. The white blood cell count was elevated at 17,700 with a shift. The hemoglobin (Hgb) was normal at 14.1. A computed tomography arterial portography (CTAP) demonstrated some mildly dilated loops of small bowel with transition to collapsed bowel at the level of an anastomosis and notes that an element of obstruction cannot be entirely excluded. The patient was evaluated in the emergency department by the surgical resident with a recommendation for admission to the surgical service, nothing by mouth (NPO), placement of a nasogastric tube (NGT) and intravenous fluids. The patient refused all further medical care, removed his own intravenous access and left against medical advice (AMA) from the emergency department.

The hospital has requested approval for an inpatient admission noting that the patient's departure against medical advice did not negate the need for acute medical care.  The health plan has denied the admission as not medically necessary.  The hospital has appealed.

No, the proposed treatment, inpatient admission, was not medically necessary.
A review of the medical records submitted document that the patient presented to the emergency department with complaints of abdominal pain, vomiting with an elevated white blood cell count. However, the records further document that he was afebrile with stable vital signs. With the exception of the white blood cells, the remainder of his laboratory values were unremarkable. On exam his abdomen is noted by the surgical resident to be distended but otherwise benign. However, the records further document that he was afebrile with stable vital signs.  Computed tomography arterial portography while suggestive of a partial small bowel obstruction is not diagnostic of same with the report noting only that it "cannot be excluded".  As such, the severity of the patient's symptoms do not rise to the level of acute inpatient services. The proposed treatment - nothing by mouth status, placement of nasogastric tube and intravenous fluids could be provided at an alternative level of care. The proposed inpatient admission is, therefore, not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by determining that the proposed treatment of the patient's condition could have been provided at an alternative level of care, the plan acted reasonable and with good judgement.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a past medical history of coronary artery disease, obesity, active smoking, hypertension, and pre-diabetes, who was admitted for pressure like chest pain. Review of systems was positive for chest pain and shortness of breath with exertion. The patient was afebrile (temperature of 36.8 degrees Celsius), described as alert and oriented, and in no acute distress. His blood pressure was 149/89, pulse rate of 82, and oxygen saturation of 100% (percent). Physical examination on admission was remarkable for bilateral edema on the lower extremities.

The inpatient hospital admission was not medically necessary.

The patient does not meet criteria for inpatient admission based on the lack of hemodynamic instability, stable serial cardiac enzymes, and negative electrocardiogram (EKG) findings. The care could have been safely rendered at a lower level of care for suspected cardiac ischemia in a moderate risk HEART [history, ECG, age, risk factors, and Troponin] and thrombolysis in myocardial infarction (TIMI) scores for major cardiac events, based on risk factors and rule out of acute coronary syndrome.

The use of validated and accurate risk stratification is paramount in the acute management of Acute Coronary Syndrome (ACS), mainly to identify those patients with immediate risk of complications, as those with an ACS. The HEART and major adverse cardiac events (MACE) scores are validated tools and can predict risk of major cardiac event for patients presenting with ACS type of symptoms. This risk prediction allows for the identification of a high-risk population, even in patients with more atypical presentations. The TIMI risk index is another simple, valid, and moderately accurate tool for the stratification of risk for early death in ST [interval on ECG]-Elevation Myocardial Infarction (STEMI) and non-STEMI patients. The TIMI risk index was strongly associated with 30-day mortality for both STEMI and non-STEMI patients.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism
Treatment: Inpatient stay

The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This is a  female with history of asthma, hypertension, anemia, and hiatal hernia who presented to the hospital with complaint of left lower extremity pain with minimal swelling. Vital signs were temp 98.0 F, pulse 80, respirations 20, blood pressure (BP) 116/80 and pulse oximetry 98%. Physical examination showed left lower extremity swelling and tenderness. Abnormal laboratory values included albumin 3.0, hemoglobin 9.9 and hematocrit 31.2. Sonogram showed deep venous thrombosis. The patient was admitted and started on intravenous heparin. The patient was seen by Cardiology and Hematology. A computed tomography (CT) angiogram showed a pulmonary embolism. 

The inpatient hospital admission was not medically necessary. This patient presented to the hospital with left lower extremity pain and swelling. She was found to have a deep venous thrombosis. The patient was also found to have a pulmonary embolism. There was no evidence of hemodynamic instability. There was no evidence of active bleeding or coagulopathy. There was no evidence of uncontrolled hypertension. There was no evidence of limb-threatening thrombosis. The patient did not require thrombolysis. There was no evidence of severe pain. The patient was able to tolerate oral intake. Based on the review of the available medical records and Milliman Care Guidelines (MCG) for Deep Venous Thrombosis, none of the severity of illness criteria were present to support inpatient admission. The inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems/Overbite/Underbite
Treatment: Dental/Orthodontic Procedure
The health plan denied the requested orthodontic treatment as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with a Skeletal Class II malocclusion, mild mandibular crowding, and mild maxillary crowding. There is severe overjet and moderate overbite. The subject to be determined is the medical necessity for Comprehensive Orthodontics.

