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

Diagnosis: Right maxillary silent sinus syndrome
Treatment: Sinus Ostium Dilation with Sinus Balloon (CPT 31295)
The insurer denied the Sinus Ostium Dilation with Sinus Balloon (CPT 31295)
The denial is overturned.

The patient is a male with a history of right maxillary silent sinus syndrome. Medical therapy has included oral and nasal steroids, rinses and antibiotics.

On exam, the patient's right eye was lower than the left. CT (computed tomography) reported complete opacification of the right maxillary sinus.

The provider is requesting coverage of balloon sinuplasty of the maxillary sinus ( CPT 31295). The request was previously denied by the health plan as not medically necessary, and the provider is appealing the denial.

Yes, the Sinus Ostium Dilation with Sinus Balloon (CPT 31295) is medically necessary.
All records were reviewed. The patient has right silent sinus syndrome on CT (computed tomography) with the right eye lower than the left. This syndrome is a well-documented condition that can lead to visual problems. Treatment consists of opening the maxillary sinus with sinus surgery, and an orbital procedure is also sometimes required due to the location of the affected orbit. Therefore, based on the information provided, the medical necessity of the (CPT 31295) maxillary sinuplasty would be confirmed. This is consistent with scientific literature on treatment of the patient's condition.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Scientific literature would not confirm the health plan's previous determination.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hip dysplasia
Treatment: Continued Rehabilitation Facility
The insurer denied the Continued Rehabilitation Facility.
The denial is overturned.

This is a female who has been admitted with the chronic condition of right developmental hip dysplasia, juvenile idiopathic levoscoliosis, vitamin D deficiency, bipolar disorder (type I) to receive pediatric inpatient rehabilitation services.  The patient underwent several surgical interventions, right femur lengthening following hardware removal in the right pelvis and left knee and right femoral osteotomy performed. In addition, the patient had right iliotibial band lengthening.  The initial acute inpatient rehabilitation stay has been interrupted by the development of psychogenic seizures. The patient has been readmitted to continue acute inpatient rehabilitation stay. The patient has been followed by the pediatric psychiatrist. for medication management.  The patient continued to receive orthopedic rehabilitation with progressive use of dynamic splinting and magnetic lengthening. Her weight bearing status has been advanced to partial weight bearing.

Yes, the proposed Continued Rehabilitation Facility is medically necessary.
Medical necessity for the proposed treatment has been substantiated by the clinical records pointing out the complex care needs of this patient with multiple comorbidities. The patient has been subjected to comprehensive goal oriented rehabilitation and psychiatric support due to her comorbid conditions.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient, based on review of available records.
The initial request for ongoing acute inpatient rehabilitation stay and beyond has been denied by the Health plan. The Health plan did not take into account the inherent complexities of this patient's care based on the dual diagnosis and aftercare needed of both the significant orthopedic intervention as well as psychiatric condition of this patient. Discharge of this patient or a change of care to a less acute or less intense setting would have hampered the efforts of the disciplinary team to stabilized and optimize care.   The patient was not safe to be discharged from the acute intensive rehabilitation settings. The patient was only partial weight bearing.  Clinical records point out a solid plan of care with discharge planning.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral Lower Extremity Symptomatic Varicose Veins

Treatment: Sclerotherapy

The insurer denied coverage for sclerotherapy.

The denial is upheld.

The patient has been recommended to undergo bilateral sclerotherapy due to failure of conservative treatment.  The documentation indicated she has had a trial of conservative care.  This included over-the-counter medication in addition to elevation as well as compression without relief.  She continues to suffer from ongoing pain and has had treatment with the bilateral phlebectomy.  Later, she was seen with complaints of bilateral lower extremity symptomatic varicose veins.  The physical examination revealed there was mild edema bilaterally to the lower extremities.  Motor and sensation were intact.  Her bilateral leg incisions were well-healing and there were dense clusters of spider veins bilaterally.  The documentation indicated she had bilateral lower extremity symptomatic varicose veins despite compression in the absence of reflux and therefore it was recommended she undergo a bilateral sclerotherapy procedure.  A duplex revealed no evidence of venous reflux to the right lower extremity with evidence of focal venous reflux in the small saphenous vein to the left lower extremity.

