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

Diagnosis: Chronic pancreatitis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld.

This patient had a history of chronic pancreatitis and a pancreatic pseudocyst. He presented with abdominal pain and vomiting. He had a couple of recent admissions and was advised to have an endoscopic ultrasound (EUS). He was treated with pancreatic enzymes. He was hemodynamically stable. Intravenous (IV) hydration and antiemetics were given. There were no peritoneal signs. An abdominal computed axial tomography (CAT) scan showed chronic pancreatitis with faint edema in the peripancreatic fat. The lipase was 43. He left the hospital against medical advice.

Clinical indications for admission for chronic pancreatitis are listed in Milliman Care Guidelines (MCG) M-250. These include inability to maintain oral hydration, evidence of infection, hemodynamic instability, severe dehydration, acute renal failure, altered mental status, and severe electrolyte abnormalities. The patient did not have these conditions.

This patient had chronic pancreatitis. The lipase was not elevated. He required IV hydration and antiemetics. This could have been given in the emergency room (ER) as an outpatient. He did not meet MCG criteria for admission for chronic pancreatitis.

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: Community acquired pneumonia (CAP)

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld.

Patient is a male with history of (H/O) chronic obstructive pulmonary disease (COPD), who presented to the emergency department (ED) with complaint of (C/O) Fever with Chills, Headache of about 1 week duration. Patient 's vital sign (VS) at presentation were Temperature 101.8F (Fahrenheit) Heart Rate 98 Respiratory Rate 22 oxygen (O2) Saturations 98% (percent) on Room Air (RA). Physical exam revealed the patient to be in no acute distress (NAD). Lungs revealed some rales over R (right) lung fields. Cardiovascular system (CVS) S1 (heart sound) S2 (heart sound) Normal. Abdomen Soft, non-tender (NT). The patient was awake alert with a non-focal neuro exam. Labs revealed White blood cell count (WBC) was 6.9K (thousand) Hb (hemoglobin) 12.4 Na+ (sodium) 128 BUN (blood urea nitrogen)/ Creatinine 13/1.1 Chest x-ray revealed (CXR) and computed tomography (CT) revealed consolidation in R (right) lung field C/W (chest wall) pneumonia (PNA). Patient was admitted to hospital with diagnosis (Dx) of community acquired pneumonia (CAP). Patient also had Sputum for AFB (acid fast bacilli) done to rule out (R/O) Active tuberculosis (TB).

This patient was started on Rocephin and Azithromycin. Patient remained stable after admission. The patient had normal WBC. Was not hypoxic with O2 (oxygen) saturations 98 % on RA. Patient had Sputum AFB done which were negative. Patient was discharged on PO (by mouth) Abx (antibiotic) to complete treatment.

This patient did not need acute inpatient hospitalization. Patient could have been placed in Observation status. Observation could be for up to 48 hrs (hours). This patient had a low PSI (pneumonia severity index) and CURB (confusion, urea, respiratory rate, blood pressure) 65 score of Zero. This patient's presentation was more like a bacterial Pneumonia and not TB (tuberculosis). However, if TB needed to be R/O (ruled out) it could be done with 3 sputum smears done 8 hours apart. Patient did not fail outpatient therapy for pneumonia. Was not hypoxic. Was tolerating PO. No pleural effusion/Empyema on CXR (chest x ray). Hemodynamically (HD) stable. This patient was stable to be placed in Observation status while diagnostic testing and treatment were initiated. Patient could have been discharged on oral (PO) antibiotics (Abx) once sputum smears were tested and came back negative. 

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

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

Diagnosis: Chronic Rhinosinusitis. 
Treatment: 31295 nasal/sinus endoscopy, surgical, with dilation (eg balloon dilation); maxillary sinus ostium, transnasal or via canine fossa. 

The insurer denied coverage for for 31295 nasal/sinus endoscopy, surgical, with dilation (eg balloon dilation); maxillary sinus ostium, transnasal or via canine fossa. 

The denial is overturned. 

This patient is a male with a history of chronic rhinosinusitis. He has complaints of headaches and congestion. He has had a poor response to medications over one year. A balloon angioplasty was requested. Computed tomography (CT) imaging of the sinus demonstrated pan sinusitis with extensive mucosal thickening and obstruction of sinusitis at the ostiomeatal units. He had a complete audiogram which was normal. 

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

The claimant has chronic sinusitis confirmed on imaging and has failed medical management. Balloon sinuplasty is an indicated, non-experimental/investigational, next step in his treatment. It is within generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards, and associations. 

