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

Diagnosis: Atypical chest pain

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission

The denial is upheld

The patient presented to the hospital complaining of chest pain.  Past medical history was significant for hyperlipidemia and gastroesophageal reflux disorder (GERD). On arrival to the emergency department (ED), vital signs were stable and physical examination revealed no abnormality.  An electrocardiogram (ECG) demonstrated normal sinus rhythm without ischemic changes.  Serum troponin and serum creatinine were mildly elevated.  Following a cardiology evaluation, cardiac catheterization was recommended. Findings demonstrated no evidence of obstructive coronary artery disease, and the patient was discharged home the same day on medical therapy.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with atypical chest pain and a past medical history of hyperlipidemia and GERD. His pretest probability of coronary artery disease was low (Reference 1).  Utilizing the HEART (history, ECG abnormalities, age, risk factors, and troponin) score he was considered low risk (Reference 2).  Utilizing the thrombolysis in myocardial infarction (TIMI) score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). Risk assessment of patients presenting with chest pain was reviewed by Hedayati et al. (Reference 3).  

Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (myocardial infarction [MI], need for percutaneous coronary intervention [PCI], need for coronary artery bypass grafting [CABG], or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, myocardial infarction [MI], and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  This patient presented to the hospital with chest pain and no significant electrocardiogram changes (ECG). Cardiac catheterization was performed and revealed no significant coronary disease. The patient was released on the same day. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. 

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied periodic orthodontic treatment. 
The denial is overturned. 

The patient is a female. She is in orthodontic treatment and had surgical exposure of impacted tooth # (number) 11. She is treatment planned for orthodontics to complete her treatment. The subject under review is the medical necessity for periodic orthodontic treatment, which was denied by her health plan.  

The requested treatment is medically necessary. This patient started treatment with an impacted canine. Pictures provided for review show that orthodontic treatment had been started on this patient and not completed. The reason it was not completed is inconsequential. Leaving the patient with unfinished treatment will leave her with a poor occlusion and is not in the best interest of the patient. It is unreasonable to leave treatment unfinished. New York State uses the Handicapping Labio-lingual deviation index to determine treatment need. This is a common index used for determining need for treatment.1 Using this index an impacted canine without an indication for tooth extraction is an automatic qualifying condition.2 Impacted canines are difficult to treat and often require an interdisciplinary treatment plan. 3,4 The patient meets standard medical necessity criteria for the requested orthodontic treatment.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 

The insurer denied extraction of tooth # 1 and # 16, and general anesthesia each 15 minutes. 
The denial is partially overturned. 

The patient is a female who has been approved for removal of impacted tooth 32 and 30 minutes of general anesthesia. Extraction of tooth #1 and tooth #16 have been denied as there is no documentation of severe pain in these teeth, or that they will not erupt on their own. 30 minutes of additional anesthesia has been denied. The subject under review is the medical necessity for extraction of impacted tooth with bone, tooth 1, 16 and general anesthesia. 

The health plan's determination is overturned in part. 

The removal of tooth #1 and tooth 16 are medically necessary. The additional anesthesia is not medically necessary without an anesthesia record that documents the need for the additional time. 

The American Association of Oral and Maxillofacial Surgeons (AAOMS) Parameters of Care states that an impacted third molar that is so positioned that it will probably not erupt by the middle of the third decade constitutes pathology with dental and medical consequences. To limit known risks and complications associated with surgery, it is medically appropriate and surgically prudent to remove impacted third molars before the middle of the third decade and prior to complete root development. An impacted tooth with completed root formation that is totally covered by bone in a patient beyond the third decade that does not meet the following indications for removal should be monitored for change in position and/or development of pathology, which may then indicate its removal. The patient meets these criteria as the patient has impacted wisdom teeth that are so positioned that they will probably not erupt by the middle of the third decade. In addition, even if the teeth erupt, they will be unopposed and nonfunctional. 

Extraction of teeth # 1 and # 16 are medically necessary and is overturned. General anesthesia - each 15 minutes is not medically necessary and is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right distal radius fracture.
Treatment: Inpatient admission.

