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

Diagnosis: Migraine headaches.  
Treatment: Nerve blocks for pain management.  

The insurer denied coverage for nerve blocks for pain management.  

The denial is overturned.  

This is a female patient with a history of asthma, febrile seizures, and migraines.  She presented to the neurologist for a nerve block procedure and evaluation.  The patient tolerated the procedure well without complications.  She noted that the headaches were stable to slightly better.  Pain was rated at a level of 6 out of 10.  The patient was previously treated with Tylenol, Advil, Fioricet, Percocet, Triptan, Elavil, Candesartan, and Seroquel without significant improvement.  The patient has recently been able to avoid using Percocet.  A significant amount of time passed with no headache and the neurological examination was non-focal.  The physician recommended continuing the current plan of care and following up with the neurologist in a month.  

This patient has refractory migraine after craniotomy for epilepsy surgery.   She sees a headache specialist.  She has tried many medications from virtually all therapeutic classes without significant relief.  She has been benefitting from sphenopalatine nerve block.  This was recently denied by her insurer as not medically necessary.  

There is peer-reviewed scientific evidence of the safety and effectiveness of this type of nerve block for migraine.  In addition, this type of injection has already been shown to be effective for this particular patient and has allowed her to live a more normal life.  

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

The carrier's denial of coverage for nerve blocks for pain management is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope.

Treatment: Full hospital admission.

The insurer denied coverage for the full hospital admission.

The denial is overturned. 

This is a male patient with a history of ischemic systolic cardiomyopathy who presented to the hospital after being unable to assume an upright position and nearly losing consciousness while walking his dog. His past medical history was significant for anterior wall myocardial infarction (AWMI) status post percutaneous coronary intervention (PCI) to the left anterior descending (LAD) and left circumflex (LCx) arteries. Physical examination revealed no major abnormalities, electrocardiogram (ECG) revealed sinus rhythm with ventricular premature complexes (VPCs), and serum troponin was not elevated. Diuretic therapy was held and the patient was admitted to the hospital for work up and observation. Echocardiogram revealed a depressed left ventricular ejection fraction (LVEF) of 30% with possible left ventricular thrombus. A second study with echocardiography contrast was required and ultimately revealed no evidence of thrombus. Given syncope, VPCs and reduced LVEF, an electrophysiology consult was obtained and a subcutaneous implantable cardioverter defibrillator (ICD) was implanted. The patient's post-operative course was complicated by bleeding from the ICD incision site requiring treatment and further observation. The patient was discharged home the day following implantation.

The hospital admission was medically necessary for this patient who presented with syncope and a history of ischemic systolic cardiomyopathy with a reduced LVEF. This patient may have been volume depleted, however he had a history of myocardial infarction and a depressed left ventricular function despite revascularization. In addition, the ECG revealed ventricular ectopy. This patient would be considered high risk for cardiac syncope requiring hospital admission for further work up and observation. Initial echocardiogram was suspicious for LV [left ventricular] thrombus and repeat testing was performed to ensure that oral anticoagulant therapy was not indicated. Ultimately subcutaneous ICD implantation was appropriately implanted and the patient had post-operative bleeding that required additional observation.

The inpatient hospital admission was medically necessary. The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the full hospital admission is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thrombocytopenia and elevated liver enzymes.

Treatment: Full hospital admission.

The insurer denied coverage for the full hospital admission.

The denial is upheld. 

This is a female patient with no prior medical history who presented to the Emergency Department (ED) for abnormal labs. The patient was instructed to go to the ED given a decreased platelet count (thrombocytopenia) and elevated liver enzymes. 

An Infectious Diseases consult advised obtaining viral serology and holding off on antibiotics since the patient did not appear to be acutely toxic. The patient's liver enzymes improved. The patient's international normalized ratio (INR) level was normal.  It was felt that the patient's abnormal liver enzymes could have been due to doxycycline.

Clinical Indications for admission for Sepsis and Other Febrile Illness, Without Focal Infection (Milliman Care Guidelines (MCG)) include hemodynamic instability, bacteremia, hypoxemia, altered mental status, coagulopathy, and fever over 104.9. In this case, this patient did not have these conditions.

