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

Diagnosis: Dental Disorder.
Treatment: D3320 endodontic therapy, premolar tooth (excluding final restoration), and D2752 crown-porcelain fused from noble metal to tooth.
The insurer denied D3320 endodontic therapy, premolar tooth (excluding final restoration), and D2752 crown-porcelain fused to noble metal to the tooth.
The determination is upheld.

The patient is a female who presented for the treatment of tooth number (#) 4. Provided for review are letters of appeal and denial, an explanation of benefits, a panoramic radiograph, bitewing and periapical films, and American Dental Association (ADA) claim forms. At issue is the medical necessity of the treatment of (3320) root canal for #4, (2954) prefabricated post and core #4, and (2752) porcelain fused to noble metal crown #4. Previous requests have been denied based on the rationale that there is no decay approaching the root canal of the tooth and the crown was denied as there is no apparent loss of tooth structure of more than 50%. At issue is the medical necessity of D3320 endodontic therapy, premolar tooth (excluding final restoration), and D2752 crown-porcelain fused to noble metal to the tooth.
The requested health service/treatment of D3320 endodontic therapy, premolar tooth (excluding final restoration) and D2752 crown-porcelain fused to noble metal to the tooth is not medically necessary for this patient.
There is no evidence of decay beyond a direct restoration on the distal of the tooth. The decay is minimal and not extending to the pulp nor involving an extensive amount of tooth structure to result in the necessity of the treatment requested.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: D2750 white glass with high gold content crown for tooth # (number) 30
The insurer denied D2750 white glass with high gold content crown for tooth #30.
The determination is overturned.

The patient is a male who presented for the treatment of tooth number (#) 30. Provided for review are letters of appeal and denial, a letter from the patient, American Dental Association (ADA) claim forms, explanation of benefits, letters of appeal and denial and radiographic images. At issue is the medical necessity of the treatment of (2750) white glass with high gold content crown for tooth #30.
The requested health service/treatment of D2750 white glass with high gold content crown for tooth #30 is medically necessary for this patient. As the extent of decay here is extensive and involving the mesiobuccal cusp, there cannot be a direct restoration as direct restorations are not indicated for replacement of lost cusps. Here, as there is a need for cuspal replacement, there is the need for an indirect restoration such as a full coverage crown. Hence, the treatment of (2750) white glass with high gold content crown for tooth #30 is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia

Treatment: Inpatient hospital

The insurer denied coverage for inpatient hospital.

The denial is upheld.
 

Reviewer Findings:

The patient is an adult male who was admitted to the hospital with complaints of abdominal pain and some diarrhea.  The patient reported they had some recent stents placed and was on some new medications for that.  The patient has been having some abdominal pain off and on.

Vital signs at presentation include: Temperature 97.1 degrees Fahrenheit, blood pressure (BP) 108/67, respiratory rate (RR) 18, and oxygen (O2) saturations 95 %.  Head, eyes, ears, nose and throat were within normal limits.  There was no jugular vein distention (JVD).  Lungs were clear to auscultation bilaterally. Heart sounds S1 and S2 were normal.  The abdomen was soft with positive bowel sounds.  Mild tenderness was noted on the right side.

The patient's white blood cell count (WBC) was 21 and polymorphonuclear cells were 84%.  Hemoglobin was 14.1.  The blood urea nitrogen was 27, Creatinine 1.59, with a baseline creatinine of 1.2.  The patient's sodium (Na+) was 139, creatine kinase 96, lactate 1.9.  The patient's urinalysis was negative.  A computed tomography (CT) of the abdomen revealed diverticulosis with no inflammation and renal cysts.  A consolidation was noted at the right lung base consistent with focal pneumonia.

The patient was started on intravenous (IV) fluids and IV antibiotics (Rocephin and Azithromycin).  The patient was seen by pulmonary and renal.  Pulmonary recommended steroids and bronchodilators for possible chronic obstructive pulmonary disease (COPD).  The patient remained stable after admission and was improve by the next day.  The patient was afebrile and remained hemodynamically stable.  Oxygen (O2) saturations were 94% on room air. The patient was tolerating oral intake.  Pulmonary recommended switching to oral antibiotics, a short course of oral steroids, and bronchodilators via inhalers.  The patient was medically cleared for discharge and discharged home.

