Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lyme disease.
Treatment: Polymerase Chain Reaction (PCR) Testing for Lyme Disease.
The insurer denied coverage for Polymerase Chain Reaction (PCR) Testing for Lyme Disease.
The denial is upheld. 

This is a male patient who has a history of 2 prior tick bites to the abdomen.  The documentation indicates that the patient was seen related to the reported tick bite.  The submitted documentation indicates that the patient was being seen via telehealth.  The patient had complaints of feeling fatigued and having generalized joint and muscle pain.  The examination was limited due to the nature of the visit.  It was recommended that the patient begin doxycycline treatment twice a day and undergo laboratory studies to include polymerase chain reaction (PCR) testing for Lyme disease.

As per literature review, the Food and Drug Administration has not approved the use of polymerase chain reaction (PCR) test in the diagnostic workup of Lyme disease. Serologic testing is the recommended method for diagnosis of Lyme disease.  There is no literature that supports a result of improvement in health outcomes by the use of polymerase chain reaction for Lyme disease. Thus, this patient is not a good candidate for Polymerase Chain Reaction (PCR) testing for Lyme disease.  From the documentation provided there is no particular indication to perform a non-serologic testing method particularly polymerase chain reaction (PCR) or any other nucleic acid amplification test (NAAT) on this patient.

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for Polymerase Chain Reaction (PCR) Testing for Lyme Disease should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lyme disease.
Treatment: Polymerase Chain Reaction (PCR) Testing for Lyme Disease.
The insurer denied coverage for Polymerase Chain Reaction (PCR) Testing for Lyme Disease.
The denial is upheld. 

This is a male patient with past medical history significant for vitamin-D deficiency who sustained tick bites on his abdomen.  No rash was noted on physical exam.  The patient was empirically started on oral doxycycline twice daily (BID) for 10 days.   

Diagnosis of acute Lyme infection can be challenging and is based on clinical findings, epidemiological risk factors, and serologic testing.  Current guidelines recommend two-tier Lyme disease serologies as a starting point to establish the diagnosis of Lyme disease in patients with potential exposure to Ixodes ticks and with signs/symptoms of Lyme.  Enzyme-linked immunosorbent assay (ELISA) is the test used most often to detect Lyme disease; ELISA detects antibodies to Borrelia burgdorferi (B. burgdorferi) but because it can sometimes provide false-positive results, it's not used as the sole basis for diagnosis.  If the ELISA test is positive, Western blot test is recommended to confirm the diagnosis.  In this two-step approach, the Western blot detects antibodies to several proteins of B. burgdorferi.

Although polymerase chain reaction (PCR)-based testing is currently available, Lyme studies are very limited, and not yet well standardized with variability in sensitivity and specificity.  Therefore, serum PCR testing has not been validated for widespread clinical use.  

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for Polymerase Chain Reaction (PCR) Testing for Lyme Disease should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male with history of autism, pervasive developmental disorder, and epilepsy, who was brought by ambulance after having three breakthrough seizure events (grand mal) which consisted of facial twitching and eyes rolling back into his head. The patient also had bruising on his lower legs. Prior to these seizure events, the patient had adjustments to his antiepileptic medication regimen. The patient usually only had a seizure once or twice a month at his baseline.  

While in the emergency department, the patient was lethargic and ill-appearing/dehydrated. He had another seizure event while in the emergency department and was given Ativan, Tylenol, intravenous (IV) fluids, and oxygen. He was then admitted for further clinical and neurological monitoring. He was started on phenobarbital and given intravenous medications due to elevated body temperature. Due to recurrent seizures and concern for possible progression to status epilepticus, the patient was transferred to a children's hospital for further management including a video electroencephalography (EEG).

Yes, the acute care admission in question was medically necessary.

The patient had increased seizure frequency, multiple seizures in the same day (which is different from his baseline), and the seizure did not stop and the patient was ill-appearing. Therefore, there was a suspicion for underlying cause for neurological deterioration, such as neuro-infection, sepsis, etc. Due to increasing frequency of seizures eventually requiring transfer to tertiary institution, there was a reasonable suspicion for early stages of status epilepticus. Therefore, neurologically the patient's clinical status was unstable, with seizures at high frequency, requiring intravenous medication loading such as phenobarbital. Due to tentative and unstable neurological status, acute care admission was medically necessary.