Clinical indications for admission for Liver Disease Complications (MCG) include hepatic encephalopathy, hemodynamic instability, peritonitis, a markedly elevated prothrombin time, severe vomiting, severe dehydration, and acute liver necrosis. In this case, this patient did not have these conditions.

Based on the review of the medical record, this patient had a low grade fever and elevated liver enzymes. The patient did not have acute liver failure. The patient's liver enzymes and thrombocytopenia could have been followed with Observation status. The patient did not meet the MCG clinical criteria for admission for either Sepsis or other Febrile Illness, without Focal Infection or Liver Disease Complications. Thus, the full hospital admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the full hospital admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory problems. 
Treatment: Home Health Care. 
insurer denied increase in home health hours to 56 hours per week. 
The denial is upheld.

The patient is a female with a past medical history significant for heart failure, depression, diabetes, osteoarthritis, lymphoma, hypertension, hearing loss and chronic pain.
This review is for the medical necessity of increase in home care hours from 42 hours a week to 56 hours a week. The patient currently receives 6 hours a day 7 days a week. The patient is requesting an increase to 8 hours a day 7 days a week. These services were denied based on medical necessity. Patient is appealing the decision.

The health plan's determination is upheld.

The requested increase in hours is not medically necessary for this patient.

Based upon the most recent assessment, patient is able to feed herself when meals are prepared. The patient needs extensive assistance with bathing and dressing lower body. The patient needs assistance with dressing upper body. She is able to do personal care with limited assistance. She uses a cane for ambulation. The patient also uses a Rollator for ambulation. Her last assessment noted that she was stable.
The patient is currently receiving 42 hours a week of services. She had an assessment and a reassessment done. She had a tasking tool performed. There were no significant changes noted in the patient's medical condition. The most recent tasking tool noted patient required assistance with both level 1 services and level 2 services. It was noted that the patient is having more trouble with ambulation but is still able to ambulate with a Rollator walker. Since the patient is still able to ambulate independently inside her place of residence, and her medical condition did not significantly change her level need did not significantly change. She still requires level 1 services which are being provided and did not change. The level 2 services did not significantly change between assessments. There is no medical need demonstrated in the physician appeal, the patient appeal, or the other assessments which would necessitate additional home care hours.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac / Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole.

The patient is a male who presented to the emergency department complaining of two days of intermittent non-exertional chest pain. His medical history was unremarkable. His cardiac risk factors consisted of a prior smoking history. His blood pressure was 117/81 millimeters of mercury (mmHg) with a heart rate of 71 beats/minute. His physical exam was unremarkable. The patient's pain increased when he was asked to breathe deeply. An electrocardiogram showed sinus rhythm without ischemic changes. His serum troponin and brain natriuretic peptide (BNP) levels were normal. He was treated with famotidine and ketorolac and admitted to the hospital to rule out acute coronary syndrome. An echocardiogram showed normal left ventricular systolic function and no significant valve disease. The next day the patient denied chest pain. His troponin level remained normal. Rest/stress myocardial perfusion imaging was performed. The patient demonstrated good exercise tolerance. Imaging showed a moderate-sized, mild intensity reversible inferior wall defect. Cardiac catheterization was recommended and planned. However, the procedure could not be performed due to technical problems in the catheterization laboratory. The patient was discharged with plans for an outpatient cardiac catheterization. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld in whole.

This patient presented with atypical chest pain that was thought to possibly represent acute coronary syndrome (ACS). Accordingly, monitoring until ACS could be ruled out was a reasonable approach. On the other hand, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. Based on his HEART (History, EKG, Age, Risk factors, and troponin) score, he was at low risk (.9-1.7%) for major adverse cardiac events. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bleeding gums
Treatment: Periodontal scaling and root planing
The insurer denied the Periodontal scaling and root planing.
The denial is upheld.

The patient is a female requesting dental benefits for full mouth periodontal scaling and root planing.

The patient's oral hygiene is said to be fair-good. She presents with bleeding gums/inflammation. Periodontal probing and charting was completed.

Full mouth debridement with Cavitron and hand scaling and polishing was performed. Treatment plan was discussed with the patient.

No, the proposed treatment of Periodontal scaling and root planing is not medically necessary.

The indication for periodontal scaling and root planing is bone and epithelial attachment loss. The records that were submitted do not support this.

