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

Diagnosis: Ischemia
Treatment:  Nuclear Stress Test (CPT 78452), Pre-service
The insurer denied the  Nuclear Stress Test (CPT 78452), Pre-service
The denial is upheld. 

The patient is a male with history of coronary artery bypass grafting (CABG) that required a follow up stent to saphenous vein graft (SVG), and further intervention for re-stenosis with brachytherapy.  Has done well and last year underwent a nuclear stress test that showed a small area of ischemia. He has remained asymptomatic and a repeat nuclear scan was requested. The patient denied chest pain, chest pressure, shortness of breath, or palpitations. The exam was unchanged. Electrocardiogram (EKG) showed no significant change from year before.

No, the proposed treatment is not medically necessary.
Surveillance screen with nuclear studies in an asymptomatic patient is not supported by the literature or common medial practice. The patient denied chest pain, chest pressure, shortness of breath, or palpitations.

Also, less complex methods of looking for active ischemia are available including routine exercise stress testing.

In addition, the Health plan's criteria for a scan were also not met, including having had a nuclear scan less than two years ago.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: trigeminal neuropathic pain.
Treatment: a neurostimulator.
The insurer is denied coverage for a neurostimulator.
The denial is overturned. 

This female patient has a history of metabolic myopathy and trigeminal neuralgia.
The patient has tried the conservative approach and also had 3 neurosurgical interventions. Thus, the next level of care is peripheral neuro stimulation. The patient already demonstrated that the pain is amenable to the peripheral neurostimulation. The recent case series and the evidence from literature suggests that neurostimulation can be a second line treatment if other modalities fail. Ni et al, reviewed 13 studies with 221 patients and noted that "Peripheral nerve stimulation may be a promising approach in the management of trigeminal neuropathic pain, especially for patients intractable to conventional therapy."

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 a neurostimulator is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries/Injury. 
Treatment: Inpatient Hospital. 

The health plan denied the requested inpatient hospital stay as not medically necessary. 

The health plan's determination is upheld. 

This is the case of a female with a history of Antiphospholipid Antibody Syndrome, on Plaquenil and noncompliant with Warfarin, who presented to the emergency department after a fall down 6 steps. The patient had no broken bones or other injuries. She did have significant pain in her left knee and ankle. She was seen by orthopedic surgery, who recommended a knee immobilizer. She was admitted for pain control and physical therapy. She was discharged to home. The issue is whether an inpatient admission was medically necessary. 

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

No. This is not a medically necessary inpatient stay. The patient had no significant injuries warranting an inpatient stay. The patient was hemodynamically stable. The patient had no surgeries requiring an inpatient stay. The admission was listed as for "pain control" in the history and physical (H&P). The pain control provided was Tylenol, Ibuprofen, and Oxycodone. These medications do not require an inpatient level of care. As an example of a peer reviewed level of care reference, this stay would not qualify for inpatient necessity by InterQual standards. This patient did not require an inpatient stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression with psychosis, anxiety, atrial fibrillation, coronary artery disease and vertigo.
Treatment: Three Hours Per Day, Five Days Per Week, Total 15 Hours Per Week, Personal Care Services Level II AND 24 Hours per Week Consumer Directed Personal Assistance Services, Total Combined 39 Hours per Week, Pre-service.

The insurer denied the Three Hours Per Day, Five Days Per Week, Total 15 Hours Per Week, Personal Care Services Level II AND 24 Hours per Week Consumer Directed Personal Assistance Services, Total Combined 39 Hours per Week, Pre-service.  The denial is overturned. 

The patient is a female with a history of  depression with psychosis, anxiety, atrial fibrillation, coronary artery disease and vertigo. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

Appeal review requested for potential approval of 39 hours per week Personal Assistance Services to offer increased activities of daily living (ADL) support.

Yes, the proposed treatment of 39 hours per week personal assistance services is deemed medically necessary.

This is a female with a history of depression with psychosis, anxiety, atrial fibrillation, coronary artery disease and vertigo. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).  Although an assessment of the patient's functionality and ability to perform activities of daily living (ADLs) was completed and revealed that the currently approved plan of 36 hours per week personal assistance services was sufficient to meet the patient's current needs, the patient's medical provider relates this reduced schedule leaves the patient home alone, completely unassisted for several hours per day. This is problematic since she has numerous medical and psychiatric conditions which render her dependent on the assistance of a caregiver for completion of her activities of daily living (ADLs). Furthermore, the patient has reported to the emergency room (ER) on six separate occasions for worsening command auditory hallucinations, panic attacks and depressive ruminations. 

Hence, provision of 39 hours per week personal assistance services can reasonably be expected to be beneficial for the patient and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the proposed treatment 39 hours per week personal assistance services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Menorrhagia from uterine fibroids.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with menorrhagia from uterine fibroids who underwent a uterine fibroid embolization (UFE) and is requesting an inpatient hospitalization.

No, the inpatient admission was not medically necessary.
The proposed inpatient hospital admission was not medically necessary.