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

This is patient with a history of a right distal radius fracture, hypertension, and hyperlipidemia. She presented to the hospital for a scheduled right distal radius open reduction internal fixation (ORIF). The surgery was performed, and the patient completed a course of intravenous (IV) antibiotics. Sequential compression devices (SCD) were applied for deep vein thrombosis (DVT) prophylaxis. The patient was seen by the Orthopedics team, physical therapy, and occupational therapy. The patient was discharged the following day after a period of medical stability.  

The medical record demonstrates a non-complicated post-surgical course. The patient was treated for an isolated distal radius fracture. Her vital signs were stable. There was no evidence of fever or infection. There were no problems with her surgical site. Her operation was not complex and of limited duration (i.e., one hour and 10 minutes) with blood loss of less than 25 milliliters. The post-surgical records show a pain level of 1/10 and an ability to tolerate oral pain medications. She did not have nausea.

The patient's discharge summary was completed the day of surgery noted a non-complicated medical stay. She did not require treatment for other underlying medical conditions. These findings do not substantiate the necessity of admission and length of stay. The services could have been completed at a lower level of care.

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

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

Diagnosis:  Deep vein thrombosis.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is upheld.

The patient was initially seen at another hospital for swelling of left leg, shortness of breath (SOB) and palpitations. The patient had a deep vein thrombosis (DVT) study which was positive for acute DVT. The patient has past medical history of seizure and DVT. The patient was referred to the admitting hospital for the same.  Vital signs at presentation: Temperature 98.3, Heart Rate 72 beats per minute, Blood Pressure 135/71, Oxygen (O2) saturations 97 percent on room air. The patient was in no acute distress. The patient's physical exam was essentially normal other than some left leg swelling. Labs were unremarkable other than an elevated D-Dimer.

The patient had a computed tomography angiogram (CTA) done which was negative for pulmonary embolism (PE).

The patient was treated with Lovenox and admitted to hospital for treatment of DVT.

This patient remained stable after admission, was saturating 98 - 99 percent on room air and in no acute distress. Physical exam was unremarkable. She denied any chest pain or SOB. Computed tomography angiogram was negative. She was switched to oral Eliquis and subsequently discharged home after 2 days.

This patient did not need acute hospitalization. She could have been placed in Observation status while diagnostic testing and treatment were initiated. The patient was afebrile, hemodynamically stable, not hypoxic and was tolerating oral intake. She was stable to be discharged home after a period under observation on oral anticoagulation.

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

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

Diagnosis: Kidney Stones.
Treatment: Inpatient admission.

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

The patient is a male. He was admitted from the dementia unit to Hospital  with a urinary tract infection. He had a ureteral stent placed three weeks prior for an obstructing ureteral calculus and a UTI (urinary tract infection). He had malodorous urine and severe urinary pain. He had numerous co-morbid conditions including dementia, BPH (benign prostatic hyperplasia), hypertension and asthma.

The patient's vitals were temperature 98.4, pulse 86, respiration rate 18, blood pressure 153/98. The WBC (white blood cell) count was 11,400. CT (computed tomography) imaging demonstrated an intact left ureteral stent with an 11 mm (millimeter) proximal ureteral calculus and mild-moderate left hydronephrosis. The urinalysis had leukocytes and WBCs (white blood cells). The WBC (white blood cell) count was 11,400. The creatinine was 0.89. IV (intravenous) antibiotics were started.

Day 1, the patient's WBC (white blood cell) count was 4120.

Day 2, urology noted that the dysuria was likely from the patient's stent. The patient was comfortable.

During the stay, the patient received IV (intravenous) antibiotics. He was seen by urology and infectious diseases. Cultures grew Proteus mirabilis and Enterococcus faecalis. He was also seen by nutrition.

On day 9, the patient was discharged home. He was afebrile and hemodynamically stable throughout the stay.

No, the Inpatient admission was not medically necessary.

An acute inpatient level of care was not medically necessary. Care could have been provided at a lower level of care. The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis. Following admission, there were no unstable vital signs reported. He did not have kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, severe vomiting. Pain control, IV (intravenous) antibiotics and IVF (intravenous fluids) in a non-toxic patient can be provided at a lower level of care. Although he had significant co-morbid conditions, these were stable.

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

Diagnosis: Dermatomyositis.
Treatment: Acthar gel 80 unit injection.
The insurer denied Acthar gel 80 unit injection.
The determination is upheld.