The denial letter says that there was no dynamic, pulmonary, neurological or metabolic reasons for acute level of care. The services and interventions provided could have been done in the observation setting. These statements are incorrect. The patient's neurological status was unstable; instead of having one seizure in months at his baseline, the patient had four seizures in the same day without reaching his baseline and was ill-appearing on exam. This constellation of symptoms is suggestive of developing status epilepticus. Therefore, acute care admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth caries.
Treatment: Code D2740: All White Glass Crowns to Tooth #8 and Tooth #9.
The insurer denied coverage for code D2740: All White Glass Crowns to Tooth #8 and Tooth #9.

The denial is upheld. 

This female patient presented for dental treatment. The patient had dental x-rays taken.  The treating dentist determined that the patient needed all white glass crowns to tooth #8 and tooth #9. The dentist recommended the aforementioned dental services including full coverage crown on tooth #8 which currently has direct placement restorations and is stated to have recurrent caries, and a replacement crown for tooth #9. The insurer has denied these services stating that the radiographs do not indicate recurrent decay or other findings that would necessitate placement of a crown on tooth #8 or replacement of the preexisting crown on tooth #9.

The objective documentation provided for review is the radiographs. There was no periodontal charting provided for review. The radiographs indicate stable intact restorations on tooth #8 and tooth #9. There does not appear to be any radiographic change or pathology that would necessitate replacement of the existing restorations on either tooth. Further, as per the letter provided in the documentation, one of the reasons for suggesting and recommending replacement of these restorations is not dental need, but aesthetic concerns. The documentation provided fails to substantiate the recommended dental service as enumerated above and therefore, it is deemed not medically necessary.

The request for D2740: All white glass crowns to tooth #8 and tooth #9 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. 

The medical necessity is not substantiated. The health plan's denial of the request for the code D2740: All white glass crowns to tooth #8 and tooth #9 is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. The patient has a history of hypertension as well as recurrent uncomplicated sigmoid diverticulitis. The patient presented to the emergency department of the facility filing the appeal with the report of left lower quadrant abdominal pain. She evidenced hypertension, mild tachycardia and no fever. She received intravenous (IV) antibiotics. The while count was normal. The computed tomography (CT) scan showed sigmoid diverticulitis but no free air or signs of perforation. The patient was admitted to the acute hospital. The patient had significant pain and responded to treatment. The patient's diet was advanced and her antibiotics were changed to oral preparations and she was discharged home.

No, the proposed inpatient admission was not medically necessary. While the services provided were medically appropriate, the level at which the care was provided was not medically necessary.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an recurrent episode of acute diverticulitis; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  Her pain was controlled with treatment. As such the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma/Injuries/Other/Rib Fracture
Treatment: Inpatient Hospital
The health plan denied the requested inpatient hospital stay as not medically necessary. 
The health plan's determination is overturned.

This patient is a female with past medical history of ectopic pregnancy who presented to the emergency department status post physical assault. The patient arrived complaining of left sided chest wall pain. Physical exam showed an intact airway without supplemental oxygen saturating 98% on room air. There was left sided chest wall tenderness without subcutaneous emphysema. A computed tomography (CT) of the chest showed a displaced left 6th rib fracture, subtle left lower lobe pulmonary contusion and a small hemothorax. She was admitted to the trauma service as an inpatient level of care. The following morning the patient's pain was well controlled. 
At issue is the medical necessity of the inpatient stay.

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

Yes, the requested health service/treatment of inpatient stay is medically necessary for this patient.

The patient's physical exam showed an intact airway without supplemental oxygen saturating 98% on room air. Left sided chest wall tenderness without subcutaneous emphysema. A CT of the chest showed a displaced left 6th rib fracture, subtle left lower lobe pulmonary contusion and small hemothorax. She was admitted to the trauma service as an inpatient level of care.

