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

Diagnosis: History of severe arthritis, chronic low back pain secondary multilevel lumbar disc herniations, Ulcerative Colitis, COPD (chronic obstructive pulmonary disease), Hypertension and Vertigo.
Treatment: Consumer Directed Personal Care Assistance services, 4 hours per day, 7 days per week - a total of 28 hours per week.
The insurer denied the Consumer Directed Personal Care Assistance services, 4 hours per day, 7 days per week - a total of 28 hours per week.
The denial is overturned. 

The patient is a male with a history of severe arthritis, chronic low back pain secondary multilevel lumbar disc herniations, Ulcerative Colitis, COPD (chronic obstructive pulmonary disease), Hypertension and Vertigo. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of 28 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the proposed service of 28 hours/week Personal Assistance Services is deemed medically necessary to offer increased ADL (activities of daily living) support. 

This is a male with a history of severe arthritis, chronic low back pain secondary multilevel lumbar disc herniations, Ulcerative Colitis, COPD (chronic obstructive pulmonary disease), Hypertension and Vertigo. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). Recent documentation of the patient's current functionality and ability to perform ADLs (activities of daily living) was noted in correspondence from the patient's medical provider. The correspondence indicates that the currently approved plan of Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 28 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral hip pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with progressive bilateral hip pain.  A little over a year ago, he underwent a right total hip replacement. His past medical history was significant for morbid obesity (BMI [body mass index] 45), hypertension, diabetes and obstructive sleep apnea (ASA [American Society of Anesthesiologists score] 3). 

The patient underwent an elective left total hip replacement earlier this year. He received spinal and epidural block. His second session of PT (physical therapy) the following day  noted he was able to ambulate 100 feet. He was cleared for discharge. 

No, the Inpatient admission was not medically necessary. 

The records show the man had a non-complicated post-surgical course. There were no problems with his wound. He was able to tolerate oral pain medication. His vital signs were stable. He was able to ambulate 100 feet the day after surgery. He did not have evidence of "fever, infection nor bleeding." The progress report of cited, "eager to discharge home today." 

The patient did not require treatment or additional testing for underlying medical problems. There were no conditions to warrant the admission and level of service provided. The records do not show any delay secondary to his morbid obesity. 

Therefore, given the above, the Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal class II, retruded mandible, maxillary spacing and mandibular crowding excessive overjet, and deep impinging overbite).
Treatment: D8080 braces and D8670 monthly visit x 12.

The insurer denied coverage for the preservice request for D8080 braces and D8670 monthly visit x 12. The denial is upheld. 

This patient is a male child who presented for evaluation for Orthodontic care. The Orthodontist recommended comprehensive orthodontics due to skeletal class II, retruded mandible, maxillary spacing and mandibular crowding excessive overjet, and deep impinging overbite. The Orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index. 

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, the HLD index is utilized. This index provides 6 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 not met as there is no evidence of soft tissue damage, and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.  This reviewer concurs with the HLD index of the insurer attaining 20 points (7 points overjet, 6 points overbite, 5 points anterior crowding and 2 points labiolingual spread).
 
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.

Peer reviewed articles conclude that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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

The preservice request for D8080 braces and D8670 monthly visits x 12 is not considered medically necessary for this patient.

The carrier's denial of coverage for the preservice request for D8080 braces and D8670 monthly visit x 12 is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer Screening
Treatment: Code 76641- ultrasound of the breast; complete study

The insurer denied coverage for code 76641- ultrasound of the breast; complete study.  The denial is upheld. 

