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

Diagnosis: Closed Loop Small Bowel Obstruction. 
Treatment: Inpatient Hospital Admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is overturned. 

This patient has a history of status post gastric bypass one month prior, who presented with 1 day of worsening acute abdominal pain and vomiting.  The patient was admitted to surgery and had a laparoscopic internal hernia reduction. 

Per clinical documentation, the patient presented to the emergency department with epigastric pain with associated nausea and vomiting. The patient has a history of a gastric bypass one month prior. Vital signs were within normal limits. White blood cell count was elevated at 13.3. A computed tomography (CT) of the abdomen and pelvis demonstrated a closed loop small bowel obstruction of the Roux limb. The patient underwent emergent laparoscopic reduction of an internal hernia. On postoperative day 1, the patient was noted to be tolerating 4 ounces of fluids per hour. The patient was advanced to a Step 1 bariatric diet, and discharged. According to Milliman Care Guidelines (MCG) criteria, goal length of stay for an intestinal obstruction is 2 days. An extended stay beyond the goal length of stay may be needed for patients who undergo surgical intervention. [3] Per the MCG, admission is indicated for patients with signs and symptoms of bowel obstruction and with imaging study consistent with bowel obstruction. [4] Per clinical documentation, the patient presented with nausea, vomiting, abdominal pain, and had imaging consistent with a diagnosis of a bowel obstruction. 

Inpatient admission was medically necessary for this patient. 

Bowel obstruction is an important cause of morbidity and mortality, and is responsible for approximately 15% (percent) of hospital admission for acute abdominal pain in the United States. [1] Afferent loop obstruction is a complication that may occur after a Roux-en-Y gastric bypass or reconstruction. The causes include entrapment by postoperative adhesions, internal herniation, volvulus, intussusception, stenosis, recurrence of cancer, or foreign bodies. Acute afferent loop obstruction is a complete obstruction, and is considered a surgical emergency. [2] 

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

Based on the above, the medical necessity for the inpatient hospital admission 
is overturned. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admission.

The denial is upheld. 

This female patient has a history of gastroesophageal reflux disease (GERD).

Milliman Care Guidelines clinical indications for admission for Gastroenteritis (M-170) include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe dehydration, severe electrolyte disorder, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient appeared to have a gastroenteritis. However, intravenous hydration, proton pump inhibitor (PPI) therapy and antiemetics could have been given with observation status. She did not meet MCG criteria for admission for gastroenteritis. The health care plan acted reasonably and with sound medical judgement. Inpatient level of care was not medically necessary. The admission is denied.

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

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD [gastro esophageal reflux disease]

Treatment: stomach surgery (procedure code 43284), placement of esophageal sphincter augmentation device

The insurer denied coverage for stomach surgery (procedure code 43284), placement of esophageal sphincter augmentation device.

The denial is overturned.

This case involves an adult female who has been recommended to undergo the Linx procedure. The documentation indicated she was seen for a follow-up. The documentation detailed she had recently undergone an esophagogastroduodenoscopy [EGD] as well as a Bravo test due to Barrett's esophagus and GERD-erosive esophagitis and irregular Z-line. She also has a hiatal hernia noted to be 3 cm (centimeter). Her DeMeester score was 40.4. She has undergone a prior manometry with normal swallowing mechanism. The physician indicated her potential of hydrogen [pH] study showed significant acid reflux exposure. The physical examination did not reveal any significant findings. The recommendation was made for surgical intervention. Prior to this she was seen where it was noted all symptoms and the endoscopy findings were consistent with GERD however, the Bravo capsule was negative. At this time, she complained of worsening symptoms and therefore it was recommended she undergo a repeat endoscopy as well as biopsy. She was recommended to increase her proton pump inhibitor to twice a day. The request has been received for surgical intervention.

This procedure has been over 80% [percent] effective in long term control of GERD symptoms. Minimal long-term complications have been reported.

