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

Diagnosis: Severe Dental Pain

Treatment: extraction of impacted tooth covered by bone, #1, 16, 17, and 32

The insurer denied coverage for extraction of impacted tooth covered by bone, #1, 16, 17, and 32

The denial is upheld

Upon review of the submitted documentation which includes copies of panoramic radiograph, in addition to insurer correspondence, it appears that this patient presented to the oraI surgeon with impacted third molar teeth. The oral surgeon ddis requesting approval for extraction of impacted teeth #1, 16, 17 and 32. The insurer has denied the services stating that specific clinical criteria including but not limited to pathology or infection are necessary to justify extraction of third molar dentition. It is their assertion that it does not appear radiographically that the teeth would need to be extracted and the clinical circumstance does not meet criteria for approval. The patient is appealing complaining of pain. 

Upon review of the limited documentation submitted by the oral surgeon, in particular the radiographic image, it appears that the maxillary third molars are soft tissue impacted and mandibular molars are bony impacted. The coronal aspect of each of the 4 teeth is fully formed and partial root formation is also noted. There are no other radiographic findings that would justify extraction and no further clinical documentation is provided for review. 

The healthcare plan did act reasonably and with sound medical judgment and in the best interest of the patient. The radiographic documentation does not support medical necessity of these procedures.
The insurer's denial of coverage for the extraction of impacted tooth covered by bone, #1, 16, 17, and 32 is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness and Chest Pain. 
Treatment: Inpatient Admission. 

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

This patient is a female who was hospitalized for possible acute coronary syndrome (ACS). Her past medical history is significant for hypertension, diabetes and recent pacemaker. 

The patient presented to the emergency department for evaluation of chest pain, shortness of breath, lightheadedness and generalized weakness. Her vitals were stable.  The patient's electrocardiogram showed atrial paced rhythm. There was normal pacemaker function. Her chest film was negative for anything acute. The patient's troponin panel was negative. The transthoracic echocardiography was negative. The patient's treatment included proton pump inhibitor (PPI) and she was discharged to home. 

This is an appeal of the denied claim that the requested acute inpatient hospital stay was medically necessary for this patient. 

No, the proposed inpatient hospital admission was not medically necessary. 
Based on the peer reviewed medical literature and expert medical opinion, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the Milliman Care Guidelines for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome (ACS), chest pain that is indicative of a serious cardiac condition like pulmonary embolism (PE) or aortic dissection, acute myocardial infarction (AMI), pneumonia, cerebral vascular accident (CVA), hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. The care the patient received for suspected, uncomplicated gastroesophageal reflux disease (GERD) / peptic ulcer disease (PUD) like in this case, is routinely provided safely and effectively at a lower level of care, such as at the observation level of care. Therefore, the proposed treatment is not medically necessary, based on the submitted information and the current published medical literature. 

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

The care the patient received is routinely provided safely and effectively at a lower level of care, such as at the Observation level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lung Mass
Treatment: Full Hospital Admission
The insurer denied coverage for full hospital admission
The denial is overturned.

The patient presented to the hospital with complaints of a dry cough and progressive shortness of breath.  After scan, a mass was found, and she underwent video assisted thoracic surgery (VATS). She underwent left VATS and 620 ml (milliliter) of serosanguinous fluid was drained consistent with probable malignant pleural effusion.  Her post-operative course was complicated by pneumothorax and subcutaneous emphysema.  She was tachypneic (30 breaths per minute) and hypertensive (157/104mmHg [millimeters of mercury]). She was admitted to the hospital for treatment of pneumothorax, subcutaneous emphysema and pain management. She was ultimately discharged with a left pleural catheter in place. 

Several investigators have reported outcomes following VATS. In one study of 154 patients undergoing VATS with drainage for pleural effusion, the average length of stay was 2.7 days.  Complications occurred in 13% (percent) of individuals and included prolonged drainage, prolonged air leakage, broncho-pleural fistula, cardiac arrhythmia and loculated effusion (Reference 1). In a published meta-analysis including over 4000 patients undergoing VATS, average length of stay was more than three days (Reference 2). 

