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

Diagnosis: Skeletal Class I Malocclusion, Anterior Crowding and openbite 

Treatment: Comprehensive Orthodontic treatment

The insurer denied the Comprehensive Orthodontic treatment. The denial was reversed. 

This is a young female patient who presented for evaluation for orthodontic care. 
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, letters from the orthodontist as well as insurer correspondence. The orthodontist identified skeletal Class I malocclusion, anterior crowding and openbite and has recommended orthodontics. The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index attaining 29 total points. 

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, 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 29 points to justify orthodontic care.  This reviewer concurs with the index completed by the orthodontist attaining a total of 29 points on the HLD index (4 overjet, 12 openbite, 10 anterior crowding, 3 labiolingual spread) which is above the threshold of 26 points to support orthodontic care.

Based on the above, the medical necessity for D8080-Comprehensive orthodontic treatment of the adolescent dentition is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:Bulbous bone on both mandible and maxilla 
 
Treatment: CT Scan; Implant Placement, Tooth 11, Tooth 13, Tooth 20, Tooth 22, Tooth 27, Tooth 29, Tooth 4, Tooth 6; Attachment Abutment, Lower Arch, Tooth 20, Upper Arch; Implant Supported Upper Denture, Upper Arch

The insurer denied the CT Scan; Implant Placement, Tooth 11, Tooth 13, Tooth 20, Tooth 22, Tooth 27, Tooth 29, Tooth 4, Tooth 6; Attachment Abutment, Lower Arch, Tooth 20, Upper Arch;Implant Supported Upper Denture, Upper Arch. The denial was upheld.  

This is a male patient who's natural dentition is in poor repair and extraction of the remaining dentition could be indicated. He has very bulbous bone on both mandible and maxilla that prevent him from ever wearing conventional dentures.  Patient documentation from mid-2019 states the patient has an active gag reflex and cannot tolerate anything on his palate. It also state that the patient is diabetic and requires proper nutrition that can be prevented if the patient does not have functional dentures.

As regards prosthodontic rehabilitation, although, implant supported overdentures would be an acceptable treatment in this case, conventional removable full dentures remain a standard of care in general dental practice. There is no specific objective documentation provided by Dr. to support the necessity of implants, nor documentation that would preclude the patient from wearing a conventional non-implant supported maxillary and mandibular full denture prosthesis.  It is only anecdotally noted the patient has a gag reflex.  Further the clinical images do not indicate overly bulbous jaws and underlying diabetes is not an indication for implant placement.

The carrier's denial of coverage for CT scan; implant placement, Tooth 11, Tooth 13, Tooth 20, Tooth 22, Tooth 27, Tooth 29, Tooth 4, Tooth 6; Attachment abutment, Lower Arch, Tooth 20, Upper Arch; Implant supported upper denture, Upper Arch is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Palpitations, hypertension, anemia
Treatment:  Inpatient admission
The inpatient admission was medically necessary for this patient.
The patient presented with new onset arrhythmia with uncontrolled heart rate, despite medical therapy in the ER, severe hypertension, c/w (consistent with) hypertensive urgency, electrolyte derangement in the setting of ESRD, severe anemia requiring transfusion, in the setting of full anticoagulation for a-fib/flutter and increased bleeding risk with the history of ESRD, respiratory failure in the setting of CHF, fluid overload, requiring BiPAP for respiratory support.  Given this presentation of new onset uncontrolled atrial flutter, anemia, hypertensive urgency, as well as multiple risk factors, co-morbid conditions and known CHF, it would be consistent with the current standard of care that this patient be managed in an inpatient setting.  Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Advanced Dementia

Treatment: Consumer Directed Personal Assistance Program Services

The insurer denied Consumer Directed Person Care Services (CDPAP) 16 hours per day, 7 days per week. The denial was reversed.

The patient has advanced dementia, is progressively declining and requires total assistance with all aspects of care. The patient cannot bathe, transfer, dress, eat or 
re-position without assistance. The patient is incontinent of both urine and bowel and requires someone to change soiled diapers to assure there is no skin breakdown. The additional hours are needed so that the patient can be re-positioned and changed to prevent skin breakdown. 

