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

Diagnosis: Palpitations (atrial fibrillation).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male with a past medical history significant for HTN (hypertension) and dyslipidemia. He presented to the ER (emergency room) with complaints of palpitations and lightheadedness.

The patient was found to have new onset atrial fibrillation with rapid ventricular response. The patient was given intravenous Cardiem in the ER (emergency room) and started on oral Cardizem, however his heart rate was still uncontrolled, and he was admitted for management of atrial fibrillation. He was started on Cardizem drip. His labs were significant for elevated BUN (blood urea nitrogen) and elevated BNP (brain natriuretic peptide).

The patient was seen in consultation by cardiology, and he was started on Eliquis for anticoagulation. Given the failure of medical therapy, the patient was transferred for TEE (transesophageal echocardiogram)-guided cardioversion.

Yes, the Inpatient admission was medically necessary.

The patient presented with new onset atrial fibrillation with uncontrolled heart rate and evidence of CHF (congestive heart failure) and acute kidney injury. His heart rate remained uncontrolled, despite treatment in the ER (emergency room), and the patient required a continuous Cardizem infusion. He was subsequently transferred for cardioversion, as he did not appropriately respond to medical therapy. Given the presentation and inadequate response to treatment, as well as evidence of CHF (congestive heart failure) and AKI (acute kidney injury), it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the Inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Vertebral Disc Problem
Treatment: Inpatient Hospital

The health plan denied the inpatient stay as not medically necessary. The health plan's determination is upheld.

The patient is a male who had presented with neck pain and left greater than right upper extremity radicular symptoms. The patient had failed attempts at conservative treatment and was offered surgery. He underwent an ACDF (anterior cervical discectomy and fusion) at (cervical) C5-6 for the diagnosis of C5-6-disc herniation and stenosis. There were no complicating events noted in the operative report, which is provided for review. The postoperative note the evening of surgery reported the patient to be neurologically intact without complaints other than expected neck pain which was controlled with the intravenous medications. He remained stable overnight, and he was transitioned from the Dilaudid patient-controlled analgesia (PCA) to oral pain medications, was able to void after the Foley catheter was removed and was cleared by physical therapy (PT). He was discharged home.
After surgery, the patient was admitted under an inpatient status. The health plan has denied the inpatient admission for not being medically necessary for this patient undergoing this procedure. That is the question for this review.

The records provided support upholding, in whole, the health plan's determination of medical necessity.

No, there is no support in the documentation provided or the medical literature for the medical necessity of an inpatient stay for this patient undergoing an elective ACDF procedure. It is very common to admit ACDF patients to an observation level of care in order to monitor them overnight, as the complications of respiratory distress from either tissue swelling or a postoperative hematoma usually occur the night of surgery and frequently require emergent attention. In addition, if any intraoperative or postoperative complications occur, then the patient can always be reclassified as an inpatient as needed. In selective healthy patients, this procedure is frequently carried out in a completely outpatient setting.
The guidelines provided for review support this standard clinical practice noting that the goal length of stay for most patients is " Ambulatory or 1 day postoperative".
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems
Treatment: Dental/Orthodontic Procedure
The health plan denied the treatment of Braces as not medically necessary. The reviewer has upheld in whole the health plan's determination.

The patient has Skeletal Class I and Dental Class II cuspids. Mild mandibular spacing and mild maxillary spacing are noted. Moderate anterior open bite and mild overjet. The subject to be determined is the medical necessity for braces and 11 monthly visits.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 14 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-millimeter (mm) or greater and underbite 3.5mm 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, braces and 11 monthly visits are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female child with medical history significant for seasonal allergies and asthma. She presented to the ED (emergency department) with same day history of erythema, swelling, pruritus, and pain of the left fifth digit. Topical Benadryl did not provide relief. She was not treated for pain.