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

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score an 18 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 mm (millimeters) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, Comprehensive Orthodontics are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Inpatient Hospital

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

The patient is a male with a past medical history significant for seizures, cerebrovascular accident (CVA), and chronic left-sided deficits who presented to the emergency department approximately one hour after he had a seizure. Per the patient's wife, he had a generalized tonic-clonic seizure that lasted three-five minutes and abated spontaneously.
The patient had aphasia afterward, which was not typical for his seizures. He also had left arm shaking, which was abnormal for him. Upon initial evaluation in the emergency department, his review of systems was positive for seizure and weakness, otherwise was negative.
Initially, when he was seen in the emergency department he had significant weakness in the left upper, right upper, and left lower extremities. He was alert. Cranial nerve deficits were present. A computed tomography (CT) scan of the head was performed in the emergency department and demonstrated no acute changes. In the emergency department, the patient received a loading dose of Keppra, also intravenous Oxcarbazepine, and Ativan. By the time the patient was seen by the admitting physician, he was oriented times three. His speech was clear, and the patient had no focal deficits.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care. Overall, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid Obesity, Fatty Liver. 
Treatment: Liver Biopsy. 

The insurer denied the Liver Biopsy. 
The determination is upheld. 

The patient underwent bariatric surgery (laparoscopic Roux en Y gastric bypass and concomitant liver biopsy). The records support that she had a body mass index (BMI) of 35 kilograms per square meter (kg/m2). The operative dictation states that the surgeon obtained a wedge liver biopsy from the left lobe of the liver. The submitted records do not include any pre-surgical lab, imaging or clinical data to indicate liver pathology. The pathology report provides the diagnosis of mild steatosis. 

The provider submitted current procedural terminology (CPT) code 47100 (liver biopsy, wedge). At issue is the medical necessity of a liver biopsy. 

The submitted documentation does not support the medical necessity of concomitant liver biopsy at the time of Roux en Y gastric bypass. There is no documentation of liver pathology as might be obtained by pre-operative imaging or lab data to warrant liver biopsy. 

Accepted indications for liver biopsy include: documentation of signs or symptoms of liver disease (abnormal liver function tests of unknown etiology, knowledge of a specific diagnosis that will likely alter the treatment plan, known liver disease where prognostic information about fibrosis may guide subsequent treatment, the presence of a mass or lesions or focal or diffuse abnormalities seen on imaging studies of unknown etiology). In this case, there is no such documentation to warrant wedge liver biopsy. Routine liver biopsy is not an accepted or standard aspect of bariatric surgery. [1] 

According to generally accepted criteria, routine liver biopsy is not medically necessary in conjunction with bariatric surgery. [1] Liver biopsy is indicated if there is a suspicious growth on the liver, if there is scarring of the liver or if there is a condition of the liver as indicated by pre-operative imaging or lab data that requires biopsy. 

In this case, the patient has morbid obesity with a body mass index of 35 kg/m2. Lab data and pre-operative imaging are not included with the review material. There is no description of clinical symptomatology to indicate liver pathology.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligodontia. 
Treatment: D6060, surgical placement of implant body; endosteal implant tooth 5, 8, 9, 10, 15, 18, and 19. 

The insurer denied coverage for D6060, surgical placement of implant body; endosteal implant tooth 5, 8, 9, 10, 15, 18, and 19. 

The denial is upheld. 

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, the dentist's narrative letter in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist recommended endosteal implants. The dentist requests implants over removable partial dentures presumably due to patient's reported dysphagia and nausea. 

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in the maxilla and mandible. As regards to endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include conventional removable dentures. Further the documentation provided does not support, justify, or substantiate the requested treatment.  Therefore, as removable dentures (full and partial removable) remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary. 

Surgical placement of endosteal implant teeth is not considered medically necessary for this patient. 

Uphold denial of coverage for dental implants as not medically necessary, as an appropriate alternative standard of care treatment would be conventional removable dentures and the medical documentation provided does not substantiate a limitation that would preclude the patient using removable partial dentures. Therefore, as other acceptable alternative treatments are appropriate, and the documentation provided does not support the recommended treatment this renders the endosteal implants and associated services not medically necessary. 