The Linx device was approved by the Food and Drug Administration [FDA] for treatment of GERD.  It is the only device so approved.  This patient has medically refractory GERD with distal esophagitis. She also has a small hiatal hernia. Her swallowing studies and manometry are normal. She is a good candidate for minimally invasive surgery for placement of the Linx device and repair of her hiatal hernia defect.  Evidence shows that this device gives improved results over the traditional fundoplication procedures. This device is a less invasive method for surgical management of GERD. It has a quicker recovery time and less perioperative complications. Long term studies show excellent symptom relief and low risk of long-term complications. In properly selected patients such as this one, the results are often excellent.

The risks are similar to more traditional repairs. Placement of the device requires less manipulation of the stomach in the area of the hiatus, and a skilled endoscopic surgeon should require less time than when performing a traditional laparoscopic fundoplication. Erosion of the device is a possible, but very rare occurrence.

The procedure is likely to be more beneficial than any other existing standard health service. 

The carrier's denial of stomach surgery (procedure code 43284); placement of esophageal sphincter augmentation device should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurrent aphthous ulcers
Treatment: Humira 40mg, Pre-service
The insurer denied the Humira 40mg, Pre-service
The denial is overturned. 

The patient has Behcet's disease / recurrent aphthous ulcers and was prescribed Humira. This was denied by the Health plan because the patient was listed as having recurrent apthous stomatitis, however the disease state is Behcet's.

Yes, the proposed Humira is medically necessary.
There is evidence that this medication and other tumor necrosis factor (TNF) agents are safe and effective in Behcet's.  This patient has failed conventional therapy and this treatment is now standard of care for Behcet's.  This is a rare disease so controlled trials are not available but there is data present in support of Humira for Behcet's.  Therefore, the requested Humira is medically necessary.

In addition, the patient meets the Health Plan criteria because the Health Plan does cover the diagnosis of Behcet's for Humira.  This patient has a diagnosis of Behcet's and therefore meets the criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive Heart Failure (CHF).

Treatment: Acute inpatient stay.

The insurer denied coverage for acute inpatient stay.

The denial is upheld.

This is the case of a male with a past medical history of hypertension, chronic kidney disease, cardiomyopathy with ejection fraction (EF) 20% [percent], presence of a defibrillator, long term use of anticoagulant, and atrial flutter. He presented to the Emergency Department (ED) with complaints of fatigue and generalized malaise. He was clinically stable. Physical examination noted mild lower extremity edema and left lower lobe decreased breath sounds. He denied chest pain and shortness of breath. He reported being compliant with his medications. He denied implantable cardioverter defibrillator (ICD) shocks. Electrocardiogram (EKG) showed normal sinus rhythm. Troponin was 0.09, decreased from prior study. B-type natriuretic peptide (BNP) was 2948. He was admitted and ruled out for acute coronary syndrome (ACS). Echocardiography noted EF 25%. He was diuresed with intravenous (IV) furosemide, with improvement in his lower extremity edema. He was discharged home. He deferred workup of stable iron deficiency anemia while in the hospital. 

Inpatient admission was not medically necessary for this patient. The patient was admitted with symptoms of congestive heart failure (CHF). The patient's care could have been rendered under observational status. There was clinical and radiographic evidence of CHF, which supported observational care. Inpatient admission status was not met due to lack of severity of disease or comorbidities. There was no evidence of myocardial ischemia, hemodynamic instability, electrolyte abnormalities, hypoxemia, or other indications to substantiate medical necessity for acute inpatient admission status for the dates under review. Troponin was borderline elevated, but trends were not consistent with ACS. Per Milliman Care Guideline (MCG) 24th Edition Guideline Heart Failure: Observation Care, the patient's care could have been provided under observational level of care. 

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

The insurer's denial of coverage for the acute inpatient stay is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervicalgia

Treatment: physical therapy

The insurer denied coverage for physical therapy

The denial is upheld.

The patient began physical therapy treatment for neck pain (cervicalgia).  Currently under review is the medical necessity of physical therapy for ongoing physical therapy.

The physical therapy treatment notes provide insufficient objective clinical information to support the medical necessity of continuing physical therapy between certain time periods.   There has been a decrease in pain complaints.  However, neck strength and range of motion have been much the same. The lack of sustained improvement is consistent with maintenance treatment and is not considered medically necessary.  In addition, the patient should have been independent with a home exercise program (HEP).  