The 31295 nasal/sinus endoscopy, surgical, with dilation (eg balloon dilation); maxillary sinus ostium, transnasal or via canine fossa is considered medically necessary for this patient. 

The claimant has chronic sinusitis confirmed on imaging and has failed medical management. Balloon sinuplasty is an indicated, next step in his treatment. 

"Balloon sinuplasty is an option in the treatment of sinusitis that has failed appropriate medical therapy. Evidence is best for limited disease in patients with CRS without nasal polyps (CRSsNP) affecting the frontal, sphenoid, and maxillary sinuses. Because BSD can be performed in the office setting, it can be a viable therapeutic alternative in patients with comorbidities who are unable to tolerate general anesthesia." (Cingi et al., 2019). 

The requested procedure(s) is within generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards, and associations.        

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 31295 nasal/sinus endoscopy, surgical, with dilation (eg balloon dilation); maxillary sinus ostium, transnasal or via canine fossa is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left index finger laceration

Treatment: code 64831, suture, digital nerve, hand/foot: one nerve

The insurer denied coverage for code 64831, suture, digital nerve, hand/foot: one nerve

The denial is overturned

This is a female with no significant past medical history. She presented to the urgent care facility with complaints of a left index finger laceration after slicing an apple. She received two stitches and a diphtheria tetanus pertussis (DTaP) vaccine at the time of injury. She reported numbness over the left index finger on the radial digital nerve. The patient had a left digital nerve repair on the left index finger. An assistant surgeon was present during the procedure. 

The medical records demonstrated a complex surgical procedure was completed. The physician specifically described the necessity for an assistant in the operative report. He performed the surgery under loupe magnification. His attention would be directed solely to the surgical field for nerve repair. He would not be able to retract nor protect associated soft tissue. He would not be able to keep the surgical field clear of blood (noted in with tourniquet, slight bleeding can occur). He would require assistance after placing sutures as tension must be maintained using both hands. He utilized a very small suture (8-0) which is adds difficulty. The American College of Surgeons, Assistants at Surgery 2020 reports "sometimes" Based upon clinical experience and support from the American College of Surgeons, the assistant would be appropriate and necessary. 

The assistant surgeon utilized during surgery, code 64831, suture, digital nerve, hand/foot: one nerve is considered medically necessary for this patient.

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 assistant surgeon utilized during surgery, code 64831, suture, digital nerve, hand/foot: one nerve is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 
The patient is a female with past medical history significant for hypertension and diabetes mellitus who presented to the emergency room with complaints of swelling and pain to right third finger.

Vitals on presentation included a temperature of 98.6 Fahrenheit, blood pressure 103/62, heart rate 99, respiratory rate 18, and oxygen saturation 97% on room air. Laboratory results included white blood cell (WBC) count of 9.8, hemoglobin 13.5, hematocrit 41.5, creatinine 0.80, and glucose 339.

The patient was started empirically on intravenous antibiotics (vancomycin) for a right third finger cellulitis. Imaging studies of the hand did not show any soft tissue abnormalities or any osseous erosive changes. The patient underwent an incision and drainage procedure where the nail was removed. Wound cultures grew beta group B Streptococcus. The patient remained afebrile, hemodynamically stable, and clinically improved. She was discharged to continue oral antibiotics (Keflex) as an outpatient. 

According to documentation, the patient was admitted with a right third finger infection. Otherwise, she was afebrile and hemodynamically stable. Laboratory results were unremarkable including a normal WBC. Based on above findings, the patient had no evidence for a disseminated infection. The patient met criteria for observation level of management; she did not meet criteria for acute hospitalization.

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

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: G83.21 - Monoplegia of upper limb affecting right dominant side. 
Treatment: Powered Upper Extremity Range of Motion Assist Device, Elbow, Wrist, Hand Finger Single Of Double Upright(s) Includes Microprocessors, Sensors All Components and Accessories, Custom Fabricated 01 (L8702). 

The insurer denied the Powered Upper Extremity Range of Motion Assist Device, Elbow, Wrist, Hand Finger Single Of Double Upright(s) Includes Microprocessors, Sensors All Components and Accessories, Custom Fabricated 01 (L8702). 

The denial is upheld. 

The patient is a male. He has a history of traumatic brachial plexus injury of the right upper extremity. Nerve grafting surgery yielded limited functional response. The patient has been recommended Myomo robotic sleeve (L8702)- powered upper extremity range of motion assist device. 

The health plan denied coverage of application of this device for diagnosis G83.21 Monoplegia upper limb right Dominant side as experimental and investigational. The patient's family appealed the health plan decision to deny coverage of this device. 

No, the health plan should not cover the requested health service. 