The proposed sclerotherapy treatments bilaterally are not medically necessary.  There is no evidence of reflux in the right lower extremity.  There is reflux in the left lower extremity, but the degree and severity of reflux in the left sapheno-popliteal junction is not quantified on the venous reflux report.

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

Based on the above, the medical necessity for the sclerotherapy is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: D8080 braces and D8670 monthly visit

The insurer denied coverage for D8080 braces and D8670 monthly visit.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, copies of peer reviewed literature as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, and overbite and has recommended orthodontics. The orthodontist has completed the Handicapping labio-lingual deviation (HLD) index attaining 6 total points to support orthodontic care. 	

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 Labio-lingual 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 6 points to justify orthodontic care.  This reviewer concurs with the index completed by the insurer attaining a total of 14 points on the HLD index (6 overjet, 5 overbite, 3 labio-lingual spread) which is below 26 points to support orthodontic care. Of note is in this case, the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.
 
Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies.

The clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the D8080 braces and D8670 monthly visit is not substantiated. The insurer's denial 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 with a history of hypertension, hyperlipidemia, diabetes, atrial fibrillation, LUE (left upper extremity) DVT (deep venous thrombosis), GERD (gastroesophageal reflux disease), migraine, splenectomy, liver abscess, invasive candida auras, cholangitis, choledocholithiasis status post multiple ERCPs (endoscopic retrograde cholangiopancreatographies). She presented with nausea and chills x 3 days.  The patient had chronic diarrhea and colicky abdominal pain.  She had decreased appetite.

ERCP (endoscopic retrograde cholangiopancreatography) was performed with cannulation of the pancreatic duct, common bile duct.  The patient had a balloon sweep and cholangioscopy.  A common hepatic duct stricture was noted.  The patient received Dilaudid for pain.  The patient had elevated liver function tests which improved.  The patient was positive for Clostridium difficile and was treated with oral Vancomycin.

On day three, the patient reported nausea and two episodes of diarrhea the day before.

On day four, there were no events overnight.  The patient's diarrhea had improved.  The patient was started on a lactose free, low residue diet along with Creon.  The patient received Dilaudid for pain.

On day five, the patient reported hesitancy with urine.  She had no other complaints.

The patient was discharged on day six.

No, the Inpatient admission was not medically necessary.
The patient did not require any surgical intervention, did not require to be nothing-by-mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, did not have fevers, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.  The patient was overall stable and required pain control, which could have been accomplished at a lower level of care.

The patient was overall stable and required pain control, which could have been accomplished at a lower level of care.

The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting.

Therefore, based on review of the submitted medical records, the requested inpatient level of care was not medically necessary for the dates of service in question, as it exceeded in scope and intensity the level of care necessary to provide safe, adequate and effective treatment for this patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a male seen in emergency department (ED) with chief complaint of "panic attack", anxiety and dyspnea. He had some dizziness without orthostasis. There was a situational event that led to this episode. 

The emergency room (ED) showed a blood pressure (BP) of 92/61, pulse 92, oxygen saturation 97%, and afebrile. The patient has a history of chronic kidney disease (his creatinine was elevated) and recent discharge from another hospital including a negative stress test. The patient received intravenous fluids (IVF), felt better and left against medical advice (AMA) the next morning.  He was noted to be hemodynamically stable, in no distress, and chronic medical morbidity was improved and being addressed.

No, the proposed inpatient admission was not medically necessary.
Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of an acute illness. The patient improved on intravenous fluids (IVF) alone and left in one day hemodynamically stable without significant symptoms. 

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. Subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of coronary artery disease (CAD) or hemodynamic instability.  While there is always a potential for an adverse event (and in this case a very low probability), one did not happen and no actual treatment was added.