This patient did not need acute inpatient hospitalization. The patient could have been placed in observation status. Observation could be for up to 48 hours during which time diagnostic testing and treatment could have been initiated. The patient had a mild community acquired pneumonia (CAP). CURB-65 (Confusion, Urea, Respiratory Rate, Blood Pressure, Age > 65) score was 1. The patient could have been placed in observation for up to 48 hours and once improved could have been discharged home on oral medications with close follow-up in the outpatient setting. This patient was discharged the day after admission after approximately 26 hours in the hospital.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Planned Cardiac Catheterization
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This is an adult male that underwent elective cardiac catheterization with percutaneous coronary intervention (PCI) and stent placement. His past medical history included smoking, hypertension, hyperlipidemia, and diabetes. He had a successful and uncomplicated procedure with two drug-eluting stents placed to the left circumflex coronary artery and angioplasty performed to the in-stent restenosis to the first obtuse marginal artery. He then had overnight observation and was discharged to home. The requested coverage for inpatient hospital admission was denied as not medically necessary based on policy. The patient is appealing the decision.

The requested health service was not medically necessary.

Based on the peer-reviewed medical literature, there was not a medical need for the requested acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. In this particular case, the patient underwent planned left heart catheterization (LHC) followed by successful and uncomplicated percutaneous coronary intervention (PCI) with stenting of the left circumflex coronary artery and angioplasty to the in-stent restenosis of the obtuse marginal branch on the same day. The information provided does not support the medical necessity for admission after his successful and uncomplicated coronary interventions. Percutaneous coronary intervention procedures are routinely performed in the ambulatory setting with observation. There is no documentation of unstable medical conditions like acute coronary syndrome/acute myocardial infarction (ACS/AMI), cerebrovascular accident (CVA), contrast nephropathy, acutely decompensated congestive heart failure, life-threatening cardiac arrhythmia, procedural complications like acute coronary perforation or vascular access complication requiring surgery, or other medical instability or acute care needs that would require acute inpatient management. Therefore, based on the submitted information and the current published medical literature, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is overturned. 

This patient has a medical history significant for diabetes mellitus, frequent skin abscesses who presented to the emergency department with complaints of erythema, swelling and tenderness to back of neck.
 
Vitals on presentation included: Temperature 98.5 degrees Fahrenheit, blood pressure (BP) 111/72, pulse 109, respiratory rate 18, oxygen saturation 99% on room air. Laboratory results included the following: white blood cell count (WBC) 11.69, hemoglobin (HGB) 12.2, creatinine 0.64, glucose 299, sodium 127. 

The patient was started empirically on intravenous (IV) antibiotics (vancomycin and Zosyn) for left posterior neck cellulitis/abscess. Infectious Disease consulted and adjusted antibiotic coverage. A computed tomography (CT) scan of head showed severe cellulitis of the left posterior neck with early phlegmonous formation. Surgery consulted and recommended excision/debridement of epidermoid/pilar cyst. The patient underwent excision and application of vacuum-assisted drainage device. Wound cultures grew methicillin-resistant Staphylococcus aureus (MRSA). Antibiotics were changed to oral Bactrim. The patient remained afebrile, hemodynamically stable, and was discharged to continue outpatient management. 

According to documentation, patient presented with a neck cellulitis/abscess. The patient was tachycardic (heart rate 109), laboratory results showed multiple abnormalities including elevated WBC (11.69), hyperglycemia (299), and low sodium (127). Based on these findings, hospital admission was medically necessary for administration of intravenous antibiotics and surgical intervention in the operating room. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary tuberculosis, bronchiectasis and hemoptysis. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

Patient is an adult female who has a history of pulmonary tuberculosis, bronchiectasis and hemoptysis. The patient was admitted for Bronchial Artery Embolization. The patient had prior Embolization. 

Computerized tomography (CT) scan had revealed left lower lobe and left upper lobe (LLL and LUL) Cystic Bronchiectasis. As the patient had some allergic reaction to the contrast dye during prior Embolization, she was given Solucortef and Benadryl intravenously (IV) as premedication. 

Vital signs at presentation were within normal limits and oxygen saturation was 94% on room air. Physical examination revealed the patient to be in no distress.  Lung auscultation revealed some rales at bases L>R (left greater than right). White Blood Cell count (WBC) was 6.8 and Hematocrit (Hct) was 39. 

The patient underwent an uneventful Pulmonary Artery (PA) Embolization and was admitted to Telemetry. The patient remained stable after admission and was discharged the next day. 

This patient did not need acute inpatient hospitalization. Pulmonary Artery (PA) embolization can be done as an Ambulatory Surgery Procedure and the patient could have been discharged home after the procedure with a 23 hour stay. If needed she could have been placed in Observation status. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: D8080 Braces and D8670 Monthly Visit x12
The insurer denied: D8080 Braces and D8670 Monthly Visit x12
The denial is overturned.