No, the requested device is not more beneficial. 

Based on the review of all available information and clinical records, the requested health service, i.e., prescription of MYOPro 2 powered upper extremity range of motion assist device, is no more beneficial than any other standard treatment options. 

There is a lack of valid clinical research and scientific evidence in support of the prescription and use of powered upper extremity assist device in brachial plexus injury.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: G83.21 - Monoplegia of upper limb affecting right dominant side. 
Treatment: Powered Upper Extremity Range of Motion Assist Device, Elbow, Wrist, Hand Finger Single Of Double Upright(s) Includes Microprocessors, Sensors All Components and Accessories, Custom Fabricated 01 (L8702). 

The insurer denied the Powered Upper Extremity Range of Motion Assist Device, Elbow, Wrist, Hand Finger Single Of Double Upright(s) Includes Microprocessors, Sensors All Components and Accessories, Custom Fabricated 01 (L8702). 

The denial is overturned. 

The patient is a male with history of multiple injuries with brachial plexus injuries. The injuries were sustained in a mountain bike accident. This led to monoplegia of the right dominant upper extremity. The treating physician is requesting a myoelectric EWHFO (Elbow Wrist Hand Finger Orthosis) to improve the patient's ADLs (activities of daily living). 

The patient has failed nerve grafting surgery, conventional therapies, including static bracing, other multiple surgical interventions, and occupational therapy. 

Yes, the health plan should cover the requested health service. 

The myoeletric elbow-wrist-hand-finger orthosis (EWHFO) device is medically appropriate, as it was provided in accordance with, and consistent with, generally accepted standards of medical practice in the US (United States). 

The patient has tried and failed to progress with standard physical and Occupational therapies. His rehabilitation has plateaued. This has affected his ADLs (activities of daily living). The use of the Myoelectric orthotics will improve his functionality/ADLs (activities of daily living). 

According to Willigenburg et al, "Repetitive Task-specific Practice (RTP) integrating myoelectric bracing may be more beneficial than RTP [repetitive task practice] alone in improving self-reported function and perceptions of overall recovery." 

Peters et al, concluded that, "utilization of a myoelectric elbow-wrist-hand orthosis significantly increased gross manual dexterity and performance of certain functional tasks." 

In this case, the Myoelectric Orthotics is FDA (United States Food and Drug Administration)-approved and is the mainstream and standard treatment for paresis secondary to neurological injury, as is the case in this patient. He has failed mainstream conservative measures as stated above. The device is currently not in clinical trial or subject of review for a clinical trial and is not for the convenience of the patient. 

Yes, the requested myoelectric EWHFO (Elbow Wrist Hand Finger Orthosis) is more beneficial than any standard treatment for the patient's condition of monoplegia of a dominant hand secondary to Brachial Plexus injury.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: G83.21 - Monoplegia of upper limb affecting right dominant side. 
Treatment: Powered Upper Extremity Range of Motion Assist Device, Elbow, Wrist, Hand Finger Single Of Double Upright(s) Includes Microprocessors, Sensors All Components and Accessories, Custom Fabricated 01 (L8702). 

The insurer denied the Powered Upper Extremity Range of Motion Assist Device, Elbow, Wrist, Hand Finger Single Of Double Upright(s) Includes Microprocessors, Sensors All Components and Accessories, Custom Fabricated 01 (L8702). 
The denial is upheld. 

The patient is a male who was in an accident. This resulted in a brachial plexus injury with permanent paralysis to the right upper extremity. He has been treated with traditional therapies. A myoelectric powered upper extremity orthosis was requested. 

Coverage for this was denied by the health plan, and is being reviewed upon appeal. 

No, the health plan should not cover the requested health service. 
The patient suffered a brachial plexus injury with resultant right upper extremity paralysis. The use of a myoelectric powered upper extremity orthosis for brachial plexus injuries is considered experimental/investigational. There is a lack of quality peer reviewed literature substantiating the efficacy of this device. The majority of the studies are case reports and case studies, and are often industry-sponsored. The available literature does not allow for final conclusions as to the safety and efficacy of this device for the patient's diagnosis. As such, it remains experimental/investigational. 

No, it is not clear that the treatment is more beneficial than any standard treatment, as there is a lack of evidence of efficacy regarding this device for the patient's diagnosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia.
Treatment: Increase in Consumer and Self Directed Personal Assistance Services (CDPAS) to 84 hours/week.
The insurer denied the increase in CDPAS to 84 hours/week.
The denial is overturned.