Inpatient hospital admission was medically necessary. 
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Psoriasis
Treatment: Taltz
The insurer denied the treatment with Taltz.
The denial is upheld.

The patient is a male with psoriasis, greater than 10% body surface area (BSA), treated with topical and systemic steroids and Otezla. The treating provider is requesting Taltz. The health plan requires use of systemic immunosuppressants and at least 3 of the preferred agents Humira, Otezla, Skyrizi, Stelara, Tremfya, Cosentyx and Enbrel. The subject under review is the medical necessity for the requested treatment with Taltz.

The health plan's determination is upheld.

Treatment with Taltz is not medically necessary. Taltz is now Food and Drug Administration (FDA) approved for pediatric psoriasis, but the patient has no documented contraindications to methotrexate, the plan preferred first line therapy, which is still widely used in pediatric psoriasis. The plan preferred agents Enbrel, Stelara, and Cosentyx also have pediatric approval, and these would also be appropriate for this patient. Therefore, Taltz is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite of tooth 7
Treatment: Braces and Periodic Orthodontic Treatment Visit
The insurer denied Braces and Periodic Orthodontic Treatment Visit.
The health plan's determination is overturned. 

The patient in question is a female with a crossbite of tooth 7. She presents with a skeletal Class III malocclusion with spacing in the maxilla and the mandible. She also has an anterior open bite. She is treatment planned for Braces and Periodic Orthodontic Treatment Visits to address the spacing, crossbite, and open bite.

Braces and Periodic Orthodontic Treatment Visit are medically necessary for this patient.
This patient presents with an anterior crossbite on tooth 7 as well as significant spacing. 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. Additionally, a major side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite.
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. For this reason, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Disruptive mood dysregulation disorder
Treatment: Mental health residential treatment 
The insurer denied the mental health residential treatment.
The determination is overturned.

The patient has a history of disruptive mood dysregulation disorder, Asperger's syndrome, post-traumatic stress disorder and borderline personality disorder. The patient was admitted to an inpatient level of care after a suicidal gesture. The patient admitted to frequent suicidal thoughts that were occurring on a daily basis. The patient was noted to have some self-harm behaviors while on the inpatient unit and initially was minimally engaged. Following discharge from inpatient treatment, the patient was admitted to residential treatment. The patient continued to self-harm while in residential treatment and frequently refused medications and visits with the psychiatrist. At issue is the medical necessity for residential treatment.

The requested mental health residential treatment was medically necessary. The patient continued to have suicidal ideation and was struggling with aggression, irritability and difficulty functioning. The patient had failed lower levels of treatment and was intermittently non-adherent with treatment despite structure of residential treatment. InterQual guidelines support residential level of care when patients are unable to be managed safely within the community and have serious emotional disturbance. In addition, American Academy of Child and Adolescent Psychiatry (AACAP) guidelines also support residential treatment when it is the least restrictive means to ensure safety (AACAP, accessed 2022). The patient was clearly a danger to self and struggled with aggression/impulse control. The patient had failed lower levels of treatment and required significant amounts of monitoring despite the structure of residential treatment. Records indicate that the patient was impulsive, agitated, endorsing self-harm and requiring significant redirection on the dates leading up to the dates in question and could not have safely been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Complex congenital heart disease/ prevent respiratory syncytial virus infection
Treatment: Synagis
The insurer denied coverage for Synagis.
The denial is overturned.

According to the clinical documentation provided for review, the patient is an infant. The patient has the medical diagnosis of complex congenital heart disease. The patient has past medical history with trisomy 21. The treating providers have requested Synagis to prevent respiratory syncytial virus (RSV) infection during RSV season. 

The treating provider is appealing the denial of Synagis. In an appeal letter the Pediatrician wrote that the patient has trisomy 21 in addition to congenital cyanotic heart disease. It is now the season for respiratory syncytial virus (RSV) and monthly injections from November to March is critical for the patient.  

A pediatric cardiologist wrote that the patient is at increased risk of hospitalization from respiratory infections due to congestion in the lungs. The requested therapy, Synagis, for prophylaxis, is recommended.

The patient meets established criteria for the use of Synagis. The patient is less than a year old at the start of RSV season and has hemodynamically significant congenital heart disease. 