The patient has dermatomyositis (DM) and is currently receiving Acthar gel from a patient support program. He has been having a positive response. The reason for the denial is not medically necessary as the patient has not tried and failed drugs such as SoluMedrol, methotrexate (MTX), Imuran, or intravenous immunoglobulin (IVIG). Per a letter from the patient's provider, he has tried medrol and did not respond and is 'continually experiencing muscle weakness and severe disease exacerbation'. Prior treatment includes SoluMedrol, prednisone (developed elevated glucose), Plaquenil (had a side effect), MTX (no response) and Cellcept.
At issue is the medical necessity of the Acthar gel.
The requested service of Acthar gel is not medically necessary at this time. There is no medical reason the patient cannot try one of the plan preferred drugs, such as Imuran, or IVIG.
There is no medical reason/contraindication to either IVIG or Imuran. According to UpToDate, 'immunoglobulin (IVIG) is a reasonable second-line therapy for patients with refractory disease'. A study published in the New England Journal of Medicine (NEJM)concluded that 'high-dose intravenous immune globulin is a safe and effective treatment for refractory dermatomyositis'. Moreover, Imuran is considered a first line steroid sparing drug in the treatment of DM and UpToDate recommends Imuran or MTX as first line steroid sparing drugs. 'A randomized trial of 16 patients compared prednisone plus azathioprine with prednisone alone. At three months, there was no difference between the treatment groups in muscle strength or creatine kinase (CK) levels. However, at three years, patients treated with combination therapy had better functional outcomes and required less prednisone as maintenance therapy (1.6 milligrams (mg)/day versus 8.7 mg/day) (UpToDate).
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Coronary Artery Disease (CAD).
Treatment: Pharmacy/Prescription Drugs. Apixaban.
The health plan denied the requested prescription drug, Apixaban.
The health plan's determination is overturned.

This case involves a male with a history of coronary artery disease, prior coronary stent, coronary artery bypass surgery, hypertension, hyperlipidemia, and a stroke. The patient has been anticoagulated with Warfarin for the prevention of a stroke. The patient's Warfarin has been switched to Apixaban, given its superior effectiveness and safety profile compared to Warfarin. In addition, given the COVID pandemic, continued treatment with Warfarin for this patient was felt to be unsafe due to patient's inability to obtain appropriate international normalized ratio (INR) monitoring with lab draws. The patient's treating cardiologist has therefore requested a formulary exception for coverage of Apixaban to prevent recurrent strokes in this patient.
At issue is the medical necessity of the requested prescription medication, Apixaban.

I recommend that the health plan's determination be overturned, in whole.

Data from several large, randomized trials has demonstrated that the NOACs (non-Vitamin K antagonist oral anticoagulants) are superior to Warfarin in preventing stroke and systemic embolism and have a lower risk of bleeding in patients with atrial fibrillation [1]. In addition, more recent cohort data comparing the effectiveness and safety profile of Apixaban versus Xarelto has demonstrated a lower risk of bleeding, ischemic stroke, and systemic embolism with Apixaban compared to patients prescribed Xarelto [2]. In the context of this data, the formulary drugs Warfarin and Xarelto would likely be less effective than Apixaban in preventing stroke and expose the patient to an increased risk of potentially life-threatening bleeding. Given this favorable safety profile and efficacy of Apixaban over the other formulary medications, I recommend that a formulary exception for Apixaban be approved in this case for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Polycystic Ovarian Syndrome (PCOS)
Treatment current procedural terminology (CPT) code 82306-GA

The insurer denied coverage for current procedural terminology (CPT) code 82306-GA.
The denial is overturned.
	
According to the medical records, the patient is a female who met with Endocrinology for possible polycystic ovarian syndrome (PCOS), obesity, and elevated cholesterol.  As part of the work - up, a Vitamin D level was obtained.  She was started on Metformin for her PCOS.

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

Current procedural terminology (CPT) code 82306-GA is considered medically necessary for this patient.  Vitamin D plays an important role in hormonal functions in the body.

Vitamin D deficiency can make symptoms of PCOS worse. Taking a daily vitamin D supplement with 600 IU [international units] may ease some PCOS problems such as infertility, weight gain, and anxiety.

