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

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 

The insurer denied orthodontic treatment and periodic treatment visit times 12.  The denial was overturned. 

The patient is a female with a unilateral posterior crossbite on the left. She has minor crowding. Her teeth 6 and 11 are in anterior crossbite. She presents with a posterior crossbite, crowding, and constricted arches. She has treatment planned for 24-30 months of orthodontics to correct her crossbite.

At issue is Comprehensive orthodontic treatment of the adolescent dentition, and periodic orthodontic treatment visit times (x) 12 for medical necessity.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Comprehensive orthodontic treatment of the adolescent dentition, and periodic orthodontic treatment visit x 12 is medically necessary for this patient.

This patient presents with a posterior crossbite, crowding, and constricted arches. The patient has teeth 6 and 11 in crossbite. 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. These problems are more time consuming to correct than the patient's current orthodontic problem. She is nearing the end of the time that orthodontics alone can correct her crossbite.  Therefore, the requested treatment is medically necessary at this time for this patient.

The requested health treatment of Comprehensive orthodontic treatment of the adolescent dentition, and periodic orthodontic treatment visit x 12 is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Advanced Imaging. 
The insurer denied PET/CT. 
The denial is overturned.

The patient is a female with squamous cell cancer of the anus. A magnetic resonance imaging (MRI) was obtained that demonstrated a 4.7 centimeter (cm) rectal lesion separated from the anal verge by 2.9 cm. T4 disease is noted. The sphincter complex is not involved and there are multiple enlarged lymph nodes bilaterally. A positron emission tomography (PET)/computed tomography (CT) was requested and is under review.

The health plan's determination is overturned.

PET/CT is medically necessary for this patient. The sensitivity of physical examination and CT/MRI is suboptimal to detect inguinal nodal metastases, many of which are less than or equal to (<=5) millimeter (mm) and below the limit of detection. Further support comes from a meta-analysis (Jones, et al.) of 12 studies concluded that, compared with conventional imaging, an additional staging PET scan changed nodal staging in 28 percent of patients The authors of UpToDate state "...Adding an integrated fludeoxyglucose (FDG)-PET/CT scan to the staging workup has a significant impact on therapy planning, particularly in identifying patients who need higher dose radiation therapy (RT) to the groin and those with otherwise occult metastatic disease...". The National Comprehensive Cancer Network (NCCN) recommends consideration of a PET/CT and in this patient, with extensive nodal disease, it could alter management if the patient is demonstrated to have distant metastatic disease. For these reasons, medical necessity criteria are satisfied for this service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post motor vehicle accident.
Treatment: Pain Injections - Bilateral Thoracic Facet Medial Branch Nerve Block at T (thoracic) 11-12 and T12-L (lumbar) 1 (64490 x2, 64491 x2).
The insurer denied the Pain Injections - Bilateral Thoracic Facet Medial Branch Nerve Block at T11-12 and T12-L1 (64490 x2, 64491 x2).  The denial is overturned. 

Yes, the Pain Injections (64490 x2, 64491 x2) are medically necessary.

The patient is a gentleman with thoracic pain that is axial non-radicular. He does have a history of previous compression fractures. He has had epidural steroid injections without any significant benefit. He is not a surgical candidate. He does have a significant compression fracture at T12 (twelfth thoracic spine vertebra) with some retropulsion. This clearly put strain on the posterior elements, particularly the facet joints. MRI (magnetic resonance image) shows no severe spinal stenosis. He has failed conservative treatments for physical therapy, trigger point injections, NSAIDs (nonsteroidal anti-inflammatory drugs), muscle relaxants, oral steroids. Given his symptoms, this is consistent with thoracic facet syndrome. Therefore the requested medial branch nerve blocks are medically necessary.

The health plan is denying the procedure because thoracic pathology is excluded as a potential diagnosis for facet injections. This is not been borne out of the literature. The literature does show thoracic facet syndrome is a common cause for thoracic axial back pain in the setting of thoracic degenerative changes /spondylosis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic Breast Cancer.
Treatment: End of Life (EOL) Care.
The insurer denied the End of Life (EOL) Care.
The denial is upheld. 