The patient's vital signs included temperature 36.8, heart rate 102, respiratory rate 20, and blood pressure 120/77. Examination was significant for blanching erythema and localized swelling of the left fifth digit overlying the middle phalanx, mildly tender to palpation with full range of motion and no abscess formation. X-ray was unremarkable except for prominent soft tissue swelling. Laboratory evaluation was significant for WBC (white blood cell) count 14.0K (thousand), ESR (erythrocyte sedimentation rate) 38, and CRP (C-reactive protein) 0.9. Blood culture was pending. She was treated with ibuprofen, Benadryl, and parenteral clindamycin.

No, the Inpatient admission was not medically necessary.
Cellulitis is an infection with inflammation of the subcutaneous layers of the skin, including the loose connective tissue, with limited involvement of the dermis and sparing of the epidermis. The most common bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Clinical presentation includes edema, warmth, erythema, and tenderness. The borders are not clearly demarcated. Regional lymphadenopathy may be present, and the patient may experience constitutional symptoms such as fever, chills, and malaise. Complications include abscess formation, joint involvement, bacteremia, and necrotizing fasciitis. Culture is indicated to allow for identification of the causative agent. Ultrasound should be limited to suspected subcutaneous abscess. Empiric therapy should be directed to the history of the illness, location, and severity, as well as age and immune status of the patient.

In this case, the child presented to the ED (emergency department) with same-day symptoms and no history of outpatient evaluation or treatment. She was appropriately evaluated in the ED (emergency department), with initiation of parenteral antibiotic therapy. While it was not unreasonable to monitor her in the hospital overnight because of the sudden onset and location of the cellulitis, she was overall hemodynamically stable with no evidence of impending sepsis or abscess formation. She did not require acute inpatient admission, and she could have been safely managed at a lower level of care, such as observation.

Plastic Surgery was consulted with recommendations to admit for IV (intravenous) antibiotics, with no indications for surgical intervention. Admission orders included continued parenteral clindamycin, anti-pyretics, and close monitoring for any worsening. The following day, with no progression of erythema, the patient was discharged home to complete five days of oral antibiotics and hydrocortisone cream.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems
Treatment: Braces
The insurer denied braces. The health plan's determination is overturned.

The patient in question is a female with an anterior crossbite on tooth 10. She presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for 24-30 months of orthodontics (braces) to address the crowding and crossbite.

Braces are medically necessary for this patient. This patient presents with an anterior crossbite on tooth 10, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. Therefore, braces are medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Severe Atopic Eczema

Treatment: Dupixent 200mg (milligrams)/1.14 ml (milliliter)

The insurer denied coverage for Dupixent 200mg/1.14 ml.

The denial is overturned.

The patient is a male with a history of atopic dermatitis (AD). The patient, according to the documentation note, is being treated with oral cyclosporine, prednisone, and hydroxyzine as well as topical steroids. The requested medication is Dupixent.  

Dupixent is medically necessary for the treatment of the patient's diagnosis. The patient has decreased systemic treatment options available which could safely be administered given his age. The patient has failed oral therapy with cyclosporine and prednisone as well as topical therapy with steroids. In a randomized trial in adolescents and older, Simpson, et al found that "In this study, dupilumab significantly improved AD signs, symptoms, and quality of life in adolescents with moderate to severe AD, with an acceptable safety profile. Placebo-corrected efficacy and safety of dupilumab were similar in adolescents and adults."

Dupixent is approved for use in the treatment of the patient's atopic dermatitis under close medical supervision and at an appropriate dosing schedule at the discretion of the treating physician. 

The insurer's denial of coverage for Formulary Exception for Dupixent 200mg/1.14 ml is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems
Treatment: Skilled Nursing Facility
The insurer denied skilled nursing facility services.
The denial was overturned. 

The patient is a male who suffered an acute ischemic right middle cerebral artery (MCA) stroke with residual left sided weakness, left side neglect, impaired attention, and impaired perception. He was admitted to acute inpatient rehabilitation. The patient had completed sit to supine transfers with minimal assistance (MINA). He was ambulating 20' forward/backwards with only MINA of 2 people.

At issue is the medical necessity of skilled nursing facility services.