The patient is a female. Her conditions include Alzheimer's dementia. She lives with her daughter, who directs her care, and several family members. Denial of increase in consumer and self-directed personal assistance services (CDPAS) to 84 hours/week is being appealed. The plan approved a partial increase from CDPAS 63 hours/week to 70 hours/week.

Uniform Assessment System (UAS) evaluation completed shows severely impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, transportation, bathing, personal hygiene, dressing, walking, locomotion, and toileting; and extensive assistance with bed mobility and eating. She has frequent bowel and bladder incontinence. There is no significant change from previous UAS evaluation completed. She had a fall when attempting to transfer from bed to wheelchair.

An appeal letter notes the patient has several chronic medical conditions and impaired functional mobility and cognitive skills. It notes that the patient has scheduled and unscheduled needs for assistance with ADLs (activities of daily living). It also notes that the current hours do not cover the span of time for the patient's needs once the aide leaves for the day.

Yes, the requested increase in CDPAS to 84 hours/week is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with ADLs, health maintenance activities, and routine support services. Denial of an increase in CDPAS to 84 hours/week is being appealed. The plan approved a partial increase from 63 hours/week to 70 hours/week.

This patient has several chronic conditions, including Alzheimer's dementia. UAS evaluation completed shows severely impaired cognition and need for extensive assistance to total dependence with ADLs. She has frequent bowel and bladder incontinence. There is no significant change from previous UAS evaluation completed. Appeal statement notes the patient has scheduled and unscheduled needs for assistance with ADLs and the current hours do not cover the span of time for needs once the aide leaves for the day. This patient requires significant care with ADLs and personal care. She requires maximal assistance to total dependence with ADLs, except for extensive assistance with bed mobility and eating. The level of assistance needed, in addition to bowel and bladder incontinence, cannot be met with CDPAS 70 hours/week. The approved CDPAS 70 hours/week is insufficient to meet the patient's needs for assistance with ADLs and personal care. The proposed increase in CDPAS to total 84 hours/week is medically necessary.

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

Diagnosis: Porcelain Fracture.
Treatment: Crown (D2750) Quad 07.
The insurer denied the Crown (D2750) Quad 07.
The denial is overturned.

The patient is a male with porcelain fracture on crown #7. The health plan's denial was stated as the crown being repairable.

Yes, the requested Crown (D2750) Quad 07 is medically necessary.
Once the porcelain fractures off of a porcelain and metal crown, it is not repairable. The photo shows large areas of missing porcelain off of crown #7. This is a major plaque trap which is not healthy for the gum tissue around tooth #7. When the existing restoration has been damaged and cannot be made serviceable, then it would have to be replaced. This crown cannot be made serviceable again. A new crown is medically necessary in this case.

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

Diagnosis: Blood Disorder-Anemia
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

The patient has a past medical history significant for anemia, alcohol use disorder, hypokalemia, hypomagnesemia, and generalized weakness who came to the emergency department according to the recommendation of her primary care physician due to anemia and the need for blood transfusion. On the day of admission, the patient was not bleeding, however, her last menstrual period ended just a day before the presentation. The patient always had heavy menstrual bleeding that was associated with a passage of blood clots. It was also mentioned that the patient used to take iron supplements. At the time of admission, the patient complained of fatigue and generalized weakness but denied fever, chills, shortness of breath, chest pain, palpitations, vaginal bleeding, discharge, dysuria, or changes in bowel movements. White blood cell count was 3.1, hemoglobin 4.8, hematocrit 17.9, and platelets 158.
The patient was admitted to the hospital with acute on chronic symptomatic anemia that was attributed to abnormal menstrual bleeding. The patient underwent  transfusion of packed red blood cells. She was seen by an obstetrics/gynecology (OB/GYN) service. They recommended a transvaginal ultrasound, which demonstrated an endometrium of 13 millimeter (mm). Outpatient follow-up with a gynecologist was recommended. The patient received supplements due to hypokalemia and hypomagnesemia. During the hospital stay, the patient remained in a stable clinical condition with improving symptoms. Therefore, she was transitioned to outpatient care and discharged from the hospital.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The patient presented to the hospital with anemia, however there was no evidence that the anemia was associated with hemodynamic instability, active bleeding, or hemolysis. The anemia was not associated with an altered mental status, recurrent syncopal, or near syncopal episodes. There was no evidence of high-risk low platelet count. The anemia was not associated with acute renal failure, heart failure, myocardial ischemia, acute peripheral ischemia, or any other signs or symptoms requiring intervention at the acute inpatient level of care. The electrolyte abnormalities did not manifest in clinically significant symptoms and were corrected within a short period of time. Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
The hospital stay was short and within the scope of a lower level of care.