Periodontal scaling and root planing is therapeutic and not prophylactic. Therefore this mode of treatment in the absence of the pathology that it is meant to treat is counter-intuitive and unwarranted.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Lung Disease; Prematurity.

Treatment: Synagis for respiratory syncytial virus (RSV) prophylaxis and chronic lung disease of prematurity.

The insurer denied coverage for Synagis for respiratory syncytial virus (RSV) prophylaxis and chronic lung disease of prematurity.

The denial is upheld. 

This female infant was born prematurely by caesarian section.  The patient's mother had gestational hypertension. The patient's birth weight was 970 grams and the patient required continuous positive airway pressure (CPAP) and oxygen treatments for 5 days. The patient required treatment with caffeine for apnea of prematurity and she remained hospitalized in the Neonatal Intensive Care Unit (NICU) for two months. The patient then required treatment with CaroSpir, Diuril and Aldactone for tachypnea and chronic lung disease of prematurity. The patient has a history of hypoglycemia which has now resolved. Respiratory syncytial virus (RSV) prophylaxis was ordered. The patient has not required any chest x-rays since the last chest x-ray during her hospitalization and this study indicated the presence of mild airspace disease. The patient has not needed any respiratory nebulization treatments. The patient was seen by pulmonary on 3 occasions.

Synagis RSV prophylaxis with chronic lung disease of prematurity is not considered medically necessary for this patient. Synagis has been approved for prophylaxis of RSV infection in premature infants who because of immaturity of their lungs are at increased risk of severe lung disease secondary to the development of bronchiolitis when exposed to the RSV virus in the first 2 years of life. 

In this case, the patient who was born prematurely required oxygen for 5 days after her birth.  She has continued to receive ongoing treatment with diuretics for chronic lung disease of prematurity. The patient does not meet the criteria for recommended treatment with RSV prophylaxis since she only required oxygen and respiratory support for 5 days after birth.  The patient has had no additional need for oxygen treatments, emergency room (ER) visits or hospitalizations for respiratory disease.  There has been no documentation of wheezing pressure but only an occasional mild cough. When seen for her last documented visit with her pediatric pulmonologist, the patient was noted to be breathing comfortably with no retractions and there was no indication of increased respiratory effort, wheezing or chest congestion. Based on the American Academy of Pediatric Synagis prophylaxis guidelines, the patient does not qualify as high risk for severe disease related to a RSV illness. Thus, Synagis for RSV prophylaxis is not considered medically necessary for this patient.

The health plan did act reasonably with sound medical judgment and in the best interest of the patient. 

Based on the above, the medical necessity for Synagis for respiratory syncytial virus (RSV) prophylaxis and chronic lung disease of prematurity is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental cavity.
Treatment: Crown to tooth #23 and tooth #25, procedure code D6751, and pontic to tooth #24, procedure code D6241. 
The insurer denied coverage for pre-service request for crown to tooth #23 and tooth #25, procedure code D6751, and pontic to tooth #24, procedure code D6241.
The denial is overturned. 

This female patient has a history of hypertension (HTN), hyperlipidemia (HLD), asthma, pre-diabetes, and allergic rhinitis. The patient presented to her dental office for an evaluation.  The patient had x-rays of her teeth taken.  The treating dentist determined that the patient needed crowns to tooth #23 and tooth #25, procedure code D6751, and pontic to tooth #24, procedure code D6241.

This patient presented for dental care with carious non-maintainable tooth #24. Recommended treatment was extraction of tooth #24 and fixed bridge from tooth #23 to tooth #25 to address the edentulous space.  

Upon review of the documentation, in particular the radiographs, it is evident that tooth #24 was non-maintainable. To restore function to the anterior mandibular dentition, after extraction of tooth #24, with a fixed prosthesis spanning tooth #23 to tooth #25 site, is the standard of care dental treatment in general dental practice, as recommended.

The pre-service request for crown to tooth #23 and tooth #25, procedure code D6751, and pontic to tooth #24, procedure code D6241, 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 pre-service request for crown to tooth #23 and tooth #25, procedure code D6751, and pontic to tooth #24, procedure code D6241 is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain.
Treatment: Surgical Services/Inpatient Hospital.
The health plan denied the requested services. 
The health plan's determination is overturned.

