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

Diagnosis: severe capsular contracture, grade IV on the left breast

Treatment: CPT code 19380 (revision of reconstructed breast)

The insurer is denied coverage for CPT code 19380 (revision of reconstructed breast)

The denial is modified. 

This female patient has a history of thyroid disease and breast cancer.

According to the American Society of Plastic Surgery "CPT Corner" article titled "Breast reconstruction coding: Everything you need to know" (June 2009), implant removal is a component part of implant replacement. To quote directly; "Implant removal (19328) is included in implant replacement procedures - one cannot place a new implant in, unless the previous implant is removed."  In addition, code 19380 is not medically necessary because the records do not document any additional procedures beyond implant replacement (19342) and capsulectomy (19370).
The insurer's denial of coverage for the CPT code 19380 [revision of reconstructed breast (e.g., significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant based reconstruction)]- modifier 50 [bilateral procedure], CPT code 19370 [revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy]- modifier 50 and 59 [distinct procedural service], CPT code 19340 [insertion of breast implant on same day of mastectomy (i.e., immediate)]- modifier 50, and CPT code 19328 [removal of intact breast implant]- modifiers 50/59 performed on 8/12/20 is modified. Medical Necessity is partially substantiated. Approve 19342 and 19370 and uphold denial of 19328 and 19380.

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

The carrier's denial of coverage for the CPT code 19380 (revision of reconstructed breast) is modified.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female patient who has a history of appendectomy and cyclic vomiting due to marijuana use.  She presented in the emergency room department (ED) with the complaints of eight to ten (8-10) out of ten abdominal pain and vomiting.  

In the emergency department (ED) the patient had abdominal tenderness in the right upper quadrant and epigastric area, as well as shortness of breath, chest pain, abdominal pain, nausea, vomiting, fatigue, diaphoresis, and light-headedness.  Laboratory values showed abnormalities with the white blood cells (WBCs) and an anion gap.  An electrocardiogram (EKG) showed bradycardia.  Urine  testing was completed and showed abnormalities as well.  Maalox, intravenous (IV)  diphenhydramine, intravenous Pepcid, intravenous ketorolac, intravenous ondansetron and intravenous metoclopramide were given in the emergency department.  Intravenous fluids were also given.  After further assessment, the patient still complained of pain and nausea.  

The patient was admitted with cyclical vomiting verses abuse-induced hyperemesis syndrome with ongoing cannabis use disorder.  She was also seen by psychiatry due to noted significant anxiety.  Pain management (intravenous morphine) was administered with relief.  Intravenous fluids (lactated ringers) was ordered and administered.  During the patient's stay, her potassium level dropped down to 3.2 with needed intravenous repletion as the patient refused oral repletion. A gastroenterology (GI) consult was done with no new recommendations.  As the plan of care continued, her pain resolved, and she was discharged home with close outpatient follow up.  

No, the proposed inpatient admission was not medically necessary.
Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had recurrent nausea; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for prolonged NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth Extractions

Treatment dental implants (code D6010) for teeth numbers 18, 19, and 21

The insurer denied coverage for dental implants (code D6010) for teeth numbers 18, 19, and 21

The denial is upheld

The patient has a history of benign neoplasm of the mouth that was excised. The patient had a panoramic x-ray, surgical tooth extraction, placement of implants and bone grafting with is dentist. The insurer has denied these services.

There are no radiographs to determine the medical necessity of implants. The records were requested from the provider in writing and again telephonically at which time the provider office advised that a special release was needed. The patient was contacted and advised of the need for the release and the lack of records.

The objectives of imaging are to decide if implant treatment is appropriate for the patient, to identify the location of vital anatomical structures such as the inferior alveolar nerve and maxillary sinus, to ascertain bone quantity, height, buccolingual width, and angulation of alveolar process, to detect any possible pathological conditions, and also to decide the length and width of the implant to be placed. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. There is not enough information to determine medical necessity for the implants in the #18, #19 & #21 areas. 

The insurer's denial of coverage for dental implants (code D6010) for teeth numbers 18, 19, and 21 performed is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Abuse, Transaminitis, Elevated triglycerides
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of alcohol abuse and was admitted with complaints of (c/o) tremors and diarrhea after stopping alcohol use. Vital signs were remarkable for sinus tachycardia. The physical exam was notable for normal appearance, no apparent distress (NAD). Lab work was notable for transaminitis and elevated triglycerides. A computed tomography (CT) scan of the abdomen showed mild pancreatitis but patient denied symptoms, a chest x-ray (CXR) showed no acute abnormality. An electrocardiogram (EKG) showed sinus tachycardia without evidence of acute ischemia. The patient was diagnosed with alcohol withdrawal and treated with intravenous fluids (IVF), telemetry monitoring, fenofibrate, nothing by mouth (NPO), and oral benzodiazepines (BZDs). An insulin drip was considered for treatment of elevated triglycerides, but not executed due to the patient being asymptomatic. 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 ED with c/o tremors and diarrhea. The patient did not have an acute co-morbid illness requiring inpatient treatment, high risk for delirium tremens, history of withdrawal seizures, long-term intake of large amounts of alcohol, serious psychiatric condition (e.g., suicidal ideation, psychosis), or severe alcohol withdrawal symptoms. He was found to have mild alcohol withdrawal, was treated with Clinical Institute Withdrawal Assessment (CIWA), BZDs, intravenous fluids, and telemetry. These interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/Childbirth. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient hospital admission. The denial was upheld.

