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

Digestive System/Gastrointestinal
Inpatient hospital

Diagnosis: Abdominal pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a woman with a history of Crohn's disease and recurrent C. diff colitis who was admitted to the hospital. She presented with the chief complaint of abdominal pain. She stated that her symptoms had been ongoing for the past four days. She noted that the diarrhea had turned bloody earlier that day. In addition, she reported multiple episodes of vomiting. At home she was taking Remicade for treatment of Crohn's disease. Review of systems was negative for fevers and chills. Vital signs showed blood pressure 101/78, heart rate 110, and temperature 98.2 Fahrenheit. On physical examination, heart was regular and rapid, breath sounds were normal, abdomen was tender to palpation in the right lower quadrant, left lower quadrant and suprapubic area. Labs showed white blood cell count (WBC) 14.9, hemoglobin 12.2, sodium 136, potassium 4.2, glucose 86, and calcium 9.2. A computed tomography (CT) of the abdomen demonstrated inflammatory colitis largely unchanged from prior imaging study. There was no evidence of obstruction. The patient was admitted for abdominal pain with concern for infection versus Crohn's disease exacerbation. 

The inpatient hospital stay was medically necessary. The patient presented with concerns for colitis in the setting of metabolic acidosis, anemia with rectal bleeding, and suspicion for infection. The patient was hemodynamically stable, but the clinical course was complex and this patient was at increased risk of rapid worsening due to progressive infection or acute bleeding. The complexity of the patient and the patient's risk for an adverse outcome would not typically be managed at a lower level of care
Although the patient was not hemodynamically unstable, the patient did have a complex presentation and was at increased risk for rapidly worsening colitis, bowel perforation, and development of sepsis. Her care required input from multiple specialists and the metabolic acidosis increased the risk of Electrolyte abnormalities. Given the overall complexity, inpatient care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal
Nursing Services (including Private Duty Nursing)

Diagnosis: Osteoporosis
Treatment: Personal Care Assistance (PCA), Level II Services 
The insurer denied Personal Care Assistance (PCA), Level II Services 24 Hours per Day, 7 Days per Week (Split Shift). 
The health plan's determination is overturned. 

The patient is a female with past medical history of osteoporosis, difficulty walking, hypertension, urinary incontinence, chronic pain, postural kyphosis, rheumatoid arthritis, scoliosis, and unspecified gait abnormality who was had an assessment tool for PCA (personal care assistance) services. The patient was assessed at total assistance with tasks of ordinary housework while maximum assistance with tasks of meal preparation, managing finances, managing medication, stairs, shopping, and transportation. The patient was assessed at extensive assistance with tasks of phone use, equipment management, bathing, dressing upper/lower body, transfer toilet, and toilet use while limited assistance with tasks of personal hygiene, walking, and locomotion. She was assessed as supervision only for eating and independent with bed mobility. The patient scored 23/30 on Mini-Mental State Examination (MMSE). 

The Personal Care Assistance (PCA), Level II Services 24 Hours per Day, 7 Days per Week (Split Shift) are medically necessary for this patient.

The patient had a task-based assessment performed early with noted total hours but had a fall later with subsequent change in her functional status due to a vertebral fracture. There was a request to increase PCA service hours to 24 hours/day, split-shift, 7 days/week due to her increased care needs. After review of medical records from the Nursing Home, there is documentation by occupational therapy that the patient was in need of moderate assistance by one person to provide care and when performing walking on the unit with a rolling walker. In addition, the patient has a stage II decubitus ulcer erythema to the sacral area requiring turning and positioning every two hours. Therefore, her needs would be met with PCA services 24 hour/day (split-shift), 7 days/week.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient hospital. 
The insurer denied: Inpatient stay. 
The health plan's determination is upheld in whole.

The patient is a male who transferred from an outside hospital with 1 day of abdominal pain, and several episodes of non-bloody non-bilious (NBNB) emesis, and a 9 millimeter (mm) hyperemic noncompressible appendix on ultrasound (US) with a white blood cell (WBC) count of 11.6.
He was taken to the operating room (OR) on 7/13/20 where he underwent a single port appendectomy, with extracorporeal removal of appendix. There was no perforation and no pus present in the abdomen. The pathology was consistent with acute appendicitis and peri appendicitis. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The inpatient admission was not medically necessary for this patient.
The patient had an uncomplicated appendectomy. There was no perforation and no pus present in the abdomen. The patient recovered. Typical acute appendicitis without perforation can be treated at a lower level of care status.
Therefore, the patient's treatment in this case could have been provided at a lower level of care status and an inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental problems (anterior cross bite with gingival attachment loss)

Treatment: D8080 braces and D8670 monthly visit x 12

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

The denial is overturned.

This is a female child seen by an orthodontist for evaluation and need of orthodontic treatment. After clinical examination and analysis by the orthodontist, the findings revealed: skeletal class II - hypoplastic maxilla, asymmetric mandible with longer the left side, vertical growth pattern, late mixed dentition, mild maxillary and mandible crowding, and anterior cross bite with gingival attachment loss. The orthodontist recommended comprehensive orthodontics due to maxillary and mandibular crowding, Class II malocclusion, hypoplastic maxilla, and anterior crossbite with gingival attachment loss.  