The patient is a female. She has metastatic sarcomatoid carcinoma of the breast. She required surgery for treatment of spinal metastatic disease. Following that surgery, she was diagnosed with COVID and had multiple further complications. This included bleeding, requiring repeated transfusions, severe protein calorie malnutrition, and a stage IV pressure ulcer. She was started on TPN (Total Parenteral Nutrition) due to malnutrition. Imaging revealed worsening metastatic disease. She was noted to have fecal and urinary incontinence and had a Foley catheter and rectal tube in place. A progress note indicated that she had been planned for discharge to a skilled nursing facility. However, it was decided to proceed with hospice transfer. The request in this case is for acute care inpatient hospitalization.

No, the requested End Of Life (EOL) Care is not medically necessary.

This patient has advanced and worsening metastatic cancer and was hospitalized for multiple complications following spinal surgery. She was planned for nursing home discharge but it was instead decided to transfer her. This is an inpatient hospice unit and she would be there as an acute care medical patient. Hospice care concerns symptom control and end of life care. It does not encompass acute care medical interventions. Furthermore, this patient was found by her treating physicians to be suitable for nursing home transfer. She required interventions such as TPN (total parenteral nutrition) and wound care, but did not require ongoing acute care inpatient hospitalization. Given that, the proposed transfer to a different acute care hospital was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Crowns for teeth 6, 7, 9, and 10.
The insurer denied the Crowns for teeth 6, 7, 9, and 10.
The determination is upheld.

The patient presented with braces and congenitally missing maxillary laterals. Crowns are being requested at this time. At issue is the medical necessity for crowns for teeth 6, 7, 9, and 10.
According to the submitted radiographs, there is no visible radiographic evidence of decay, trauma, or missing tooth structure on teeth #6 and #9. The maxillary laterals #7 and #10 are congenitally missing. The maxillary canines have erupted into the lateral incisor position. 
Teeth #7 and #10 are congenitally missing; they are not present in the mouth.  The provider indicated the maxillary canines have been moved into the space of teeth #7 and #10.  The provider mislabeled the teeth that are present.  There are no teeth #7 and #10; therefore, crowns on these teeth are not medically necessary. Based on this discussion and the provided documentation, medical necessity has not been established. Therefore, the request for crowns on teeth #6, #7, #9, and #10 is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal-Diverticulitis
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 medical history of diabetes mellitus type II, hypertension, hypothyroidism, chronic kidney disease stage II, breast cancer, and thyroid cancer. She presented to the emergency department  with left lower quadrant abdominal pain, urinary urgency, and loose bowel movements for 3 weeks. Physical examination was notable for left lower quadrant abdominal tenderness, left lumbar tenderness, mild guarding, and lack of costovertebral angle tenderness. Labs showed an elevated white blood cell count of 16.7 thousand/cubic milliliter (K/uL), low sodium of 135 millimoles per liter (mmol/L), elevated blood urea nitrogen of 42 milligrams per deciliter (mg/dL), elevated creatinine of 2.3 mg/dL, and elevated lactic acid of 2.4. Computed tomography scan of the abdomen and pelvis showed acute uncomplicated colonic diverticulitis in 2 places (proximal sigmoid colon and splenic flexure), solitary left kidney with nonspecific perinephric stranding similar to the prior study, no renal calculi or hydronephrosis, and hepatomegaly with steatosis. She was treated with intravenous fluids, ceftriaxone, metronidazole, morphine, and ondansetron. She was discharged on ciprofloxacin and metronidazole for 14 days, with a plan for Primary Care follow-up. 

The medical necessity of the inpatient level of care is not supported. In patients with uncomplicated diverticulitis (without complications such as abscess or perforation), lower level of care management is the standard of care [1]. The safety and efficacy of lower level management of acute uncomplicated diverticulitis has been demonstrated [2]. A prospective randomized trial demonstrated that patients can be given intravenous antibiotics in the Emergency Department and then discharged to a lower level of care with oral antibiotics [3]. A systematic review of the literature underscored this [4]. Lower level of care can be appropriate when there are significant symptoms and leukocytosis, as in this case [5]. However, there was no protracted fever or hypotension to suggest that antibiotics were ineffective. There had been no evidence of abscess on imaging [4-6]. The patient improved on intravenous antibiotics [7,8]. No other cause for the inpatient level of care, such as peritonitis, toxic megacolon, bowel obstruction, sepsis, abscess, fistula, or other complication was documented. The care provided could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arrhythmia.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned. 