Home care nursing notes indicate the patient has bilateral upper and lower extremity flexion contractures and limited range of motion. Braden scale for pressure ulcer risk: 11 (high risk); has stage 2 pressure ulcer on coccyx. This patient is totally dependent on caregiver assistance for all IADLs and ADLs. Re-positioning in bed needs to be done at regular intervals throughout the hours the patient is in bed; this generally means at regular intervals at least through the night. Various practice guidelines have recommended re-positioning at 2-4 hour intervals, depending on risk. Greater frequency is generally needed for patients at high risk and who already have skin injury, which would include this patient. Considering all the patient's physical, mental and functional impairments, it is apparent that the patient needs caregiver assistance for the requested hours. This is a high risk situation and needs to be given priority attention. The physician has indicated the need for assistance with incontinence care and turning/positioning to prevent skin breakdown.
Appeal type: Medical necessity
Decision: Upheld

This patient was sent to the emergency department (ED) by her pediatrician for evaluation of possible appendicitis. She had generalized abdominal pain without a fever, vomiting or diarrhea. On arrival to the ED her vital signs were normal. Her white blood cell count (WBC) was significantly elevated. Her ultrasound was initially read as "suspicious" for possible appendicitis, but on further review, was deemed to be equivocal. The ED then proceeded to a computed tomography (CT) scan, which was also equivocal, because it could not identify the appendix. The health plan's determination is upheld.
Since the physicians were unable to rule out appendicitis clinically or radiographically, and because appendicitis was still considered a possible diagnosis given her history, physical exam, and elevated WBC, observation of the patient was needed. Depending on the clinical suspicion, the ability of the parents to monitor at home and return for care, and resources of the facility, this could have occurred at a lower level than inpatient. Acute hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hypokalemia secondary to diarrhea
 
Treatment:  Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was upheld. 

This is a female immunocompromised patient with a past medical history significant for asthma/Chronic Obstructive Pulmonary Disorder (COPD), hypertension, and depression/anxiety who presented to the emergency department with complaints of myalgias, nausea, and vomiting.

Vitals on presentation included:  Temperature-100 F, Blood Pressure-114/77, Pulse-89, Respiratory Rate-18, oxygen saturation-99%. Laboratory values were notable for the following: WBC-12.8, Hgb-12.6, Hct-38.3, creatinine-0.8, glucose-102, D-dimer 1.19.  She received some intravenous fluids and nebulizers in the emergency department.  CT angiogram showed no acute findings.  She was empirically started on oral vancomycin and IV metronidazole.  Stool work-up was negative, including C. difficile.  She remained afebrile, hemodynamically stable with clinical resolution of symptoms.  There was no evidence for a systemic infection.  She was discharged to follow-up as an outpatient.

Based on the above, the medical necessity for the inpatient hospital services is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

The patient is a young female who developed right knee pain after a fall. She had a normal general exam, her vital signs were stable and there was no rash. However, on the local exam, there was right knee swelling. Fluid drawn from the knee contained white blood cell count of approximately 47,000. She was transferred to another hospital where Lyme disease tests were done that returned positive. The patient was admitted overnight and started on antibiotics. The health plan has denied the admission as not medically necessary. The health plan's determination is upheld. The admission was not medically necessary.

The patient was not in distress. She was completely hemodynamically stable. The lab values did not show serious concern - the WBC was not showing leukocytosis. After the patient was admitted there was no perturbation of lab status nor hemodynamic status. As per the retrospective chart review (ref 2), the knee arthritis Lyme in pediatric patients has excellent prognosis. The patient improved rapidly and if one were to calculate the PEWS (Pediatric Early Warning Score) the PEWS would be 0 or 1 which indicted the patient could be managed in a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a case of a female with end-stage hemodialysis on schedule Monday, Wednesday, Friday through a left upper extremity arteriovenous (AV) fistula, who presented to the emergency department with multiple bouts of what she describes as fever and chills, occurring during dialysis, with rapid resolution after dialysis.  The symptoms were improved by taking Tylenol. This type of episode occurred during the past several dialysis rounds, and when she informed her nephrologist of it, she was referred to the emergency department to be evaluated.  The symptoms did not occur at all during times when the patient is not receiving hemodialysis.  Other associated symptoms include slight rhinorrhea, and mild suprapubic pain.  She also complained of chronic shortness of breath.  The patient denied any sick contacts.