The patient is a female. She was seen by her family practice physician for a history of low back pain. She complains of achy pain in the right side of her back that radiates down the right leg and to a lesser degree on the left. She has been using ibuprofen and topical like the pain patches which gave her moderate relief to get her through the workday. Physical examination demonstrates point tenderness to palpation on the right SI (sacroiliac) joint and L5 (lumbar) paraspinal area to a lesser degree on the left. Positive straight leg raises in the seated position on the right ipsilaterally at 70 degrees. 2+ patellar and Achilles reflexes. Assessment is acute right lumbar radiculopathy. She was given a Medrol Dosepak and is going to consider manipulation treatments. She was also given muscle relaxer. Her body mass index (BMI) is 38.64. She is a former smoker. She was seen in the emergency room for stabbing pains down the back of her leg and outer side of her leg. She does not have any bowel or bladder symptoms. She was given Decadron, Toradol, and a prescription for physical therapy and instructed to follow-up with her physician. She was subsequently seen by a spine surgeon and she had been taking Tylenol and over-the-counter pain patches and the medication previously prescribed. Standing and walking increases her pain. She denies numbness. Her pain is 9 out of 10. X-rays and magnetic resonance imaging (MRI) were ordered, and she was to start physical therapy. She began physical therapy and was unable to continue due to the virus pandemic. 

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

Yes. The patient had months of worsening back and lower extremity radiculopathy and pain. It affected her activities of daily living. The pain was rated at a 9 out of 10. She tried activity modification, anti-inflammatories, steroids, Tylenol, Tramadol, muscle relaxers, physical therapy, and epidural injections without relief. The MRI imaging showed a large synovial cyst causing significant compression which correlated with her neurological findings of a positive right straight leg raise and right lower extremity radicular symptoms. The patient underwent a laminectomy with total facetectomy and excision of a large synovial cyst with multiple dural adhesions. Due to the iatrogenic instability created intraoperatively, a fusion at L4-5 was necessary to restore spinal stability. There were no other reasonable options the patient could have tried or performed to alleviate her symptoms and return to a normal functioning status. She met all of the appropriate indicators for lumbar spine surgery with fusion. There were no other less costly methods to treat her pathology. Therefore, the back surgery and hospital admission are considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I malocclusion.
Treatment: Braces/monthly visits.
The insurer denied braces/monthly visits.
The health plan's determination is upheld. 

The patient in question is a female with a diagnosis of Class I malocclusion, appropriate overjet and overbite. The upper and lower arches are both mildly crowded. She is treatment planned for 24-30 months of orthodontics to correct her malocclusion. Braces and monthly visit (x 12) were denied as not medically necessary. 

Braces and monthly visit (x 12) are not medically necessary at this time.

The patient has an appropriate overbite and overjet. Yes, there is mild crowding, but that alone does not rise to the threshold of medically necessary. The photos do not support a diagnosis of a crossbite of tooth 27 with tooth 6, and the gingival margin of 27 appears to be the same as tooth 22. There does not appear to be attachment loss. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. The diagnosis states the patient has a skeletal Class I relationship which is the most efficient jaw relationship for mastication. If her teeth were aligned, it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons, treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Malocclusion. 
Treatment: Orthodontics (Braces) and Follow up Visits. 

The health plan denied the requested orthodontic treatment and follow up. 
The health plan's determination is upheld. 

The patient is a female with a Skeletal Class II malocclusion, mild maxillary crowding and mild mandibular crowding. She has moderate overjet and moderate overbite. The subject to be determined is the medical necessity for braces and monthly visits. 

The health plan's determination is upheld, in whole. 

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 13 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9mm or greater and underbite 3.5mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces and monthly visits are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental problems-Teeth spacing problem.
Treatment: Dental/Orthodontic procedure-Braces and monthly visits.
The health plan denied the Dental/Orthodontic procedure-Braces and monthly visits as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This patient has a Skeletal Class III malocclusion. There is mild maxillary crowding and mild mandibular crowding. There is also an anterior end to end crossbite.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 4 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeter (mm) or greater and underbite 3.5mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary.

Although an anterior crossbite is present, there is no sign of clinical attachment loss nor recession of the gingival margin. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces and monthly visits are not medically necessary for this case.