"Vitamin D is one of the essential nutrients to sustain the human health. As a member of the steroid hormone family, it has a classic role in regulating metabolism of calcium and a non-classic role in affecting cell proliferation and differentiation. Epidemiological studies have shown that 25OHD [vitamin D] deficiency is closely associated with common chronic diseases such as bone metabolic disorders, tumors, cardiovascular diseases, and diabetes. 25OHD deficiency is also a risk factor for neuropsychiatric disorders and autoimmune diseases. 25OHD deficiency is highly prevalent in the world. It is therefore necessary to know the adverse health effects of 25OHD deficiency, and to design interventions and early treatments for those who are likely to have low levels of 25OHD." (Wang, H. et al. 2017). 

Based on the above, the medical necessity for the current procedural terminology (CPT) code 82306-GA is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional-hypogonadism
Treatment: Pharmacy/Prescription Drugs-Testosterone 1.62% Gel Pump
The health plan denied the Testosterone as not medically necessary. 

The reviewer has upheld in whole the health plan's determination.

The patient has a diagnosis of lower urinary tract symptoms including urinary frequency, urgency and nocturia. He has been given a diagnosis of urethritis. His testosterone level was noted to be 132 drawn at an unknown time. Medical necessity for testosterone gel is under review.

The requested treatment of Testosterone 1.62% Gel Pump is not medically necessary for this patient. There is inadequate documentation submitted for review to support the diagnosis and type of hypogonadism. The time of the patient's initial diagnosis is unknown. The recommended 2 AM (morning) testosterone levels below reference range prior to initiation of therapy are not documented. All guidelines (European Association of Urology (EAU), The International Society of Sexual Medicine (ISSM) and Endosociety (Endocrine Society)) recommend 2 morning testosterone levels below the reference range prior to the initiation of therapy. There is also no luteinizing hormone (LH) or follicle-stimulating hormone (FSH) documented. All guidelines (EAU, ISSM and Endosociety) recommend measurement of LH and FSH levels to evaluate the type of hypogonadism. The patient's specific symptoms of hypogonadism are not documented. This information is not available in the documentation submitted for review. The attached documentation does not support that the patient has had persistent signs and symptoms of androgen deficiency and has had 2 pretreatment testosterone levels taken in the morning on 2 separate days.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post large composite filling
Treatment: D2751 White Glass With Metal Crown, Tooth 29
The insurer denied the D2751 white glass with metal crown, tooth 29.
The denial is overturned.

The patient has had a root canal procedure as well as a post and core in tooth # (number) 29. Prior denial was because he has too many back teeth that touch and that is reason for denying the crown.

Yes, the crown on tooth #29 is medically necessary.

Tooth #29 needs a crown to prevent it from fracturing. It has a post in it with a large composite filling. A crown is needed to insure this tooth doesn't break during chewing. The patient has lost multiple teeth already and cannot stand to lose another one due to fracturing. The crown, code D2751 is medically necessary for the oral health of this patient.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. Please see the rationale, above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic foot pain
Treatment: PNS implant procedure (cpt 64555 x 2)
The insurer denied the PNS implant procedure (cpt 64555 x 2)
The denial is upheld.

The patient is a female with a history of chronic foot pain. She has tried various medications, physical therapy, cortisone injections, and PRP (platelet-rich plasma). Physical exam shows right foot pain with ambulation. A peripheral nerve stimulator (PNS) has been recommended. This was denied by the insurance as not medically necessary. Imaging was not available.

No, the requested health service is not medically necessary.
This is a female with a history of chronic foot pain. She has tried various medications, physical therapy, cortisone injections, and PRP (platelet-rich plasma). Physical exam shows right foot pain with ambulation. A peripheral nerve stimulator (PNS) has been recommended.

The requested procedure is not a commonly accepted treatment for this condition, and has not been shown to be effective in the treatment of chronic foot pain, as shown by high quality randomized control trials (RCT). There is a randomized controlled trial in the setting of chronic pain following amputation, but not this condition. These pathologies are quite different. Other case reports, and observational studies show some benefits in other pain conditions. Other more proven, conventional treatments have been shown to be superior in the literature, such as spinal cord stimulation, physical therapy, and medication management. Given the lack of data to support an invasive procedure for this type of condition, the requested PNS (peripheral nerve stimulation) is not medically necessary.

Yes, the medical records and accompanying information are sufficient.