This is a female patient with a history of multiple cysts on a prior breast ultrasound study. The patient underwent a screening mammogram with tomosynthesis. The results showed breasts with scattered fibro-glandular densities and bilateral partially circumscribed nodules seen including the central right breast, central left breast and outer left breast with no overall change from multiple prior studies, no suspicious mass or clustered micro-calcification seen and new finding. The impression stated that there was no evidence of malignancy, stable benign nodularity with recommended follow-up mammogram in one year. 
As per the patient's medical record, this patient had a normal mammogram tomosynthesis. The patient has no personal or familial history of breast cancer. The addition of digital breast tomosynthesis increases cancer detection rates and may increase the positive predictive value of the screening exam. The breast ultrasound is not typically used in the routine screening for breast cancer. Although whole breast ultrasound screening may detect additional early-stage breast cancers that are mammographically occult, particularly in women with dense breast tissue, the additional screening test carries a substantial risk for false-positive results leading to patient anxiety, breast biopsies with benign results, and follow-up imaging. As per Lee et al. (2019), the study indicates that women who underwent both studies compared with those who underwent mammography alone had similar cancer detections rates (5.4 versus 5.5 per 1000) and similar interval cancer rates (1.5 versus 1.9 per 1000) but higher false-positive biopsy rates (52 versus 22 per 1000). 

As per literature review, a breast ultrasound is indicated for the evaluation of an abnormal finding observed on mammography. Ultrasound can determine whether the lesion is a simple cyst or skin lesion requiring no intervention or a suspected malignancy needing a biopsy. This patient's mammogram did not show any abnormal lesion requiring biopsy. No further studies were requested by the reading radiologist. As such, the requested breast ultrasound was not medically necessary for this patient.

The coverage for code 76641- ultrasound of the breast; complete study is not considered medically necessary for this patient. 

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

Based on the above, the medical necessity for code 76641- ultrasound of the breast; complete study is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated creatinine level and back pain
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld. 

This is a female patient who was admitted to the hospital for worsening back pain. In the Emergency Department (ED), the patient's vitals were: temperature 98.4, blood pressure 156/93, pulse 84, respiratory rate 16, and oxygen saturation 98%. The patient was noted to have possible pneumonia on lung imaging and she was treated with antibiotics. The patient's laboratory results revealed an elevated creatinine level of 2.31 and she was started on intravenous (IV) fluids. The patient left the facility against medical advice (AMA) on day 3 of admission.

Although the patient had an abnormal creatinine level, there was no documentation of significant change from the patient's baseline, she did not have severe electrolytes abnormality and she did not require renal replacement therapy. The patient's Computed Tomography (CT) scan of the abdomen/pelvis showed normal morphology kidneys with no evidence of hydroureteronephrosis, renal or ureteral calculi. The patient had degenerative disc disease and spondylotic changes. In addition, the patient was hemodynamically stable, with normal oxygenation, and did not have cardiac arrhythmias. On examination, the patient did not have altered mental status or persistent nausea and vomiting with dehydration. There is no documentation of refractory pain, and the patient was able to tolerate oral diet and did not need total parenteral nutrition (TPN). The patient's condition was stabilized within 48 hours with IV fluid and antibiotics. As per literature review, there is no evidence-based clinical finding to support the inpatient level of care. The patient's condition could have been safely treated at a lower level of care, such as in the ED and/or Observation. Thus, the inpatient admission was not medically necessary for this patient.

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

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Surgical Services. 
The insurer denied: MAZE Procedure. 
The health plan's denial is upheld.

The patient is a male with history of atrial fibrillation, hypertension, and atrial fibrillation ablations. He was also treated with antiarrhythmic medications, including Multaq and flecainide, which were ineffective. He was also treated with Tikosyn for years after the last ablation. For further treatment he underwent a minimally invasive Maze procedure which is under review. The subject is whether the Maze procedure is likely to be more beneficial than any standard treatment or treatments for the patient's condition.

The health plan's determination is upheld.

The treatment of atrial fibrillation initially generally includes medical therapy including rate lowering medications and antiarrhythmics. For those with refractory symptoms more invasive treatments are warranted. These include cardioversions, and various types of ablations, including percutaneous and surgical. The Maze procedure is a minimally invasive fluoroscopic treatment for atrial fibrillation ablation. It is generally reserved for those with ongoing symptomatic or unstable atrial fibrillation despite more non-invasive treatments. In this case this individual underwent multiple cardioversions, antiarrhythmic medications, and ablations. There was report that he was on Tikosyn for many years after his ablations. There is no report that on this medication he was experiencing symptomatic or clinically unstable atrial fibrillation. In this setting more invasive treatments, including the Maze, has not been established as standard of care, compared to for example ongoing medical therapy (Tikosyn), towards improved atrial fibrillation outcomes. It is therefore considered not to be more beneficial for this patient than standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Surgical Services. 
The insurer denied: MAZE Procedure.
The health plan's denial is upheld.