According to trauma guidelines for rib fractures, the following require inpatient admission:
1) Specifically, in the age group 65 years and older, (Criteria not met) 2) consider admission for patients age >=85 years, (Criteria not met) 3) or with initial systolic blood pressure < 90 mm Hg, (Criteria not met) 4) hemothorax, (Criteria met) 5) pneumothorax, (Criteria not met) 6) 3 or more unilateral rib fractures, (Criteria not met) 7) or pulmonary contusion. (Criteria met)

According to the Milliman Care Guidelines (MCG), inpatient admission is indicated for rib fracture for the following: 
1) 3 or more traumatic rib fractures (Criteria not met) 2) Flail chest (Criteria not met) 3) Inpatient admission required rather than observation care. 4) Pain inhibiting ability to cough or clear airway that is severe or persistent and requires inpatient treatment (Criteria not met) 5) Injury identified that requires inpatient care (Criteria met) 6) Rib fracture exacerbation of comorbid illness that is severe or persistent (Criteria not met) 7) Other significant finding or clinical condition judged not to be within scope of observation care (Criteria not met)
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis.
Treatment: Tremfya.
The insurer denied Tremfya. The health plan's determination is upheld. 

The patient is a male with moderate to severe psoriasis (10% body surface area involvement) of the forearms. The patient has tried and failed topical triamcinolone, calcipotriene, betamethasone, and ammonium lactate. The patient drinks alcohol weekly.

Tremfya is not medically necessary for this patient.

The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate, Acitretin, or other standard/traditional oral Disease-Modifying Anti-Rheumatic Drugs (DMARDs).

Modern dermatology literature supports use of the health plan-covered and preferred medications as similarly efficacious to the requested Tremfya, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, and recommend use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Tremfya is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Austedo. 
The denial is overturned.

The patient is a male with a diagnosis of tardive dyskinesia. It is reported patient has been on different psychiatric medications, for unknown reasons, for many years. Risperidone was used the majority of the time. Examination reports presence of involuntary movements compatible with tardive dyskinesias. abnormal involuntary movement scale (AIMS) score reported as 24. The subject under review is the medical necessity for Austedo in this case for the treatment of tardive dyskinesia.

The health plan's determination is overturned.

The treatment with Austedo is medically necessary for this patient.
The patient has an established diagnosis of tardive dyskinesias, disabling, for which Austedo is both Food and Drug Administration (FDA) approved, and proven in the high quality peer reviewed literature, through well designed, blinded, randomized trials. The records clearly document disability associated with the dyskinesias, and medical necessity of Austedo is supported by the documentation. Clonazepam is neither FDA approved, nor proven for such indication in the high quality peer reviewed literature. There is no indication or literature support for the use of clonazepam in place of the proven alternative, Austedo.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral below the elbow amputations.

Treatment: Prosthetic Arm Additions (extra socket for left artificial arm).

The insurer denied coverage for Prosthetic Arm Additions (extra socket for left artificial arm).

The denial is upheld. 

This male patient has bilateral below elbow amputations of the arms. A request for bilateral myoelectric prostheses has since been approved. However, the request for prosthetic arm additions (extra socket for artificial arms), that was separately coded as L7499, has been denied.  

The insurer appropriately approved base code L6883 -Replacement socket, below elbow/wrist disarticulation, molded to patient mode, for use with or without external power.  However, the requested L7499 code- Skeletal contoured and dynamic below elbow socket- is an inappropriate unbundling code that should be incorporated into the base code of the replacement sockets (L6833).  Such unbundling of codes from the base code are inappropriate and have been previously adjudicated in case law.

The health plan acted reasonably, with sound medical judgement and in the best interest of the patient.  Including but not limited to, the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, nation or professional medical societies boards and associated were taken into consideration.  All decisions are evidenced based.

The medical necessity is not substantiated. The carrier's denial of coverage for prosthetic arm additions (extra socket for artificial arms), should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures, cerebral palsy, global development
delay
Treatment: Inpatient admission
The insurer denied the inpatiet admission.
The denial is upheld. 