The patient is a gravida (G)1, para (P)1 female, status post a low transverse cesarean delivery at 39 1/7 weeks. The baby was noted to have a fetal cardiac anomaly that required transfer of the baby to an outside hospital. 

In this case, the patient was post-operative day 1 from a cesarean delivery with low hemoglobin due to blood loss. The baby was transferred to another hospital for surgery evaluation, and the mother was transferred with the baby for mother-baby bonding. The patient was noted to have an uneventful postpartum stay and was discharged in stable condition. The patient had a stable hemoglobin and did not require transfusion, and her vital signs remained stable.

At issue is the medical necessity of the Inpatient stay.

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

The requested health service/treatment of Inpatient stay was not medically necessary for this patient.

In this case, the admission to an acute inpatient level of care was not medically necessary for a stable postpartum patient on day one after cesarean. The patient was admitted and underwent a cesarean delivery for an infant with congenital cardiac disease. The patient was noted to have a postpartum hemorrhage of 1.4 liters (L) at the time of cesarean delivery but did not require a blood transfusion or intervention at that time. The patient was transferred to another hospital to accompany the baby for consideration of possible surgery on the baby.  The service of acute inpatient care as a transfer patient from a facility with the ability to provide care is not medically necessary, as the service would not improve the health outcome for this patient.  In this case, the maternal care was available at the delivery hospital and did not require transfer for maternal health or benefit. In a patient recovering from postpartum hemorrhage after a cesarean delivery, management and monitoring can be performed at the delivery hospital and would not have required admission to an acute inpatient level of care at the outside facility.

Therefore, the Inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: otitis media with effusion 
Treatment: speech therapy
The insurer denied speech therapy. 
The health plan's determination is overturned. 

The patient is a male who presents largely with speech deficits but some language deficits as well. The patient's mother commented that his speech is difficult to understand and that he experienced chronic ear infections. He had been diagnosed with chronic serous otitis media with effusion (OME) as a toddler. The patient was seen for a speech and language evaluation. The results of this evaluation yielded a speech sound disorder characterized by motor planning weakness which affected prosody, speech rate, and diminished intelligibility when producing utterances of increasing length and complexity. His speech intelligibility was 80% whereas an intelligibility level of 100% is expected for his age. Formal testing of his language abilities yielded a mild delay in receptive language.
Under review is the medical necessity of speech therapy (ST).

Speech therapy is medically necessary for this patient.
The services of a speech-language pathologist with his or her specialized training play a critical role in the assessment and treatment aspect of speech and language disorders. Speech-language pathology services are medically necessary to treat speech-language disorders including disorders that have an organic basis such as the patient's with his diagnosis of chronic serous OME. Without proper intervention from a qualified speech-language pathologist, the patient's abilities in these areas will not progress toward remediation.
Organically based speech sound disorders such as chronic OME can lead to long-term deficits in speech and/or language acquisition as well as academic achievement without proper intervention. Specifically, upwards of 60% of children with chronic OME are reported to have delays in speech and language development.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite.
Treatment: Braces/Monthly visits.
The insurer denied braces/monthly visits.
The health plan's determination is overturned. 

The patient is a male with teeth # (number) 8 and #9 in anterior crossbite. He is in the mixed dentition phase. He has a Class I occlusion. Teeth 24 and 25 have gingival recession. The patient is treatment planned for 30-36 months of comprehensive orthodontics. Under review is the medical necessity of braces and monthly visits.

Braces and monthly visits are medically necessary for this patient.

It is a generally accepted practice guideline in orthodontics to treat anterior crossbites as soon as feasible because of the damage that can occur to the patient's dentition if left untreated. This patient is already developing gingival recession on teeth 24 and 25 due to the anterior crossbite.

Treatment for the patient's anterior crossbite in the mixed dentition is medically necessary. 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. These problems are much more time consuming and difficult to correct than the patient's existing orthodontic problem.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Handicapping labio-lingual deviation (HLD) score was 17.

Treatment: D8080 braces and D8670 monthly visit x 12

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

The denial is overturned. 

This male patient has a history of skeletal Class I, Class II canines, maxillary and mandibular crowding, excessive overjet, and deep impinging overbite.

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a significant 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.

ln this case, the treating Orthodontist claims an automatic qualifying condition of deep
impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. ln this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic 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. This is confirmed by several studies.

Each of the 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, and in the best interest of the patient.