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. From a physical medicine and rehabilitation/pain management perspective, physical therapy visits were not medically necessary for this patient.

The insurer's denial of coverage for physical therapy visits is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Displaced fracture of olecranon process without
intraarticular extension of right ulna, initial encounter for closed fracture
Treatment: Durable Medical Equipment (Wrist-Finger Orthosis), Pre-service
The insurer denied the Durable Medical Equipment (Wrist-Finger Orthosis), Pre-service.
The denial is upheld. 

The records report that the patient is a female with a history of a fall resulting in an extensive, displaced left elbow fracture.  She underwent surgical repair.  There was loss of "all range of motion" in her elbow, hand, wrist and fingers.  She underwent therapy with partial recovery of range of motion.  A custom wrist hand finger brace was recommended to maximize her therapeutic gains and functional recovery from occupational therapy.  It was reported that she relies on this brace to execute her household chores and to care for her children.

A final adverse determination from the health plan noted that the patient had not received the service in the immediate postoperative period for an orthopedic surgery.

No, the proposed treatment with the Wrist-Finger Orthosis is not medically necessary.
The records do not indicate why the patient developed severe or total wrist, hand, and finger range of motion loss following an elbow fracture while receiving therapy.  There are no indications that she could not have moved her affected wrist and hand actively to prevent range of motion loss.  There are no indications she could not have used her contralateral hand to mobilize the affect wrist and hand passively if the affected wrist and hand were neurologically compromised or otherwise stiff.  There are no descriptions of the exact type of orthosis and how it exactly improves her function.  There are no indications why she requires a custom orthosis and not an off the shelf orthosis.  The records, overall, do not indicate that the patient requires a custom wrist-hand-finger orthosis.

The records do not establish any medical necessity for the service in question.  The patient is described as having some distal upper extremity functional deficits, but there is no clinical rationale provided that specifies how exactly an orthosis would change the patient's outcomes or clinical course.  A patient may have symptoms, but a treatment must have a clinically sound basis for its application, and no such rationale is provided in the available records.  The rationale for the denial of coverage by the health plan (i.e., that it was not requested for application immediately postoperatively) does not make clinical sense, but the service ultimately is not medically necessary based on the available records, so the denial of coverage was nevertheless appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep Impinging Overbite

Treatment the insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit)

The insurer denied coverage for the insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit).

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage. 

It is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage.  This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care as on examination of the intraoral clinical images there is evidence of palatal gingival recession due to direct impingement of the teeth on the gingival soft tissues. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Overturn denial as the clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care.

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

Based on the above, the medical necessity for the insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit) is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a male with a past medical history significant for HTN (hypertension), dyslipidemia, drug abuse, polysubstance abuse, CAD (coronary artery disease), status post PCI (percutaneous coronary intervention) x 3 stents several months prior. He presented to the ER (emergency room) with new onset chest pain, mid-sternal, at rest, severe, radiating to his left chest and back, associated with diaphoresis. The patient reported he had stopped all his medications, including antiplatelet therapy one week prior and went on cocaine binge for six days. 

The patient was hemodynamically stable. The ECG (electrocardiogram) revealed no acute ST changes. Initial troponin level was normal. His HEART (History, Electrocardiogram, Age, Risk factors, initial Troponin) score was determined to be 5. The patient had persistent pain despite the treatment provided in the ER (emergency room), and he was admitted to telemetry for suspected unstable angina/ACS (acute coronary syndrome). 

The patient was started on medical therapy for ACS (acute coronary syndrome), as well as medications for treatment of suspected withdrawal symptoms. He was seen in consultation by cardiology, and a nuclear stress test was obtained. The patient was found to have mild ischemia in multiple distributions, however a decision was made to treat him medically, and no further cardiac catheterization was planned. The patient improved clinically with treatment, and he was discharged home with a plan for outpatient follow-up. 

Yes, the Inpatient admission was medically necessary. 