The patient is a male with a history of atrial fibrillation and two percutaneous endovascular atrial fibrillation ablation procedures. The patient had also been treated with Tikosyn and had had multiple cardioversions. The patient was referred for operative Maze procedure to treat the atrial fibrillation. Echocardiogram showed left ventricular (LV) ejection fraction (EF) of 40%.

The patient was taken to the operating room and underwent general anesthesia. The patient had transesophageal echocardiogram which showed no evidence of thrombus in the left atrial appendage. After chest incision, endoscopic guidance was used to ablate areas of the left atrium, particularly the posterior wall, isolate of the pulmonary veins by ablation, and occlude the left atrial appendage occlusion.
The subject under review is whether the Maze procedure is likely to be more beneficial than any standard treatment for this patient's condition.

The health plan's determination is upheld.

No. Based on the current documentation it cannot be stated that the Maze procedure is likely to be more beneficial than other treatments for atrial fibrillation. What has been stated is that patient has had two percutaneous radiofrequency ablations and multiple cardioversions to maintain sinus rhythm. Thus, it is likely that the treating provider feels that a more invasive approach to treatment, namely the Maze procedure, is necessary to maintain sinus rhythm. In this case, the Maze procedure would be reasonable as described in current American Heart Association (AHA) American College of Cardiology (ACC) guidelines for an individual patient as follows:

"Class IIb

1. A stand-alone atrial fibrillation (AF) surgical ablation procedure may be reasonable for selected patients with highly symptomatic AF not well managed with other approaches (168). (Level of Evidence: B)" (January)

That being said, there is not adequate justification in the provided documentation to state that this particular patient is suitable as described in the recommendation. The procedure performed is occasionally deemed necessary/appropriate if percutaneous intervention is considered to be ineffective. Without documentation from the electrophysiologist stating another percutaneous intervention is not recommended and that surgical intervention is required, it cannot be stated that the Maze procedure is likely to be more beneficial for this patient than any standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Surgical Services. 
The insurer denied: MAZE Procedure. 
The health plan's denial is overturned.

The patient is a male with atrial fibrillation who had failed multiple cardioversions, anti-arrhythmic therapy and 3 prior endocardial ablation procedures. It was decided to pursue a convergent MAZE procedure with concomitant left atrial appendage occlusion (LAAO) via a subxiphoid approach. This was successful. The subject under review is whether this procedure is likely to be more beneficial than standard treatment for this patient's condition.

The health plan's determination is overturned.

Yes, the convergent MAZE is likely to be more successful than prior therapies that have failed. Based on the information provided, this was a standalone convergent procedure with LAAO in a patient with symptomatic, treatment refractory, longstanding persistent atrial fibrillation. While it could be argued that a hybrid approach may have been even better, the treatment provided is likely to be of greater benefit than any of the prior therapies that had failed, and it is likely to be safer than a traditional surgical approach with cardiopulmonary bypass.

Studies have been performed demonstrating efficacy and safety in a particularly challenging subset of patients with limited options.
Appeal type: Medical necessity
Decision: Upheld