It is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion a Handicapping Labiolingual Deviation (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.

In this case, the treating orthodontist claims an automatic qualifying condition of
crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is clearly 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 with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for D8080 braces and D8670 monthly visit x 12 is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental problems (skeletal class I, maxillary and mandibular crowding, deep impinging overbite and severe overjet).
Treatment:  Braces (comprehensive orthodontic treatment).

The insurer denied coverage for braces (comprehensive orthodontic treatment).  The denial is overturned.

This is a female child, who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to skeletal class I, maxillary and mandibular crowding, deep impinging overbite and severe overjet.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index, as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage.  The insurer has denied coverage for orthodontic treatment as not medically necessary, as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements attaining a score of 19 points on the HLD index where 26 points is required. 

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, the 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.

In 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.  In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

The coverage for braces (comprehensive treatment) is considered medically necessary for this patient. 

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

Based on the above, the medical necessity for braces (comprehensive orthodontic treatment) is substantiated.  The insurer's denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Genetic Testing. 
The insurer denied: Genetic Testing: Exome Sequence Analysis/WES-Whole Exome Sequencing. 
The denial is upheld in whole. 

The patient is a male with developmental delay and an episodic hyperkinetic movement disorder. He has been making episodic abnormal movements. The abnormal movements are choreiform and last several minutes at a time. They occur 3-4 times per day and have been increasing in frequency. Electroencephalogram (EEG) obtained at the time of the abnormal movements have suggested that they are not epileptic in nature. In addition, treatment with the anticonvulsant oxcarbazepine has not impacted the movements, which provides further evidence that they are not likely epileptic. Magnetic resonance imaging (MRI) scan of the brain has been normal. There is no family history of a movement disorder in the patient's family. His pediatric neurologist believes that the patient's condition is most likely genetic in origin. In an attempt to identify the genetic basis of his condition, the provider has ordered a whole exome sequencing test. The issue under review here is whether Whole Exome Sequencing is more likely to be beneficial than any standard approach for treating the patient's condition.

The health plan's determination is upheld.
Whole exome sequencing is a recently-developed laboratory technique that analyzes virtually all of the exons of an individual's deoxyribonucleic acid (DNA) in a single setting. In this process, tens of thousands of genes are analyzed simultaneously. As a result, this technique has the potential to elucidate genetic mutations that underlie a patient's condition.
Whole exome sequencing carries a great deal of promise to become a valuable clinical tool in the future. However, at this time, insufficient information is known to allow the data acquired from the test to be clinically useful for most patients. In particular, the technique may allow gene mutations and polymorphisms to be identified, but the clinical significance of those mutations would remain unknown. In other words, a patient with a neurologic condition, like this patient, may have one or more genetic mutations identifiable by whole exome sequencing, but whether those mutations underlie or contribute to his disease would remain unknown. Furthermore, even if a causative genetic condition is identified by whole exome sequencing, this information is generally useful only for genetic counseling purposes and is almost never valuable for patient management. Thus, for all of these reasons, whole exome sequencing should be considered not standard of care at this time. The standard approach to diagnosis is to conduct the tests that have already been done and that were negative. In many cases like this, the ultimate cause of a child's developmental delay and movement abnormalities remains unknown.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive sleep apnea syndrome
Treatment: Upper airway stimulation treatment for obstructive sleep apnea (outpatient surgery code 64568 x 1, 0466T x1)
The insurer denied coverage for the upper airway stimulation treatment for obstructive sleep apnea (outpatient surgery code 64568 x 1, 0466T x1).
The denial is overturned.

This is a female patient who has been recommended to undergo the implantation of an upper airway stimulation device. The patient has been diagnosed with obstructive sleep apnea (OSA) syndrome. The patient has had a trial and failure of continuous positive airway pressure (CPAP). The patient has a body mass index (BMI) of 29.2. The patient underwent a sleep study revealing an apnea-hypopnea index (AHI) of 24.4 in the supine position, and her respiratory distress index (RDI) was 15.1. The patient's sleep study revealed evidence of moderate OSA with moderate oxygen desaturation. The patient's breathing events did increase in the supine position and titration may be considered. The patient underwent a drug-induced sleep endoscopy which did not reveal complete concentric collapse. It has been recommended that the patient utilize an upper airway stimulation unit.

As per literature review, CPAP is a first-line of treatment for OSA; however, long-term use for many patients is suboptimal. The hypoglossal nerve stimulator in the United States (U.S.) was approved by the Food and Drug Administration (FDA) for the treatment of moderate and severe OSA. A five-year study indicated that the treatment was effective and improved sleepiness, quality of life and respiratory outcomes. In their updated (2017) position statement, the American Academy of Otolaryngology-Head and Neck Surgery stated that it considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult OSA syndrome to be an effective second-line treatment of moderate to severe OSA in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP). Candidates for this therapy are selected based on appropriate polysomnographic testing, age, BMI and objective upper airway evaluation. Literature notes that patients with OSA, unable to tolerate CPAP, and with an elevated BMI can be successfully treated with upper airway stimulation therapy.  