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

The requested service/treatment of skilled nursing facility services is medically necessary for this patient.

The patient suffered an acute ischemic right MCA stroke with residual left sided weakness, left side neglect, impaired attention, and impaired perception. He was admitted to acute inpatient rehabilitation. While slow, he has made progress. The patient had completed sit to supine transfers with MINA and requiring "no more than intermittent cueing to promote effective rate/volume of intake and oral clearance with intake of least restrictive diet." He was ambulating 20' forward/backwards with only MINA of 2 people, from maximum assistance (MAXA) of 2 people. However, the patient has required continuous physician oversight. The patient reported left sided chest pain and required an electrocardiogram (EKG), troponin lab work and then was started on baclofen for what was thought to be spasticity related pectoral pain. Baclofen was increased. An EKG noted a-flutter and the patient had shortness of breath (SOB) with worsening edema. Cardiology consult was necessary and medication changes were made. Amantadine had to be held secondary to concern for peripheral edema and the patient had increased confusion, necessitating an infectious workup. Cardiology, again, changed the patient's diuretic dosing. This required monitoring of electrolytes as diuretics can result in electrolyte abnormalities. For these reasons, it is medically necessary and appropriate for the patient to go to a skilled nursing facility to continue therapy while the patient receives close physician oversight and care.

Therefore, skilled nursing facility services stay is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genetic Diseases/Other/Monoallelic Mutation in STXBP1 Gene
Treatment: Physical Therapy
The health plan denied the requested health services as not medically necessary. 
The health plan's determination is upheld.

The patient is a male who has a genetic disorder (monoallelic mutation in the STXBP1 gene), dyspraxia, and epilepsy. The patient's parent reports in a letter that the patient cannot walk or pull to stand. Per a physical therapy evaluation the patient also cannot move into quadruped position on his own.

I uphold, in whole, the health plan's determination of medical necessity.

The requested health service/treatment of therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance) is not medically necessary for this patient. The patient has documented impairments and disabilities which do warrant therapy. These requested therapies are not medically necessary because the patient is receiving multiple therapies with the same or similar therapeutic goal. Duplicative or redundant services expected to achieve the same therapeutic goal are considered not medically necessary. The requested therapeutic activities do represent duplicative services and thus are not medically necessary for this patient.
The standard of care is that physical therapy services are considered medically necessary to improve, adapt or restore functions which have been impaired or permanently lost and/or to reduce pain when all of these are met:
- The individual's condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time
- The program is individualized, and there is documentation outlining quantifiable, attainable treatment goals
- Improvement is evidenced by successive objective measurements
- The services are delivered by a qualified provider of physical therapy services
- Physical therapy occurs when the judgment, knowledge, and skills of a qualified physical therapist is needed to safely and effectively furnish a recognized therapy service based on the treatment plan and the medical condition of the individual, with the goal of improvement of an impairment or functional limitation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypodontia.
Treatment: Plate replacing some lower and upper teeth (partial denture).

The insurer denied coverage for plate replacing some lower and upper teeth (partial denture).  The denial is upheld.

Upon review of the submitted documentation, which included copies of occlusal and periapical radiographs, dental chart notes, patient medical history and insurer correspondence, it appears that this patient with a complex medical history and multiple medical comorbidities presented for dental treatment. Recommended treatment was for replacement maxillary and mandibular partial dentures. The insurer has denied these services stating that dental treatment on some teeth is required before approval and that other teeth may exhibit a poor long-term prognosis. The patient is appealing the decision stating that his current dentures no longer fit, and he only has 4 remaining teeth.

The radiographic images indicate several remaining teeth. The handwritten clinical notes do not offer justification for replacement of the partial dentures. As the information provided is inadequate to support the recommended treatment, the partial dentures are deemed not medically necessary. The patients underlying medical issues have no bearing on the decision or necessity of treatment.

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

The plate replacing some lower and upper teeth (partial denture) is not considered medically necessary for this patient, based on the documentation, which fails to support the recommended treatment.