The patient was admitted to the hospital for fever of unknown origin, consideration was given to possible sepsis of unclear source, reaction to hemodialysis versus other.  The patient was started on empiric antibiotic regimen with intravenous (IV) Zosyn.  She was seen by nephrology, who recommended obtaining blood cultures and scheduling for dialysis while hospitalized.  On the following day, the patient developed 6 or 7 bouts of watery stool, consistent with diarrhea.  Stool sample was sent, which came back 24 hours later, positive for rotavirus.  Clostridium (C.) difficile was negative.  The patient's symptoms improved.  She tolerated hemodialysis.  No further fevers are recorded in the medical record.  Daily labs, including chemistry panels, were obtained and were typical for a patient on hemodialysis.  White blood cell count remained normal; vital signs remained normal, and all of the blood cultures and urine culture remained negative.  The diarrhea was treated with loperamide and resolved, as did the suprapubic tenderness.  The patient tolerated hemodialysis without difficulty and was eventually discharged to home in stable condition, without the need for further antibiotic therapy.

The health plan's determination is upheld. 

The patient was evaluated for possible causes of infection, given the low grade temperature.  A typical evaluation would include monitoring the temperature curve and looking for signs of sepsis.  This patient did not satisfy the criteria for sepsis.  In the absence of clear sepsis criteria, the patient can be monitored at a lower level of care status, with blood cultures, empiric antibiotics and monitoring of vital signs.  Patients with ESRD will have abnormal creatinine, lactate, and electrolytes, which is controlled by performing hemodialysis treatments.  Viral gastroenteritis caused by rotavirus can also produce all of the patients symptoms and certainly does not require inpatient admission.  This hemodynamically stable patient could have been appropriately evaluated and treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Coronary Angiography 

Treatment:  Inpatient Admission Hospitalization

The insurer denied the Inpatient Admission Hospitalization.  The denial was upheld.    

This is a male patient who presented to the Emergency Room in 2019 with complaints of chest pain.  He has a past medical history for coronary artery disease, coronary stents, hypertension, and hyperlipidemia.  His electrocardiogram showed sinus bradycardia, and Troponin was negative.  He was admitted and underwent coronary angiography, which resulted in placement of a stent to a 90% stenosis of the right posterolateral branch.  There were no complications, and the patient remained clinically and hemodynamically stable.  He was discharged home the next day.  

Inpatient admission status was not medically necessary for this patient.  Per Milliman Care Guidelines (MCG) Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), the clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization and stenting.  This is an outpatient procedure, and it could have been performed on an outpatient basis. 

Based on the above, the medical necessity for the inpatient admission for acute level of care is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dehydration, Hypoglycemia, and Metabolic Acidosis due to Diarrhea.
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.

This is a young female child who presented to the Emergency Department with diarrhea for four days, vomiting every 30 minutes for the prior seven hours, decreased intake by mouth and a decrease in the amount of wet diapers. The patient had a decreased activity level. Her initial blood sugar was 59. The serum glucose was 60. Sodium was 133 and bicarbonate was low at 12. She was treated with intravenous fluids containing dextrose and was given Zofran. She was started on an intravenous infusion and repeat blood glucose was normal. The patient was placed on contact isolation and intravenous (IV) fluids were continued with blood glucose monitoring. The patient's blood glucose levels during the admission ranged from 59 to 87 and improved after (IV) hydration.

The patient required close monitoring of the glucoses, as well as intravenous hydration and treatment of the acidosis. Given the presence of other findings other than dehydration that required evaluation, treatment and follow-up, an observation admission would not have been appropriate. The acute inpatient admission is consistent with generally accepted standards of medical practice and is therefore medically necessary [1-3].

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  OCD; Tardive dyskinesia
Treatment:  Austedo
The requested Austedo is not medically necessary.

There is no reason the patient cannot be treated with the preferred formulary agents, tetrabenazine.  This medication has been demonstrated to be effective for her condition and is standard of care first line treatment.  There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Austedo relative to the preferred agents.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Esophagitis.
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.     

The patient presented with chest pain. There was an initial tachycardia in the Emergency Room which resolved. At the time of admission, he was afebrile and the vital signs were stable. A Computerized Axial Tomography (CAT) scan revealed esophagitis. The patient did not have a pulmonary embolism or acute coronary syndrome (ACS). The esophagitis was treated with proton pump inhibitor (PPI) therapy and Carafate.