"Delays in administering palivizumab at the beginning of the season increases the rate of RSV infection-related hospitalization. To maximize prophylactic effectiveness, administering the first dose as early as possible in the RSV season is crucial, with priority for cyanotic children or those with siblings." (Kamori, et al., 2021)

"RSV causes annual epidemics of acute respiratory illnesses in children, ranging from mild upper respiratory tract infections to severe lower respiratory tract disease including bronchiolitis or pneumonia. Severe RSV disease occurs primarily in infants younger than 6 months during their first fall and winter season of life.

RSV activity in the United States usually begins in the late fall and extends through spring; peak activity typically occurs in early February, although there can be regional variation." (American Academy of Pediatrics. 2022)

"INDICATIONS AND USAGE: Synagis is a RSV F protein inhibitor monoclonal antibody indicated for the prevention of serious lower respiratory tract disease
caused by RSV in children at high risk of RSV disease. Safety and efficacy were established in children with bronchopulmonary dysplasia (BPD), infants with a history of premature birth (less than or equal to 35 weeks gestational age), and children with hemodynamically significant congenital heart disease (CHD)." (Synagis Package Insert)                                                       

The insurer's denial must be overturned. 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 Synagis is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Consumer Directed Personal Assistance Services (CDPAS), Level 2: 84 Hours per Week
The insurer denied Consumer Directed Personal Assistance Services (CDPAS), Level 2: 84 Hours per Week. 
The health plan's determination is overturned.

The patient is a female with past medical history of osteoarthritis, stage III lung cancer, gastroesophageal reflux disease (GERD), coronary artery disease, lumbar spinal stenosis, aortic stenosis, memory impairment, hyperlipidemia, hypertension, anxiety, and osteoarthritis who had been assigned CDPAS (Consumer Directed Personal Assistance Services).

Consumer Directed Personal Assistance Services (CDPAS), Level 2: 84 Hours per Week are medically necessary for this patient.

The patient's medical providers documented the need for increased CDPAS services. The insurer assumed the patient had informal support outside of currently assigned CDPAS services. The patient's own plan documented a decline in activities of daily living (ADL) status and overall self-sufficiency in the last 90 days. The patient requires at least extensive assistance with tasks of walking, locomotion, transfer toilet, and toilet use. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in CDPAS services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADL). The patient's medical provider documented medical necessity for increased CDPAS services. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services 84 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute diverticulitis
Treatment: Inpatient Admission
The health plan denied the inpatient stay.
The health plan's determination is upheld.

The patient is a male with a medical history of gastroesophageal reflux disease (GERD), hyperlipidemia and depression. He presented to the emergency department with generalized abdominal pain, constipation, nausea and vomiting. His vital signs were notable for an elevated blood pressure of 166/77 millimeters of Mercury (mm/Hg). His physical examination was notable for left lower quadrant tenderness and mild guarding. The patient's labs showed an elevated white blood cell count of 12.3 kilo per microliter (K/uL), a low sodium of 134 millimoles per liter (mmol/L) and an elevated lipase of 1,742 units per litre (U/L). A computed tomography scan of the abdomen and pelvis showed colonic diverticulosis with mild stranding/infiltration surrounding the left colon, likely acute diverticulitis (cannot rule out focus of contained perforation). The computed tomography also showed a target-like focus of pericolonic adipose tissue infiltration in the left lower quadrant suggestive of possible appendicitis, trace pelvic fluid (likely reactive) and no evidence of free perforation. He was treated with intravenous fluids, Ondansetron, Morphine and Zosyn. 