The insurer's denial of coverage for the plate replacing some lower and upper teeth (partial denture) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neural Reflex Syncope. 
Treatment: Inpatient Level of Care. 

The insurer denied coverage for inpatient level of care. 

The denial is upheld. 

This patient presented to the hospital following syncope.  The patient awoke early in the morning and was not feeling well.  He stood up and noted that his hands were clammy prior to passing out and hitting his chin on the kitchen counter.  He reported drinking 5 beers the night before.  The patient has no past medical history and was taking no medication.  He reported a previous vasovagal episode of syncope many years earlier.  Family history was negative for syncope or sudden cardiac death.  Physical exam was unremarkable with the exception of a bruise on the chin and a small laceration of the tongue.  Vital signs on presentation were Pulse 87 bpm, Blood Pressure 136/81.  12 lead electrocardiogram (ECG) revealed normal sinus rhythm with normal intervals and axis.  Echocardiogram revealed a mildly dilated right ventricle and mildly decreased right ventricular function and bubble study revealed a right to left shunt with valsalva maneuver.  The patient was admitted to the hospital where cardiac telemetry revealed no significant abnormality and a cardiac magnetic resonance imaging (MRI) was performed.  Cardiac MRI revealed mild dilatation of the right atrium and right ventricle and no delayed gadolinium enhancement.  The patient was discharged home with a diagnosis of neural reflex syncope. 

The health plan acted reasonably, with sound medical judgement, and in the best interest of the patient.  According to the American Heart Association (AHA) and the European Society of Cardiology, this patient was a low-risk patient for future morbidity and mortality. [1, 2]  In a study of individuals presenting to the Emergency Room, patients that were low risk or intermediate risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing. [3]  The history in this case is consistent with the diagnosis of either neural reflex syncope or volume depletion syncope.  Findings on ECG and telemetry were completely normal.  Findings on echocardiogram of mild dilatation of the right atrium and right ventricle with probable patent foramen ovale are unrelated to the clinical presentation.  In conclusion, the patient falls into a low-risk category and could be managed a lower level of care.  An inpatient level of care was not medically necessary. 

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

Diagnosis: Migraine headaches. 
Treatment: J0585 Botox 100 unit vial, 200 units every 3 months by intramuscular (IM) injection to treat chronic migraines.  

The insurer denied coverage for J0585 Botox 100 unit vial, 200 units every 3 months by IM injection to treat chronic migraines. 

The denial is overturned. 

This is a female patient who has been diagnosed with migraine headaches. The patient presented to an office visit for the evaluation of migraines. She has had several migraines daily, totally incapacitating her for years. Many years prior to this visit, the patient started receiving botulinum toxin injections, which made a huge improvement in her life as her migraines were substantially improved by about 90% and there were essentially no side effects. The prior provider had stopped seeing the patient due to insurance issues. On examination there were no obvious external deformities. The patient demonstrated areas of rather severe pain in her bi-temporal regions. The patient had some associated numbness in her left periocular region during some of her migraine episodes. It was noted based on her long history and excellent response to botulinum toxin injections in the peri-cranial region, this was supported as a correct diagnosis. The provider recommended botulinum toxin. 

The request for Botox indicated the patient had 30 headaches per month all day. The provider noted the patient had a reduction in monthly migraine days or hours with the medication. The patient had previously tried Wellbutrin 150 milligrams (mg) daily. The patient was also utilizing nortriptyline as needed. 

The medical literature supports the use of Botox for chronic migraines. The patient had tried and failed nortriptyline. The patient had been having 30 headaches per month that were disabling. The patient had previously utilized Botox with excellent headache relief. It would be imprudent to remove medication that has been effective for the patient. Therefore, J0585 Botox 100 unit vial, 200 units every 3 months by intramuscular (IM) injection to treat chronic migraines is considered medically necessary for this patient. 

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

The insurer's denial of coverage for J0585 Botox 100 unit vial, 200 units every 3 months by IM injection to treat chronic migraines is overturned. Medical necessity is substantiated.