Clinical indications for admission for esophageal disease (M-550) include hemodynamic instability, esophageal perforation, esophageal obstruction, mediastinitis and caustic ingestion. The patient did not have these conditions. He also did not have severe vomiting, severe dehydration, or an inability to maintain oral hydration.

Clinical indications for admission for chest pain (M-89) include having cardiac ischemia, hemodynamic instability or respiratory distress. The patient did not have these conditions.

Based on the above, the medical necessity for the inpatient hospital services is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission
The proposed inpatient admission was medically necessary.
This patient presented with chest pain and dyspnea.  Her pretest probability of coronary artery disease was intermediate.(Reference 1)  Utilizing the HEART score, the patient was considered intermediate risk (five points). (Reference 2) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 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 at a higher level of care. Serial troponin measurement, echocardiography and ischemia work up were warranted prior to discharge.    In conclusion, admission to the hospital to treat an acute cardiac event was medically necessary. In conclusion, given the patient's presentation and multiple cardiac risk factors, inpatient hospital admission was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intervertebral Disc Disorder, Muscle Spasm Back, Myalgia, Unilateral Primary Osteoarthritis, and Iliotibial band left leg.

Treatment: Manual Therapy Techniques

The insurer denied the Manual Therapy Techniques.  The denial was upheld. 

This is a female diagnosed with left-sided low back pain, intervertebral disc disorder, muscle spasm back, myalgia, unilateral primary osteoarthritis, and iliotibial band left leg.  The physical therapy initial evaluation from early 2019 indicated that the patient had low back pain limiting her functional capability.  The initial evaluation revealed strength on the left hip flexion of 3+/5, abduction 3+/5 and extension of 3/5.  She had decreased range of motion of the lumbar spine, tenderness to palpation in the left posterior superior iliac spine (PSIS), gluteus, and piriformis. The patient also had osteoarthritis. She had physical therapy treatment three sessions per week for 4-6 weeks. The patient underwent a re-evaluation which revealed lumbar spine flexion within normal limits and extension.

Per peer-reviewed medical literature, given that most patients with acute or subacute low back pain improve over time with aggressive treatment, clinicians and patients should select nonpharmacologic treatments with superficial heat, massage, acupuncture, spinal manipulation and active modalities for addressing symptoms. Nonpharmacologic interventions are considered as a first-line treatment options in patients with low back pain, as there are fewer harms associated with these treatment modalities then with the use of medications.
Based on the above, the medical necessity of CPT codes 97140 (x3) Manual therapy techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes, 97110 (x7) Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility and 97014 (x3) Application of a modality to 1 or more areas; electrical stimulation is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a history of obesity who presented to the hospital with an acute onset of left abdominal/flank pain which radiated to his groin. The patient was afebrile on presentation and rated his pain a 9/10 for which he was treated with intravenous (IV) morphine for. His blood pressure was markedly elevated at 208/120 for which the patient received IV lopressor. His exam showed that he was in acute distress due to pain but without costoverterbral angle tenderness or abdominal tenderness.
An electrocardiogram (EKG) showed atrial flutter with variable atrioventricular (AV) block and a left bundle branch block for which he was placed on systemic heparinizaiton. A computed tomography (CT) scan of the abdomen/pelvis showed a left proximal/mid ureteral 6 millimeter (mm) stone with left hydroureter and moderate hydronephrosis. The right kidney was normal in appearance.
The patient was admitted for management of his ureteral stone in the setting of aflutter and accelerated hypertension. He was seen by cardiology for his aflutter with rapid ventricular response and was started on IV cardizem for rate control and further blood pressure control. An electrophysiology consult was also obtained to discuss cardioversion versus ablation of the atrial flutter. The health plan's determination is overturned.
The patient presented with an obstructing left ureteral stone. In this case, the patient was also found to be in atrial flutter which required systemic anti-coagulation, IV cardizem for rate control and the need for ablation prior to the patient being able to undergo the definitive urologic procedure to treat his renal colic. This necessitated the urologic procedure to be done in a controlled inpatient environment as monitoring for hematuria and management of his anti-coagulation therapy were necessary post-procedural elements of his care. Sending the patient home and performing the ablation as an outpatient would have put the patient at risk for worsening hematuria with possible worsening of kidney function and continued suboptimal pain control as ureteral obstruction could not be safely performed without first treating the atrial flutter.