This patient is a male child who was delivered via normal spontaneous vaginal delivery (NSVD). The patient's Appearance, Pulse, Grimace, Activity, Respiration (APGAR) scores were 9 and 9 at 1 and 5 minutes, respectively. The patient's maternal history included asthma on albuterol as needed (PRN), anaphylactic reaction to penicillin, and history of marijuana use. The patient's mother received adequate prenatal care at another facility and was transferred due to detection of fetal arrhythmia.  Following birth, the patient was admitted to the Neonatal Intensive Care Unit (NICU) for monitoring and evaluation of arrhythmia.  Upon admission, the patient had a normal newborn examination.  The cardiology work-up ended up being negative and the patient was transferred to the well newborn nursery.  While in the newborn nursery, phototherapy was applied for treatment of hyperbilirubinemia with total serum bilirubin (TSB) in high-risk zone close to cutoff.  Otherwise, the patient was well throughout.  

According to the Milliman Care Guidelines (MCG), 24nd Edition, Newborn Care, Term, with Severe Illness or Abnormality, Clinical Indications for Admission to In-Patient Care: Higher-level neonatal care (i.e., other than Level I nursery) for neonate with a certain gestational age is needed as indicated by 1 or more of the following: Treatment or monitoring required due to abnormality in fetal heart rate or rhythm during labor. Thus, the insurer's denial was not supported by the cited guideline.

In view of the above, the patient's admission to the neonatal intensive care unit (NICU) was medically necessary.  

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

The insurer's denial of coverage for the inpatient hospital admission should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke.

Treatment: Subacute inpatient stay.

The insurer denied coverage for continued subacute inpatient stay.

The denial is upheld. 

This male patient has a history of multiple medical problems including coronary artery disease status myocardial infarction, stroke and alcohol abuse.  The patient was admitted to a skilled nursing facility for subacute rehabilitation of his stroke.  The patient tested positive for Covid-19.  Under review is the medical necessity of continued subacute inpatient stay.

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the patient was initially an appropriate candidate for subacute rehabilitation at the skilled nursing facility. The nursing facility had planned for the patient to be discharged home. However, the patient tested positive for Covid-19 and was asymptomatic. The patient was at a high functional level and there were no acute medical or complicated skilled nursing needs to support continued subacute level of care at the skilled nursing facility.  In addition, quarantine at the skilled nursing facility (SNF) was not medically necessary or supported for the addition length of stay.

Considerations included the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendations and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and/or associations.  All decisions are evidence-based.    

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, continued subacute inpatient stay was no longer medically necessary.

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

Based on the above, the medical necessity for continued subacute inpatient rehab stay is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal/Abdominal pain.
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 determination.

The patient has a medical history of hypertension, asthma, gastritis, hypothyroidism, and hyperlipidemia. She presented to the emergency department with right upper quadrant and left lower quadrant abdominal pain, nausea, and vomiting. She has been taking nonsteroidal anti-inflammatory drugs several times per week. Vital signs were unremarkable. Physical examination was notable for upper quadrant, epigastric, and left lower quadrant abdominal tenderness. Electrocardiogram showed sinus tachycardia. Labs showed elevated hematocrit 47.5% and unremarkable comprehensive metabolic panel. Computed tomography scan of the abdomen and pelvis showed several hyperdense foreign bodies in the transverse colon, and lack of acute intra-abdominal pathology. Ultrasound of the abdomen showed mildly heterogenous hepatic parenchyma compatible with fatty changes or diffuse hepatocellular disease. She was made nil per os(NPO). Surgery consultation recommended nil per os, serial abdominal examinations, intravenous fluids, monitor urine output, pain control, and ondansetron as needed. She was discharged with a plan for Primary Care follow-up. 

The admission is not supported as medically necessary at the inpatient level of care. The patient had abdominal pain, nausea, and vomiting, and imaging showed foreign bodies in the colon, but did not show bowel obstruction as a cause for symptoms. Additionally, imaging did not show any complications of foreign body, such as gastrointestinal perforation or intra-abdominal abscess, and did not show any other complications such as toxic megacolon, bowel obstruction, gastrointestinal bleeding, peritonitis, sepsis, or other complications warranting inpatient level of care [1-6]. Her symptoms improved by two days later with conservative therapy. No surgical intervention was deemed necessary. The measures which were undertaken, such as observation of the patient, monitoring, labs, Surgery consultation, and intravenous fluids could have been performed without the inpatient level of care, at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Astigmatism.
Treatment: Toric intraocular lens. 
The insurer denied the toric intraocular lens.  The determination is upheld.