The uterine fibroid embolization (UFE) procedure is usually done as a short-stay/outpatient procedure or if needed as observation. "In many interventional practices, UFE is followed by overnight observation in a hospital setting. The purpose of this admission is to assure adequate pain control. However, many practices have been successful in discharging patients the day of the procedure. The decision regarding discharge must be made on a case-by case basis, and should be based on the patient's level of comfort rather than the potential difficulty of making an admission. All patients should successfully complete a trial of pain control with oral agents before leaving the hospital (1)."

This patient underwent an uneventful uterine fibroid embolization (UFE) procedure. There were no periprocedural complications and she had a normal postembolization stay with expected abdominal pain, which was treated appropriately. The left radial artery compression band was removed and was without complication as documented in the nursing note. The patient was advanced to regular diet and was ambulating on the physician assistant (PA) note. The medical doctor (MD) note states the patient was cleared for discharge and was tolerating pain and nausea with minimal medication and was to be discharged with oral medications. The provided patient's progress notes do not indicate a necessity for continued hospitalization following the procedure.  The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: severe crowding and impacted maxillary canine
Treatment comprehensive orthodontic treatment of adolescent dentition (braces)
The insurer denied coverage for comprehensive orthodontic treatment of adolescent dentition (braces)
The denial is overturned

Upon review of the submitted documentation including individual radiographic images, narrative letters, and dental record, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontic care due to severe crowding and impacted maxillary canine. The orthodontist has completed the Handicapping Labio-Lingual Deviation HLD index as required and has chosen the automatically qualifying condition of impacted permanent anterior where extraction is not indicated. 

It is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation 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.

In this case, the treating orthodontist claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

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

Based on the review, comprehensive orthodontic treatment of the adolescent dentition (braces) is medically necessary for the patient. 

The health plan's denial of coverage for comprehensive orthodontic treatment of the adolescent dentition (braces) is reversed. Medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type II Diabetes Mellitus.
Treatment: Formulary exception for Humalog Kwikpen, Pre-service.
The insurer denied the Formulary exception for Humalog Kwikpen, Pre-service.
The denial is overturned. 

The patient is a female with type 2 diabetes with insulin resistance, requiring over 160 units daily on insulin pump therapy. She has tried and failed Novolog due to hyperglycemia. Her A1C (glycated hemoglobin) was 8.4%. Per the appeal letter, the patient is unable to use Fiasp insulin, as it is U-100 (100 units per milliliter) insulin. The prior request was denied, as the health plan formulary requires trial and failure of Fiasp and Novolog.

Yes, the health plan should cover the Formulary exception for Humalog Kwikpen.
This patient has type 2 diabetes. She has tried and failed Novolog. Fiasp insulin, like Novolog, is a form of aspart insulin, which is not appropriate in this clinical situation, as she has tried and failed Novolog. This patient has marked insulin resistance. The use of concentrated insulin, such as Humalog U-200 (200 units per milliliter) insulin, is supported by the American Diabetes Association clinical guidelines in the setting of insulin resistance. Novolog and Fiasp insulin are U-100 (100 units per milliliter) formulations, not U-200 (200 units per milliliter) formulations. Without Humalog U-200 (200 units per milliliter), this patient is at risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, the health plan should cover the formulary exception for Humalog Kwikpen.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: left arm amputation

Treatment: prosthetic arm

The insurer is denied coverage for prosthetic arm

The denial is overturned. 

This male patient has a history of atrio-ventricular (AV) malformation and left arm amputation.

Upper extremity prostheses are a tool that can provide assistance with function and/or aesthetics. A passive or cosmetic prosthesis provides an option with a similar size and color of the sound hand. It is the ideal first time option and has been used by the child for several years. It provides an opportunity for the family to develop a consistent wearing pattern with a simple prosthesis. The cosmetic glove can be vinyl or silicone. Silicone gloves can be cleaned more easily. It provides a personalized option for cosmesis.

Amputation of an upper extremity leads to loss of function, affecting the patient physically and mentally. Major amputation is defined as amputation proximal to the wrist joint; minor amputations involve the hand and digits.

Following upper extremity amputation, options to optimize functionality include the use of a prosthesis or undergoing a hand transplant. Patients may choose not to use a prosthesis. Those undergoing stump revision for congenital deficiencies can sometimes function well without using prostheses, preferring the normal tactile sensation of the stump.

Types of prosthesis for upper extremities - The main types of upper extremity prostheses include passive (cosmetic), body powered, and externally powered.

Passive - Passive prostheses focus on improving appearance and do not improve active motor control. Passive prostheses can be static or adjustable. The former cannot move and is limited to basic tasks, such as fastening and stabilizing objects. As an example, the patient can use the prosthesis to stabilize the trunk by balancing the spinal column. The adjustable prosthesis includes some sort of movable mechanism that can be used by adjusting the prosthesis posture with the normal hand, enabling the patient to grasp objects. In many cases, passive prostheses have relatively good appearances and do not impede patients in their daily activities.