The patient presented with new onset chest pain, suggestive of unstable angina in the setting of non-compliance with antiplatelet therapy and cocaine abuse. The patient had multiple risk factors for CAD (coronary artery disease), including drug abuse as well as a known history of coronary artery disease, requiring prior percutaneous revascularization. The ECG (electrocardiogram) was unrevealing for ACS (acute coronary syndrome), but was abnormal with frequent PVCs (premature ventricular contractions). Given the presentation, non-compliance with antiplatelet therapy, as well as clinical suspicion for an acute coronary syndrome/unstable angina, he would not be an appropriate candidate for an ED (emergency department) chest pain observation unit. It would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthostatic Hypertension

Treatment: inpatient hospitalization

The insurer is denied coverage for inpatient hospitalization.

The denial is upheld. 

This patient has a history of a stroke with residual left-sided weakness/facial droop as well as a history of hypertension, hyperlipidemia, asthma, pulmonary edema, morbid obesity, aortic valve replacement, congestive heart failure, major depression, and non-ST (interval on echocardiogram) elevated myocardial infarction.  The submitted documentation indicated she was seen with complaints of dizziness.  The documentation indicated she complained of persistent ataxia with lightheadedness.  She was at therapy when she had an episode of ataxia and lightheadedness.  She was told to go to the emergency department by therapy.  The documentation indicated that on physical examination her vital signs revealed a blood pressure 138/83 with a pulse of 69 bpm (beats per minute).  Oxygen saturation was 95% (oxygen) on room air.  She was alert and oriented.  She did have residual left facial weakness with a positive Romberg and narrow gait.  The physical examination also revealed an appropriate mood.  EKG (echocardiogram) was without evidence of STEMI [ST elevation myocardial infarction] or ischemia.  She was not hypoglycemic, and her clinical picture did not suggest another stroke.  It was recommended she undergo additional studies to include laboratory studies as well as a computed tomography (CT) scan.  The laboratory studies revealed her warfarin level was subtherapeutic.  It was recommended she undergo consultation by Neurology.  She was admitted for further monitoring and testing.  The documentation does indicate upon further evaluation the patient was noted to have orthostatic hypotension.  She did not experience any further events while hospitalized.  Given the continued stability and lack of adverse events, she was discharged with instruction to follow-up.

Regarding the requested inpatient stay, referenced literature indicates a patient may be admitted to inpatient services when there is documentation detailing significant hemodynamic instability that is not correctable with a lower level, evidence of vomiting that has severe persistent, the inability to ambulate, or suspected etiology requiring admission for treatment such as a vertebral artery dissection.  The documentation does not detail the above.  Upon presentation to the emergency department, her vital signs were stable.  She was alert and oriented.  Initial diagnostic testing did not reveal any significant abnormalities that would warrant inpatient admission.  Therefore, the health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospitalization is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Disease
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient in this case is a male who has a history of sickle cell anemia.  He presented to the emergency department with complaints of generalized body aches, most prominent in his lower back and legs.  The pain had been present for two weeks.  He said that these symptoms were typical of sickle cell crisis.  He had no other symptoms and noted that he had been treated in the outpatient setting over the past two weeks but the pain was worsening.  

The patient's vital signs were unremarkable except for mild elevation in heart rate to 101.  Physical exam was without significant abnormal findings. Labs were notable for hemoglobin of 6.3 grams per deciliter (g/dl).  This was noted to be stable for him.  He was treated with two doses of intravenous (IV) Dilaudid and continued to complain of pain.  He was admitted. He was not transfused. Chest x-ray revealed a questionable ground class opacity.  He was treated with intravenous (IV) fluids and Dilaudid and left against medical advice.

No, the proposed inpatient admission was not medically necessary.
This patient had been having pain for two weeks and did not have any hemodynamic instability, respiratory compromise, acute kidney injury or active infection requiring intravenous (IV) antibiotics.  He also did not have severe pain requiring frequent use of intravenous pain medication.  He had persistent pain over a period of two weeks and was well enough to leave against medical advice soon after admission.  He did not require acute care inpatient admission based on these considerations.