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

The insurer's denial of coverage for D6060, surgical placement of implant body; endosteal implant tooth 5, 8, 9, 10, 15, 18, and 19 is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Scrotal Cellulitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has no past medical history (PMH) and was admitted with complaints of (c/o) progressive scrotal swelling associated with a fever. His vital signs were notable for a temperature (T) of 103.2 degrees Fahrenheit and pulse 112. The physical exam was notable for scrotal swelling. Lab work was notable for a white blood cell count (WBC) of 22.1 and creatinine 1.42. A testicular ultrasound (US) showed scrotal thickening, consistent with (c/w) scrotal cellulitis. The patient was diagnosed with scrotal cellulitis and epididymitis and treated with broad-spectrum antibiotics, anti-inflammatories, and pain control. Infectious disease evaluated the patient and diagnosed the patient with cellulitis and epididymitis. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.
The hospital stay was medically necessary at an acute inpatient level of care.
This patient presented to the ED with c/o scrotal swelling associated with a fever. The US showed findings consistent with scrotal cellulitis and this was confirmed by specialty consultation, as well as epididymitis. Given the patient's septic presentation, this patient met sepsis criteria, met the Infectious Diseases Society of America (IDSA) definition of severe cellulitis, and the expected length of stay was greater than 48 hours. In addition, the infection was present in a high-risk location (genitals) that required a close level of monitoring that was not appropriate for an observation level of care. Overall, this systemically ill patient presented with scrotal cellulitis and epididymitis complicated by an acute kidney injury and required immediate treatment for the infection with intravenous antibiotics and an inpatient level of care was required for safe medical evaluation and treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: B-cell acute lymphoblastic leukemia (B-ALL) and isolated extramedullary relapse (IEM)
Treatment: Kymriah (tisagenlecleucel)

The insurer denied coverage for Kymriah (tisagenlecleucel).
The denial is overturned.

This is a child with a history of B-cell acute lymphoblastic leukemia (B-ALL) and isolated extramedullary relapse (IEM). The patient's physician is requesting approval for Kymriah (tisagenlecleucel).					
The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.  As detailed in the references provided by the appealing physician, and as supported in the references detailed below, "Chimeric antigen receptor (CAR) T-cells have transformed the therapeutic options for relapsed/refractory (R/R) B-cell ALL." (Ref 1). "Tisagenlecleucel and huCART19 (therapy treatement) are active at clearing central nervous system (CNS) disease and maintaining durable remissions in children and young adults with CNS relapsed or refractory B-cell acute lymphocytic leukemia or lymphocytic lymphoma, without increasing the risk of severe neurotoxicity; although care should be taken in the timing of therapy and disease control to mitigate this risk. These preliminary findings support the use of these CAR T-cell therapies for patients with CNS relapsed or refractory B-cell acute lymphocytic leukemia." (Ref 3). 

Medical records indicate that the patient's CNS relapse has responded to initial triple intrathecal chemotherapy making the patient a good candidate for further consolidation with Kymriah both from an efficacy perspective and in an effort to limit long term toxicity for this young child.

Efforts to avoid and/or delay CNS irradiation is vital to reduce the risk of long-term neurocognitive deficits.  Kymriah (tisagenlecleucel) is also promising based on the available published data with regard to improved disease control.

Risks may be different, but not "increased" over standard treatment.

Based on the peer-revied published literature, and as detailed above and in the appealing physician's letter, the requested service of Kymriah (tisagenlecleucel) is likely to be more beneficial than any of the standard treatments for this patient. Thus, the denial is overturned.

The carrier's denial of Kymriah (tisagenlecleucel) should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: B-cell acute lymphoblastic leukemia (B-ALL) and isolated extramedullary relapse (IEM)
Treatment: Kymriah (tisagenlecleucel)

The insurer denied coverage for Kymriah (tisagenlecleucel).
The denial is overturned.

This is a child with a history of B-cell acute lymphoblastic leukemia (B-ALL) and isolated extramedullary relapse (IEM). The patient has isolated central nervous system (CNS) relapse for plan of T-cell apheresis; also received Vincristine (VCR), and intrathecal chemotherapy. The patient is being considered for either re-induction with AALLP2P-2 (gene), if proceeding with Kymriah. The patient's physician is requesting approval for Kymriah (tisagenlecleucel).
Scientific evidence in peer-reviewed literature does support a result of improvement in health outcomes with Kymriah.      
Kymriah has final approval from the appropriate regulatory bodies for this diagnosis. The Food and Drug Administration (FDA) approved Kymriah for certain pediatric and young adult patients with a form of acute lymphoblastic leukemia (ALL).
Kymriah is the best available treatment for this patient at this time given AALLP2P-2 would require cranial radiation, with potential significant radiation toxicity, in addition to two years of chemotherapy. Therefore, using CAR-T [Cluster of Differentiation 19] cell would obviate the need or delay for use of radiation. Also patient was at cycle eight (8) of maintenance of AALLP2P-2, when he was found to have a recent CNS relapse. It is noted that the bone marrow biopsy report showed B-cell acute lymphoblastic leukemia.     
The adverse risks are not increased over standard treatment/services. 
Per Myers, R. M., Dolan, J., & Teachey, D. T. "Though 85 percent of children and young adults with acute lymphoblastic leukemia (ALL) are cured, until recently, the prognosis of relapsed or refractory disease has been dismal. The advent of chimeric antigen receptor (CAR) T-cell therapy has transformed the treatment of relapsed/refractory ALL."
The carrier's denial of Kymriah (tisagenlecleucel) should be overturned.