This case involves a teenage female patient. The appeal is for D8080 braces and D8670 monthly visit x12. The initial review denied the treatment as there were no automatic qualifying conditions and the patient did not score a 26 or greater on the Handicapping Labio-Lingual Deviation (HLD) index.

The proposed treatment is medically necessary.

The patient in this case did have an automatic qualifying condition. There is an anterior crossbite of the right maxillary lateral and the mandibular right canine. Based on the 
documentation submitted, there is some recession on the mandibular canine as a result of the crossbite. This is considered an automatic qualifying condition. The monthly visits are required to monitor progress.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Gastroesophageal Reflux Disease (GERD)

Treatment: Dexlansoprazole Delayed-Rel (release)

The insurer denied coverage for Dexlansoprazole Delayed-Rel (release)

The denial is upheld

 
The patient has been on proton pump inhibitor (PPI) therapy. The application for Dexilant (Dexlansoprazole Delayed-Release) states that she has tried omeprazole and pantoprazole and that she has failed both of these medications. She has a diagnosis of gastroesophageal reflux disease without esophagitis. 

UpToDate has an article titled "Proton pump inhibitors: Overview of use and adverse effects in the treatment of acid related disorders." The article states that the choice of a specific oral PPI is often determined by patient preference and payer coverage. A systematic review of 12 randomized trials examining the relative effectiveness of different PPI doses and dosing regimens found no consistent difference in symptom resolution and esophagitis healing rates. Switching PPls is reasonable in patients with side effects to an individual PPI. However, it is again noted that there is no consistent difference in relation to symptom resolution and esophagitis healing rates. 

This patient has been prescribed PPI medications for reflux. She has tried omeprazole and pantoprazole. The insurance company is offering formulary medications of esomeprazole and lansoprazole. 

It is not likely that the formulary drugs would cause an adverse reaction. 

The esomeprazole and lansoprazole have not yet been tried so they have not been shown to be ineffective. 

The medical literature does not support the idea that one particular PPI is more effective than the others. Therefore, the exception for dexlansoprazole is denied.

The carrier's denial of a request for a Formulary Exception for Dexlansoprazole Delayed-Release is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elective thyroidectomy
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult female with a hospital admission under review. The patient underwent total thyroidectomy electively with no intraoperative complications or postoperative complications. The patient was hemodynamically stable throughout the admission. The patient's vital signs on the date of surgery were temperature 98.3 degrees Fahrenheit, heart rate 79, blood pressure 110/69, respiratory rate 18, and oxygen 95% (percent) room air. The patient was on calcium supplements during the hospitalization. Her serum calcium was 9.1 on day one, 8.8 six hours later, and 8.3 the next morning.

The proposed treatment was not medically necessary.

The patient could have been managed at a lower level of intensity than acute inpatient care. The patient had no complications of surgery and had normal postoperative calcium levels. After total thyroidectomy without complications of hypocalcemia, patients can be managed outpatient with calcium supplementation and monitoring, such as at an observation level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Supraventricular tachycardia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Stay.
The determination is upheld.

This is a female patient who presented to the emergency department (ED) via Emergency Medical Services (EMS) after an episode of supraventricular tachycardia. She had been walking when she developed heart racing, dyspnea and chest pain. EMS was called and an electrocardiogram showed a narrow complex tachycardia that was terminated with a dose of intravenous adenosine. Her medical history was remarkable for gastroesophageal reflux disease. An electrocardiogram showed sinus tachycardia at 110 beats/minute without acute changes. The patient was treated with ondansetron and famotidine. She was admitted to the hospital. Oral metoprolol was prescribed. She remained in sinus rhythm. An echocardiogram was performed and was normal. The patient was discharged. The medical necessity for an inpatient admission is at issue.

Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient presented after an episode of paroxysmal supraventricular tachycardia (PSVT) that was terminated with a dose of intravenous adenosine. While there are no established guidelines regarding disposition for patients presenting to the emergency department with PSVT, most authors suggest that, in the absence of serious comorbidities, syncope, or rapid pre-excited atrial fibrillation or flutter, hospital admission is not necessary for adults whose PSVT is converted to sinus rhythm without complications. One single-center, retrospective study of patients presenting to emergency department with PSVT found that 71 percent (%) were discharged home after an average stay of four hours. The 24-hour recurrence rate in those patients was less than 5%. Likewise, data from the National Hospital Ambulatory Medical Care Survey 1993-2003 database revealed a 76% discharge rate for PSVT after evaluation in the emergency department.
While this patient's serum troponin level was elevated, this is common with PSVT, even in the absence of coronary stenosis. It is not recommended that troponin levels be checked based on PSVT alone but only when there is reasonable suspicion of acute coronary insufficiency. In this young patient, this would have been unlikely. In summary, this single episode of hemodynamically stable PSVT that was terminated with intravenous adenosine did not require an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obstructive Sleep Apnea

Treatment: Sleep study (continuous positive airway pressure [CPAP] titration), 95811 x (times) 1

The insurer denied coverage for sleep study (continuous positive airway pressure [CPAP] titration), 95811 x 1.