The patient has a history of a radial keratectomy followed by a penetrating keratoplasty due to herpes simplex keratitis. She now has a nuclear sclerosing cataract, Fuch's disease and high astigmatism. Her physician has recommended that she undergo cataract extraction with intraocular placement of a toric lens and Descemet stripping automated epithelial keratoplasty (DSAEK). At issue is the medical necessity of the toric intraocular lens.

The toric intraocular lens is not medically necessary. Toric intraocular lenses (IOLs) have been shown to be effective for reducing patient dependence on contact lenses/spectacles after cataract surgery. However, there is no evidence that visual outcomes with toric IOLs is superior to the outcomes with contact lenses or spectacle correction. In this case, the patient has a history of penetrating keratoplasty (PK) after radial keratectomy and herpes simplex virus (HSV) infection. PK can result in large amounts of astigmatism postoperatively. There have been several small, non-randomized case reports and retrospective studies evaluating the effectiveness and safety of toric IOLs in patients with corneal disease such as keratoconus and previous penetrating keratoplasty. While it appears that the procedure may be safe and effective in these patients, the studies are small and unrandomized. Further study with larger, more consistent cohorts are necessary to establish the safety and effectiveness of toric IOLs in these cases. Further, there are no studies comparing toric IOL implantation to the use of spectacles or contact lenses, which are the current standard of care. Therefore, despite some small promising studies, toric IOLs are not medically necessary. Although this patient has high astigmatism related to her previous corneal surgeries, there are not currently studies demonstrating that toric IOLs result in better visual outcomes than spectacles or contact lenses which are the current standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 

The insurer denied an inpatient stay. 
The denial is upheld. 

The patient is a previously healthy female who presented to the hospital with a history of progressively worsening abdominal pain of 1-day duration. Her evaluation included physical exam, labs, and computed tomography (CT) scan. She was without fever at the time of presentation. Lab data identified a white blood cell (WBC) count of 10.4 thousand (K). Computed tomography (CT) scan yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was obtained. 

The patient underwent laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. She was provided intravenous (IV) fluid and perioperative antibiotics. Vital signs remained normal throughout the hospitalization without fever. Diet was advanced and pain management was converted to oral medications. She was discharged home. The subject under review is the medical necessity for the inpatient stay. 

The inpatient stay was not medically necessary for this patient. The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient presented with abdominal pain and underwent uncomplicated appendectomy. The care and treatment provided could have appropriately been rendered at a lower level of care status. The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care status would have provided for presurgical assessment, serial examination, operative treatment and post-surgical monitoring. This lower level of care would have also allowed for overnight monitoring.
Generally accepted guidelines / criteria indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications the procedure may be performed at a lower level of care status. In this case the patient tolerated oral hydration, diet and medication and pain was well controlled. Inpatient care was not required or medically necessary in this case per generally accepted medical standards.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Braces (comprehensive orthodontic treatment). 

The insurer denied Braces (comprehensive orthodontic treatment) for medical necessity. 
The denial was upheld. 

The patient is a female with a Class I occlusion with appropriate overbite and overjet. She has moderate maxillary and mandibular crowding. She has treatment planned for orthodontics to correct her malocclusion.

At issue is the requested health service/treatment of braces (comprehensive orthodontic treatment) for medical necessity.  

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Braces (comprehensive orthodontic treatment) is not medically necessary for this patient.

There is no medical reason to correct the patient's malocclusion with braces. While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. The patient presents with none of the functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.

This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. If her teeth were aligned, it would provide an aesthetic improvement, but it would not create a medically significant improvement to the patient's health. Her overbite is appropriate and there is no indication of damage to the incisors. Her cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication that there is severe soft tissue damage (or any soft tissue damage) on this patient. For these reasons, the treatment is not medically necessary.

Therefore, the treatment of Braces (comprehensive orthodontic treatment) is not medically necessary for this patient.