The patient was placed on a hold for food and fluids by mouth (nil per os status). A surgery consultation concluded that he had acute sigmoid diverticulitis with microperforation. The recommendation was for intravenous fluids, intravenous antibiotics, serial abdominal exams, and to follow his lipase level and white blood cell count along with non-operative management. The following day he had no new complaints. The patient's labs showed a low hemoglobin of 13.7 grams per deciliter (g/dL) and a hematocrit of 41.8 percent (%), an unremarkable basic metabolic panel and an elevated lipase level of 600 U/L. Another set of labs showed an elevated white blood cell count of 11.6 K/uL, a low hemoglobin of 13.5 g/dL and a hematocrit of 40.9 %. The patient's labs also consisted of a low sodium level of 134 mmol/L, a low potassium level of 3.4 mmol/L and an elevated lipase level of 66 U/L. His abdominal pain had improved and he was tolerating a clear liquid diet without nausea or vomiting. The latest set of labs showed a low hemoglobin of 13.2 g/dL and a hematocrit of 39.5 % along with a low sodium of 135 mmol/L. He was discharged on Augmentin, with a plan for Surgical Oncology follow-up.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. The inpatient admission is not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Peripheral nerve stimulator
The insurer denied a peripheral nerve stimulator.
The health plan's determination is upheld.

The patient is a female with complaints of low back pain, knee pain as well as shoulder pain. She sustained a motor vehicle accident and has had multiple prior accidents. Prior treatments have included low back injections. Her diagnoses include vertebral genic low back pain. She has undergone physical therapy as well as other modalities.

The proposed peripheral nerve stimulator is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient is noted to have low back pain, which has failed multiple modalities. Peripheral nerve stimulation involves placing a small electrical device (a wire-like electrode) next to one of the peripheral nerves. These are the nerves that are located beyond the brain or spinal cord. The electrode delivers rapid electrical pulses that are felt like mild tingles/paresthesias. This modality is not recommended until there is higher quality research, including research on adverse events. The supporting evidence is limited to case reports, retrospective reviews, and small case series, mostly focusing on migraine treatment. Given the lack of support in the medical literature, the requested peripheral nerve stimulator is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Peripheral nerve stimulator
The insurer denied a peripheral nerve stimulator.
The health plan's determination is upheld.

The patient is a female with chronic pain in the knee, shoulder and low back. She has been treated with lumbar epidural steroid injections. Her provider recommended a peripheral nerve stimulator.

The proposed peripheral nerve stimulator is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Chronic low back pain (CLBP) is often multifactorial and a complex condition to treat. Its prevalence in the United States has been recently estimated to be ~13%, with afflicted individuals showing a higher likelihood of health care utilization. Innovative approaches utilizing peripheral nerve stimulation (PNS) for the treatment of CLBP are showing continued clinical improvement in pain, function, and quality of life with a reduced need for multiple interventions.

At present, there are two emerging techniques to PNS of the lumbar medial branches of the dorsal ramus for CLBP. The ReActiv8 (Mainstay Medical Limited, Dublin, Ireland) chronically implanted system utilizes two percutaneously placed leads and an implanted pulse generator, whereas the SPRINT PNS device is a percutaneous, temporarily implanted fine wire open-coil lead system. Both target the peripheral nervous system via the medial branch of the dorsal ramus.
Although the literature shows promising results, further studies examining the long-term efficacy, mechanism of action, cost, and utilization are areas of ongoing and future investigation. Therefore, the peripheral nerve stimulator is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Peripheral nerve stimulator
The insurer denied a peripheral nerve stimulator.
The health plan's determination is upheld. 

This is a female who has a long-standing history of low back pain after a motor vehicle accident (MVA). In addition, she has constant knee, shoulder and neck pain. This patient had tried meloxicam, diclofenac, physical therapy (PT), lumbar epidural injection and sacroiliac (SI) injections. According to her medical record, she had 80% pain relief from lumbar medial branch nerve blocks. Physical exam (PE) was unremarkable except bilateral axial tenderness, positive facet loading tests. 

The proposed peripheral nerve stimulator (PNS) is not likely to be more beneficial than any standard treatments for the insured's medical condition.

The etiology of this patient's persistent low back pain is discogenic and facetogenic pain. There are clinical evidence to support the efficacy of PNS for chronic migraine headaches via occipital nerve stimulation; chronic hemiplegic shoulder pain via stimulation of nerves innervating the trapezius, supraspinatus, and deltoid muscles, failed back surgery syndrome via subcutaneous peripheral field stimulation and lower extremity neuropathic and lower extremity post-amputation pain. However, there is no clinical evidence for PNS in the management of facetogenic and discogenic back pain.