The denial is upheld. 

According to the provided record, this is a patient with a history of excessive daytime fatigue who is being worked up for possible multiple sclerosis based on brain lesion seen on a magnetic resonance imaging (MRI).  A home sleep study was performed which revealed abnormalities and a continuous positive airway pressure (CPAP) titration study was recommended.  The insurer felt that the sleep study did not confirm sleep issues and denied coverage for the titration study.

The home sleep study that was provided for review was a WatchPAT (peripheral artery signal for Sleep Apnea diagnosis) study which is a commonly performed home sleep study.  The study report includes various different indices used for interpreting sleep studies.  In this particular case an apnea hypopnea index (AHI) using 4% (percent) oximetry criteria was normal at 2.1 events per hour.  Oxygen desaturation index was 2.1 events per hour and the respiratory disturbance index (RDI) was reported as 9.1 events per hour.  

Standard scoring criteria for sleep studies both home studies and laboratory studies use the AHI as the primary measure of sleep disordered breathing.  The AHI can be measured reliably using home testing.  The RDI or respiratory disturbance index reflects more subtle breathing events which technically require laboratory polysomnography for diagnosis.  Many home sleep devices report an RDI (respiratory disturbance index), but this is a number obtained by inference and not by direct measurement.

This sleep study falls into a "gray zone" that sleep physicians often encounter.  The study is not quite normal but would not meet the criteria for a sleep apnea diagnosis for some clinicians.  Further work-up would be indicated.  It depends also on whether there is another explanation for her symptoms.  Based on the fact that the patient has an abnormal MRI there may be other factors contributing to daytime sleepiness and nonrestorative sleep.  It would be reasonable to obtain laboratory polysomnography or split-night polysomnography for further evaluation and assessment.  It should be pointed out if there was a high clinical suspicion the request to proceed directly to a titration study is not unreasonable.  However, the health plan is acting reasonably by interpreting the study as normal and by denying the titration study.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for sleep study (continuous positive airway pressure [CPAP] titration), 95811 x (times) 1 is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #3:

Diagnosis: Low back pain

Treatment: Intracept procedure

The insurer denied coverage for Intracept procedure

The denial is upheld 

The Intracept procedure is "intraosseous ablation of the basivertebral nerve". It has been proposed to address low back pain identified by Modic changes.  The procedure is performed within the vertebral body. It has been proposed that pain relief is manifested by patients no longer requiring their narcotics. For one level of disc disease each vertebral body requires precise targeting. The operation is not recognized by practicing neurosurgeons or spine surgeons. 

The procedure is not mainstay nor current accepted treatment by the practicing medical community.

Scientific peer reviewed literature is unclear. There are several studies however no conclusions can be made. No definite statements or guidelines showing  definitive efficacy have been reported.

Food and Drug Administration (FDA) approval had been granted for Pre-Market approval. The FDA does not provide statements regarding benefit.

The records do not substantiate the basivertebral nerve as a pain generator. The facts are there is severe disc pathology localized to lumbar (L)3-4. There is severe loss of disc space resulting in the edema (i.e. Modic change). The symptoms of pain with motion are more likely secondary to a degenerative segment with instability. There was evidence of foraminal stenosis with nerve root compression. There was evidence of non-specific edema in the conus. These abnormal findings would more than likely be responsible for the pain pattern. It is important to note the "improvement with discogram". A discogram is utilized to determine the level of pathology prior to planning an arthrodesis. This would correlate with possible instability pattern. 

The Intracept Procedure for intraosseous ablation of basivertebral nerve, codes 64628 Thermal destruction of intraosseous basivertebral nerve is not  the best available treatment for this patient at this time.
 
The procedure is invasive. There have been reported complications of infection, broken hardware, endplate fracture and retroperitoneal hematoma.

The requested service is NOT likely to be more beneficial than any of the standard treatment/procedures. 

In summary, the denial of Intracept Procedure for intraosseous ablation of basivertebral nerve, codes 64628 Thermal destruction of intraosseous basivertebral nerve and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.