Neither InterQual nor Milliman criteria requirements were fulfilled.

All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease, low back pain, recurrent
depressive disorder, urinary incontinence and
osteoarthritis
Treatment: Increase Social Day Care to Four Days a Week
The insurer denied the Increase Social Day Care to Four Days a Week
The denial is upheld

This female patient has multiple chronic medical conditions including coronary artery disease (CAD), low back pain, recurrent depressive disorder, urinary incontinence and osteoarthritis.  The patient lives with her spouse and receives personal care assistance at 15 hours per week as well as shared hours with her spouse.  She is appealing the denial of increase Social Day Care to four days a week.  The Plan approved Social Day Care for one day per week.  The patient is requesting four days to avoid home isolation and depression.

No, the proposed treatment is not medically necessary.
Adult day care centers may focus primarily on social interaction, provide medical care, or be dedicated to Alzheimer's care.  Adult day care can provide a break from the caregiver and social interaction.  They provide a variety of services and activities, including social activities.  Social Adult Day Care usually do not need medical attention during the day but may need supervision for safety and activities of daily living.  

This patient lives with her spouse and receives personal care aide (PCA) 15 hours per week and additional shared hours with her spouse.  The patient does not have a major depressive disorder.  Based on the patient's clinical status, living conditions, and personal care aide (PCA) hours, the requested increase in Social Day Care to four days a week is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trouble Swallowing
Treatment: Speech/Hearing/Voice/Communication Therapy; Individual
The insurer denied the Speech/Hearing/Voice/Communication Therapy; Individual
The denial is overturned.

This patient is a male.  He has had feeding difficulties including food refusal and dysphagia. He was seen by gastroenterology (GI) and was referred for feeding and swallowing evaluation, which included a speech pathology (therapy) evaluation. The speech therapy evaluation found moderate oral dysphagia and requested further speech therapy. 

The prior denial reason was that there was no documentation for speech delay. The reason for appeal is that the patient has feeding difficulties and needs feeding therapy including speech therapy.

Yes, the proposed treatment is medically necessary.
Feeding difficulties/disorders in children are commonly seen and include food refusal, food selectivity, avoidant/restrictive intake disorder (ARFID) and various other feeding/eating conditions. 

The available evidence suggests intensive multidisciplinary feeding program treatment holds benefits for children with severe feeding difficulties. Multidisciplinary intervention should involve, at a minimum, a professional team that includes psychology, medicine, nutrition, and speech-language pathology/occupational therapy (Sharp et al). 

As part of the multidisciplinary team, the speech-language pathologist (SLP) has an integral role in determining whether a child cannot or will not eat and working with the team to identify and carryout appropriate interventions (Gosa et al).

As documented, this patient has had feeding difficulties (pediatric feeding disorder). He was evaluated by a pediatric gastroenterologist. As a standard medical practice, he was referred for multidisciplinary feeding evaluation, including speech pathology evaluation and therapy. The speech-language pathology evaluation and therapy here is not for speech or language delay; it is to determine whether a child cannot or will not eat and working with the team to identify and carryout appropriate interventions (Gosa et al). 

Thus, the proposed speech therapy is medically necessary.

The enclosed medical policy for speech pathology and therapy does not have a specific criteria for pediatric feeding disorder or feeding difficulties. Current literature and clinical guidelines recommend that multidisciplinary intervention should involve, at a minimum, a professional team that includes psychology, medicine, nutrition, and speech-language pathology/occupational therapy (Sharp et al; Gosa et al).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Esophagitis

Treatment: esophagogastroduodenoscopy (EGD) - scope test services (Procedure code 43239)

The insurer denied coverage for esophagogastroduodenoscopy (EGD) - scope test services (Procedure code 43239).

The denial is overturned.