The device is made of a continuous piece of silicone that covers the forearm through to the shape of the hand which includes internal adjustable five finger armature, rigid crafted fingernails and custom color matched skin. The armature allows for optimal passive function due to its large range in adjustability while the custom matched skin and nails increase the patients acceptance and use of the prosthesis. It is made of lightweight and durable silicone material that is specifically fabricated to match the size and shape of his opposing hand. It is medically necessary for the patient to perform his basic ADLs (activities of daily living) at home, school and community with an acceptable level of independence that is age appropriate.
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 prosthetic arm is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: Orthodontic Treatment (Pre-service). 

The insurer denied the Orthodontic Treatment (Pre-service). 
The denial is overturned. 

The patient is a male. The request is for orthodontic benefits. 

Yes, the orthodontic treatment is medically necessary. 

The patient has a deep, impinging overbite with soft tissue damage to the palate. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem. 

Therefore, given the above, the orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion. 
Treatment: Braces. 

The insurer denied Insertion of Braces (Comprehensive Orthodontic Treatment of the Adolescent Dentition). The health plan's determination is overturned. 

The patient in question is a male presenting with a skeletal Class I malocclusion with maxillary and mandibular crowding. He has an anterior open bite. Teeth 6 and 11 are delayed in their eruption. Tooth 7 is in crossbite. The patient is treatment planned for orthodontics to address the open bite, crowding and crossbite, but the treatment was denied due to lack of medical necessity. 

The Insertion of Braces (Comprehensive Orthodontic Treatment of the Adolescent Dentition) is medically necessary for this patient. 

Anterior open bite patients are among the most difficult patients to treat. One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. 
This patient's condition is not something that will self-correct without orthodontic intervention. Therefore, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High Blood Sugar. 
Treatment: Inpatient admission. 

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

The patient is a male. He was admitted because of elevated blood glucose value of 435. The patient presented for elective 2nd and 3rd metatarsal head resection, because he has an extensive history of diabetic foot ulceration. Upon preoperative workup, he was found to have the high blood sugar value. His scheduled surgery was canceled, and he was admitted for "close blood glucose monitoring and therapy." He did not have any symptoms referable to the elevated blood sugar. He was discharged the following day after an endocrine consult. 

The admission was denied on the basis that the patient did not have a condition that warranted hospitalization. The appeal letter does not provide any specific medical reason for the admission, except to say that the decision was based on "multiple considerations including the patient's working diagnosis with inherent potential complications, the severity of illness at the time of evaluation, and an estimate of the risk to decompensate based on the clinical features of the case combined with the patients [sic] known co-morbid conditions." 

No, the Inpatient admission was not medically necessary. 

This patient had an elevated blood glucose in the context of known and long-standing type I diabetes. Episodes of hyperglycemia are common in such patients and do not, per se, represent a reason for hospital admission. The indications for hospitalization are well-discussed in a position statement by the American Diabetes Association [1]. Reasons include acute metabolic complications (e.g., diabetic ketoacidosis, hyperosmolar state), uncontrolled diabetes with a complicating feature (e.g., volume depletion, refractory hyperglycemia), and an acute associated unstable medical condition (e.g., coronary ischemia, sepsis). This patient did not have any such factors. Based on the Endocrine consult, his blood glucose elevation was related to the fact that he took several sugary snacks because he was worried about getting hypoglycemic. His glucose responded appropriately to insulin that was given in the preoperative holding area. There was no medical reason for hospital admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: alcoholism and withdrawal symptoms

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission.

The denial is overturned. 

This male patient has a history of alcohol abuse, alcohol liver disease, and hyperlipidemia.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. 

This patient could not safely be treated in a less restrictive detoxification treatment level of care as he was at risk for severe, complicated, and life-threatening withdrawal due to large amounts of alcohol use. He reportedly had alcohol withdrawal symptoms including tremors and had multiple active medical issues due to alcohol use putting him at high risk medically. He reportedly was put on a Librium taper. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated in a less restrictive treatment setting as he continued to use large amounts of alcohol despite medical issues and he required and needed detoxification medication to modify withdrawal. Detoxification medication included a Librium taper and he also needed 24 hour treatment as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting including severe and life threatening withdrawal symptoms. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required inpatient detoxification protocol treatment and was at risk medically as he had active medical issues putting him at risk medically as well and required 24-hour hospital treatment.

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: palpitations and shortness of breath

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission.

The denial is upheld. 

This male patient has a history of hypertension, hyperlipidemia, and coronary artery disease (CAD).

The patient's pretest probability of CAD is intermediate. (1) Utilizing the History, electrocardiogram (EKG), Age, Risk factors, and Troponin (HEART) score, he was considered low-intermediate risk. (2) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (3). Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. These findings are concerning and warrant management and evaluation that includes serial troponin measurement, echocardiography and ischemia work up prior to discharge. However, numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care. (4,5) They found no significant difference in outcome at 30 days between the two groups. Fernando Bellolio et al. noted that patients presenting with chest pain, that were managed in an observation unit, had similar 30-day myocardial infarction rates as those admitted to the hospital. (5)

The health plan did 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 upheld.  The medical necessity is not substantiated.