Infectious Disease: Bacterial Infection
Inpatient hospital

The patient is a male with a past medical history significant for hypertension, diabetes mellitus (DM) and obesity who presented with complaints of fever and chills that had been present for roughly three days prior to presentation. Associated symptoms included some nausea and decreased by mouth (PO) intake as well as flank pain. His discomfort of flank pain was described as similar pain he had experienced before, and he attributed it to a slipped disc that causes occasional pain. Upon arrival in the emergency department, he was found to be tachycardic with a pulse of 117, febrile with a temperature of 38.9C / 102.02 F, normal respiratory rate of 112 and a stable blood pressure at 126/70. No physical abnormalities were present on the admitting team's history and physical. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The two-midnight rule that is widely known and accepted states that inpatient admissions are appropriate when the treating physician expects the patient to require a stay that crosses two midnights and admits the patient based on that expectation. There is no documentation to support that the admitting provider felt this patient was going to require a two midnight stay. The documentation supported that the patient was already improving at time of admission and discussions were in place on whether or not the patient could be discharged later on that same day. Given the lack of clinical documentation supporting the two-midnight rule and early talks of discharge with "disposition pending improvement", the inpatient stay was not medically necessary. Throughout treatment this patient was stable and in no acute distress. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep vein thrombosis (DVT)   

Treatment: Acute inpatient stay

The insurer denied coverage for acute inpatient stay.  The denial is upheld. 

This patient is a female who presented to the Emergency Department with complaints of leg pain.  She had an acute foot injury and was noted to have undergone a prior procedure with immobilization.  Documentation indicated that the patient underwent an ultrasound showing a deep vein thrombosis (DVT) and she had been referred for anticoagulation.  The physical examination revealed a pulse of 70 beats per minute (bpm) with a temperature of 97.4.  Her blood pressure was 128/64 and her oxygen saturation was 100%.  It was recommended that the patient undergo laboratory diagnostic studies.  The patient did have an elevated white blood cell count at 11.2.  Her chest x-ray was normal.  It was recommended that the patient be admitted for management related to the lower extremity DVT.  

It was recommended that the patient receive Lovenox.  She also underwent additional imaging to include a CT angiogram of the chest which showed a left lower lobe pulmonary embolism (PE).  She continued to have complaints of a headache and a CT scan of the head was performed.  The CT scan of the head was normal.  The patient did continue with treatment to include immobilization.  It was noted that she was improving and was recommended to continue with full dose anticoagulation.  She was recommended to undergo an echocardiogram to assess her ejection fraction as well. She had not had any further significant adverse events.  An echocardiogram was performed the prior day showing an ejection fraction at approximately 55%.  There was a lack of further acute adverse events and she was discharged.

This reviewer agrees with the denial of coverage for the inpatient stay. The patient in this case was hemodynamically stable, her oxygen saturation was 100% and she was not at high risk for bleeding from anticoagulation.  She had no other extenuating medical conditions; therefore, she was a low risk patient.

The best way to categorize whether these patients can be treated safely is the pulmonary embolism severity index (PESI).  According to this scale, this patient had no risk factors and her effective score was zero.  Thus, she could easily be treated as an outpatient with adequate anticoagulation.

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. 

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

This is the case of a male with history of anxiety, depression, attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and recent inpatient behavioral health admission who presented to the emergency department (ED) after altercation at school. He reported non-compliance with his medications with resulting agitated and disruptive behaviors.
ED vitals were temperature (T) 37.5C, heart rate (HR) 87, respiratory rate (RR) 18, blood pressure (BP) 102/64, and oxygen (O2) saturation was 98% on room air. Per ED documentation by both the nurse and nurse practitioner (NP), the patient denies suicidal ideation (SI) or homicidal ideation (HI) or command hallucinations. Physical examination and electrocardiogram (EKG) were normal. Labs included complete blood count (CBC) and basic metabolic panel (BMP), and urinalysis which were unremarkable. Urine toxicology screen was positive for Cannabinoids.
The patient was admitted to the inpatient unit with a 1:1 sitter. Home medications of Tenex and Zoloft were continued, along with Haldol as needed. He was able to be discharged home the following day with outpatient follow-up.

The health plan's determination is upheld.

Per the medical records provided, this patient with a significant psychiatric history and recent inpatient hospitalization, was brought to the ED after an altercation at school. He had reportedly been non-compliant with prescribed medications and outpatient therapy since his discharge. In the ED as well as the psych consult notes it was documented that the patient had no SI, HI, or hallucinations. His vital signs and laboratory evaluations were normal except for cannabis. EKG and monitoring were normal. The patient was admitted as mother refused to take him home until he was back on his medications. There was no other documented justification for inpatient hospitalization, versus lower level of care.