This patient was complaining of severe gastroesophageal reflux disease and heartburn with vomiting and pain radiating into her back.  The documentation indicated she has had some increase in reflux and was utilizing omeprazole without relief.  She has also started utilizing famotidine with some relief.  She had an ultrasound which was unremarkable and was given a prescription for hepatobiliary iminodiacetic acid (HIDA) scan.  However, she has not had it done due to fear of presenting to the hospital.  She complained of feeling severe pressure to the chest and has had a negative electrocardiogram (EKG).  Upon physical exam there was tenderness in the epigastric area.  The physician indicated given the complaints of severe pain it was recommended she present to the emergency department; however, the patient refused the emergency department visit.  She was also recommended to undergo an esophagogastroduodenoscopy (EGD).  The documentation indicated she underwent an EGD revealing esophagitis to the middle third of the esophagus.  Biopsies were taken.  There was inflammation at the gastric antrum.

EGD is an appropriate test in this patient.  She has had long standing symptoms of intermittent chest pain and acid reflux.  She has used omeprazole and famotidine with no significant improvement.  In addition, her pain is significant enough to warrant a recommendation to go to the emergency room.  The most appropriate step in this clinical scenario is an esophagogastroduodenoscopy.  There's no benefit in continuing to treat with acid suppression with such severity of symptoms despite having not responded to them before.

The insurer's denial of coverage for esophagogastroduodenoscopy (EGD) - scope test services (Procedure code 43239) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, vomiting, and abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

This male patient, with a history including polysubstance abuse disorder, presented to the emergency department with nausea, vomiting, and abdominal pain.  He was admitted for detox.  

The patient's vital signs were as follows: temperature 98.6, pulse 117, respiratory rate 20, blood pressure 162/110, and oxygen saturation 95%. His Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA) score was 15.  The patient's exam was remarkable for mild tremors.  Labs revealed the following: complete blood count (CBC) and basic metabolic panel (BMP) was unremarkable.  The patient's electrocardiogram showed new onset atrial fibrillation with no ischemic changes.  He was given Ativan and Tygan in the emergency department.  

The patient was admitted for alcohol withdrawal.  Cardiology was consulted.  Day two, vital signs were stable.  The patient's Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale score was seven.  Cardiology recommended echocardiogram and medications - Toprol for atrial fibrillation.  The patient was to continue the Ativan taper.  Day three, the patient's Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale score was seven. The patient signed out against medical advice (AMA).

No, the proposed inpatient hospital admission was not medically necessary.
This patient, with a history of alcohol abuse, was admitted for alcohol withdrawal.  He was not acutely intoxicated.  The patient was hemodynamically stable and afebrile.  He had tachycardia with new onset atrial fibrillation.  He was noted to have mild tremors but did not have findings of severe alcohol withdrawal.   The patient was admitted with plan for Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol.  During his hospital stay, he did not have findings of severe alcohol withdrawal.  He was being managed with oral medication assisted treatment as well as medications for control of heartrate.  He did not have symptoms that required an acute inpatient level of care and he had not failed a lesser level of care.

Yes, the health plan acted reasonably with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Allergy

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient is a male who presented to the hospital emergency department (ED) late in the evening with an apparent food allergic reaction. He has a history of EoE [eosinophilic esophagitis), asthma, eczema and food allergies. He claims he ingested a cashew containing desert and felt throat closing and dysphagia. He claimed vomiting enroute to the ED. Initially, he was treated with antihistamines and steroids and later developed skin redness of face/arms and felt funny/nauseous/SOB [shortness of breath]. He was then placed on a cardiac monitor, given oxygen, epinephrine, more steroids, Zofran, Duonebs, more Benadryl and Tylenol. He responded to this treatment.  Eventually, he was seen by ENT [ear, nose and throat] who did not find any airway compromise. He was discharged.  The discharge summary stated that the patient was ready for discharge. There is no documentation of stridor, wheezing, hoarseness, hypotension or angioedema/urticaria at any point during the hospital encounter.

This patient responded to care that is consistent with observation treatment. He was stable within an 8-hour period of care at the hospital and was deemed ready for discharge approximately 12 hours after presenting to the ED. 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 admission is upheld. Medical Necessity is not substantiated.