In this case, this patient meets all inclusion criteria to be a candidate for this requested procedure and device. 

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

Based on the above, the medical necessity for the upper airway stimulation treatment for OSA (outpatient surgery code 64568 x 1, 0466T x1) is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Benign prostatic hyperplasia
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male with BPH (benign prostatic hyperplasia). He was admitted  for a transurethral prostatectomy.  The surgery was uncomplicated.  He was treated with continuous bladder irrigation (CBI).  He required IVF (intravenous fluids), IV (intravenous) antibiotics, and IV (intravenous) pain medications.

The patient was discharged home after removal.   He was afebrile and hemodynamically stable. 

No, the Inpatient Admission was not medically necessary.

Care after an uncomplicated TURP (transurethral resection of prostate gland) can be provided at an observation level of care.  Because there were no signs of complications, infection, excessive bleeding, or instability, an acute inpatient level of care was not necessary.  The care of his comorbid conditions was routine.  An observation level of care was appropriate, even with use of CBI (continuous bladder irrigation).
Appeal type: Formulary Exception
Decision: Upheld

Endocrine/Metabolic/Nutritional
Pharmacy/Prescription Drugs

Diagnosis: Hypoandrogenism, Testicular Hypofunction
Treatment: Testosterone 50MG/5GM (1%) TD GEL 
The insurer denied Testosterone 50MG/5GM (1%) TD GEL. The health plan's determination is upheld. 

The patient is a male with Hypoandrogenism, Testicular Hypofunction. Testosterone 1% gel was prescribed for hypogonadism. The total testosterone level was 96 (reference range 250-627). Under review is the use of testosterone 50mg/5gm (1%) TD gel.

In this case, the use of Testosterone 50MG/5GM (1%) TD GEL is not indicated. The patient has not failed or been intolerant to and has no contraindication to the following formulary alternatives: testosterone transdermal gel 25 mg/2.5 g per (1%), testosterone transdermal gel 10 mg per actuation (2%), testosterone cypionate, and testosterone enanthate. All of these medications are approved for treatment of hypogonadism and represent appropriate therapeutic options in this case. None of these medications is associated with a greater side effect profile than the requested non-formulary drug. In summary, the formulary drugs will not be and had not been ineffective, would be as effective as the non-formulary drug, and would not cause adverse effects. A formulary exception is not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied the Braces.
The determination is overturned.

The patient has an anterior crossbite on tooth 10. He presented with a skeletal Class I malocclusion with minor crowding in the maxilla and minor crowding in the mandible. He is treatment planned for 18-24 months of orthodontics to address the crowding and crossbite. The treatment was denied due to a lack of medical necessity. At issue is the medical necessity of braces.

The braces are medically necessary. This patient presents with an anterior crossbite on tooth 10, as well as significant crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3)  If left untreated, the damage that will likely occur to the patients teeth will be much more time consuming to correct than the patient's existing orthodontic problem. Therefore, the treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Traumatic knee arthrotomy.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient tripped down some stairs in a subway terminal landing onto her elbow and left knee and leg. She was seen in the emergency department for assessment of her injuries. Plain radiographs of both affected body areas confirmed no fractures and no dislocations. A 5 centimeter (cm) laceration on the patient's left tibia was closed in the emergency room (ER) but there was a smaller skin laceration surrounding the left knee that was of greater concern. A computed tomography (CT) scan of the left knee confirmed some free air on the left knee joint which confirmed a traumatic knee arthrotomy. The patient was then admitted and taken to the operating room for irrigation and debridement of the left knee traumatic arthrotomy. The patient tolerated this surgery well with no documented complications. Her hospital stay was uneventful and she was deemed stable for discharge home the following day. At issue in this case is the medical necessity of this inpatient stay.

The requested health service/treatment of an inpatient stay was medically necessary for this patient. The medical records document that this patient sustained a leg laceration and traumatic knee arthrotomy after a fall down subway steps. The records also document that she received the appropriate care with administration of antibiotics and an emergent irrigation and debridement of the knee open wound. This care was consistent with the recommendations of the current, peer-reviewed literature as documented by Brubacher and colleagues in the Journal of the American Academy of Orthopedic Surgeons in 2019. This patient had a hemovac drain in place for drainage of the knee after surgery and she required 48 hours of intravenous antibiotics after her injury. This is clearly documented in the progress notes provided. Thus, the inpatient stay was medically necessary for this patient based on the injury she sustained, the documentation provided and the recommendations of the orthopedic literature.
The provided records document that this patient had a drain in place and she was receiving Ancef and Gentamycin intravenous (IV) antibiotics for the prevention of infection after her injury. This care is consistent with the recommendations of the current, peer-reviewed orthopedic literature and it required inpatient care. Thus, the inpatient stay was medically necessary.