The patient is a male with cerebral palsy, generalized tonic-clonic seizures, and global development delay who is dependent on gastric tube feedings. The patient was brought by ambulance to the emergency department due to seizure activity with new-onset fever, cough, stiffness, jerky movements, eye fixation, and frothing at the mouth. The patient was given diazepam by his mother but he continued to have seizure activity. 

While in the emergency room, the patient was tachycardic and pupils were nonreactive. There was quadriplegia with hypertonicity in all four extremities and there were signs of dehydration. The patient was administered intravenous (IV) hydration as well as clonazepam. The patient was admitted for management of his seizure activity due to concerns for acute breakthrough seizures with status epilepticus, possibly due to an acute febrile illness, and further evaluation was needed to determine any alternative infection sources. The patient received antibiotic therapy as well as baclofen and gabapentin along with clonazepam and diazepam as needed.  No further seizure activity was observed throughout his hospitalization.  He underwent various screenings as well as neurology consult. He required close monitoring for continued fever.  He was discharged the following day after he was deemed clinically stabilized.

No, the proposed inpatient admission was not medically necessary.

The patient's seizures stopped before he arrived to the emergency room, the patient was not post ictal upon arrival, vital signs stabilized after intravenous hydration, and no additional seizures were reported. There was no evidence of infection of the central or peripheral nervous system, no evidence of ongoing seizure activity, and the patient's hydration was restored. There was no evidence of any new focal neurological deficits, brain edema, diminished level of consciousness, or signs of increased intracranial pressure. The patient has neurological handicaps so quadriplegia and hypertonicity are at his baseline.  Tachycardia was a sign of dehydration.  Pupils not reactive is not a sign of seizure or being postictal, likely to be his baseline.  Therefore, acute inpatient admission was not medically necessary, and the patient's needs could have been met at a lower level of care, such as emergency room or observation status level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tricuspid valve vegetation.

Treatment: Inpatient Hospital Admission.

The insurer denied coverage for the Inpatient Hospital Admission.

The denial is overturned.

This is a male patient with a past medical history significant for endocarditis, substance abuse, bacterial meningitis, deep venous thrombosis (DVT), and schizoaffective disorder who presented to the hospital for evaluation of inpatient rehabilitation after recent methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia, endocarditis, and septic emboli. The patient was initially transferred for acute rehabilitation, but desaturated to 70s, and became tachycardic with complaints of rigors and chest pain. While he was admitted for acute rehabilitation the patient clearly needed medical/surgical acute inpatient care and was thus transferred to inpatient care. The patient's repeat transthoracic echocardiogram (TTE) showed right ventricular failure due to persistent endocarditis. The patient's computed tomography (CT) scan of the chest showed bilateral multifocal opacities. Cardiovascular Surgery and Infectious Disease services were consulted. The patient was admitted to the cardiac care unit (CCU) for catheter directed extraction of tricuspid vegetation. The patient's magnetic resonance imaging (MRI) of the lumbar spine was done to evaluate other source of metastatic infection. Post-operative course was uneventful and the patient was ultimately discharged to continue outpatient management.      

According to documentation, although the patient was initially admitted for rehabilitation, the patient was hemodynamically unstable with tachycardia (heart rate ranging from 130 to 150), and low oxygen saturation (~77% on room air), and complaints of shaking chills. The patient's echocardiogram revealed mobile tricuspid valve vegetation, right-sided heart failure, pulmonary hypertension, as well as other cardiac abnormalities requiring consultations from Infectious Disease, Cardiology, and Cardiovascular services. The patient required surgical intervention for tricuspid valve vegetation removal. Based on above findings, inpatient hospital admission was medically warranted for surgical management of progressive worsening tricuspid valve (TV) endocarditis, with previous failure of intravenous (IV) antibiotics, in a high-risk patient with numerous co-morbid conditions.  

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

The medical necessity for the Inpatient Hospital Admission is substantiated. The insurer's denial should be overturned.