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

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

The patient is a male who presents to the office for evaluation and treatment of the entire mouth with the therapy of scaling and root planning per quadrant (4341) for the UR (upper right), UL (upper left), LL (lower left), and LR (lower right). Provided for review are previous letters of appeal and denial, full mouth radiographic images, one page of American Dental Association (ADA) claim forms, periodontal indices, and health plan language. In question is the medical necessity of scaling and root planing per quadrant (4341) for the UR, UL, LL, LR. Previous denials of the claims have been on the basis that the patient does not display bone loss nor the presence of calculus.

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

No, the requested health service/treatment of deep gum and root cleaning all four quadrants is not medically necessary for this patient. The utilization of scaling and root planing as a periodontal therapy requires that the patient have evidence of attachment loss. The mere presence of deep probing depths does not indicate that the patient has any attachment loss as periodontal pocketing also occurs due to anatomical variation and is considered to be a psuedopocket. The therapy of scaling and root planing in a patient without periodontal attachment loss has been shown to damage the periodontal attachment and result in attachment loss. For patients who have evidence of attachment loss in the presence of active inflammation and with concomitant pocketing, scaling and root planing is the therapy of choice. Here, the radiographic presence of an intact lamina dura, radiographic evidence of intimate proximity of the bone to the CEJ (cementoenamel junction), no recorded attachment loss, absence of recession, and absence of bleeding upon probing are signs of an absence of periodontitis. Hence, considering the above documentation and rationale and also the absence of any diagnosis provided by the doctor, the treatment of scaling and root planing per quadrant (4341) for the UR, UL, LL, LR is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned.

This is the case of a female patient who was admitted to inpatient hospital on the pediatric floor due to psychotic symptoms including paranoid and bizarre delusional thinking, disorganized thinking, internal preoccupation with suspicion of delusions, agitation, and reportedly had headache and weakness. She was minimizing her symptoms. It was reported that she was almost arrested a few weeks prior to admission. She had a past psychiatric hospitalization and was diagnosed with schizophrenia and started on Risperidone. She took Olanzapine. The patient was transferred to the psychiatric unit for hospital treatment due to her acute psychotic symptoms. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, severe agitation, aggression, suicidal or homicidal intent or plan, or inability to adequately care for basic needs are in need of hospital treatment. 

This patient reportedly had severe psychiatric symptoms interfering with the ability to care for her basic needs. She reportedly had psychotic symptoms including paranoid and bizarre delusional thinking, disorganized thinking, internal preoccupation with suspicion of delusions, agitation, and reportedly had headache and weakness, and this interfered with her ability to function, so she required 24-hour hospital treatment, even in the pediatric unit until she was transferred to the psychiatric unit. She also had a past psychiatric hospitalization for psychotic symptoms and was almost arrested a few weeks prior to admission. She also lacked insight and was minimizing her problems so she likely would not have been compliant outside of a hospital setting until her psychotic symptoms lessened. The patient was transferred to a psychiatric unit for further hospital treatment so she required the hospitalization days. This patient required and received active psychiatric treatment in this hospital even though she was on a pediatric unit until she was transferred to the psychiatric unit for psychiatric hospital treatment. She required hospital treatment even in this pediatric hospital setting as she had reports of severe psychiatric symptoms including psychotic symptoms requiring hospital treatment. 

Hospital treatment was medically necessary as the medical records provided enough specific evidence to support that she had acute psychiatric symptoms including psychotic symptoms and was unable to care for her basic needs and required hospital treatment on the pediatric unit until transferred to the psychiatric unit for further mental health inpatient hospital treatment. It did not appear that the health care plan acted reasonably or had sound medical judgment or acted in the best interests 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: Hemoptysis. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is overturned. 

The patient  had a history of coughing especially with exertion or heavy work with associated hemoptysis. Imaging noted a left lung lesion. The patient underwent a bronchial artery embolization (BAE) as treatment of the hemoptysis. She had a history of hemoptysis, hyperlipidemia and tuberculosis with related bronchiectasis. The past medical records note that a blood culture revealed mycobacterium peregrinum. She had a pertinent past history of obesity and a previous cholecystectomy. Lab work was reviewed. 

The current treatment plan of bronchial angiogram with embolization for treatment of the lesion and also with necessary access to an anomalous chest artery with evaluation/treatment, was completed. There was no need for pulmonary angiography. At issue is the medical necessity of an inpatient stay. 

The requested health service/treatment of an inpatient stay was medically necessary for this patient with post-procedural evaluation. 
Bronchial artery embolization (BAE) is a safe, universally accepted procedure for control of hemoptysis of varying etiologies. BAE can be safely performed with immediate clinical impact as in this case. However, there are several possible complications that require observation post-procedure. 

The patient needed an inpatient admission for evaluation including medications, IV hydration, surgical site evaluation and cardiac monitoring. Neurologic complications are possible after this procedure is performed including paralysis, requiring ongoing nursing care. The patient had a reasonable treatment for hemoptysis. She had many co-morbidities. The stay was medically necessary at an inpatient level of care, not at a lower level of care in the hospital.