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

Diagnosis: Chest pain, Tachycardia 
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission. 
The denial is upheld. 
This is a male patient with medical history notable for L4-5 herniated disc, status post lumbar decompression, low back pain and tachycardia. The patient presented to the Emergency Department (ED) with complaints of chest pain, chest heaviness and back pain radiating to the chest. The patient's symptoms had been present for several hours prior to ED arrival. In the ED, the patient's troponin was negative. The patient's electrocardiogram (EKG) revealed sinus rhythm with abnormal R-wave progression. The patient was administered aspirin, nitroglycerin, Tylenol, and ibuprofen. The patient was admitted for pleuritic chest pain and persistent tachycardia, pain management and to rule out pulmonary embolism. The patient's repeat EKG showed sinus rhythm with abnormal R-wave progress and minimal ST depression. The patient's transthoracic echocardiogram showed a left ventricular ejection fraction of 56% to 60% and mild mitral valve regurgitation. A V/Q scan did not find pulmonary embolus. After treatment, the patient was cleared for discharge to home with follow-up.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient presented with atypical chest pain. The patient's initial evaluation in the Emergency Room (ER) was unremarkable, including non-diagnostic electrocardiogram (EKG) and cardiac biomarkers. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted, however inpatient admission criteria was not met. There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. The patient could have been safely monitored and treated at the observational level of status.

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 the inpatient admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Aortic stenosis
Treatment: 33361 - Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach

The health plan should not cover the 33361 - transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach.

The patient is a male with a history of CAD (coronary artery disease), carotid disease, dyslipidemia and HTN (hypertension). He was evaluated for aortic stenosis. The patient had a history of a syncopal episode, for which he was treated with hydration, as well as dyspnea. 

He underwent a cardiac catheterization, which revealed two-vessel disease and aortic valve peak gradient of 12 mm Hg. His EF (ejection fraction) was preserved at 65% based on transthoracic echo. The valve area was reported at 1.1 cm2. The patient also had a TEE (transesophageal echo), with reported moderate to severe AS (aortic stenosis) with no gradients or planimetry measurement reported.  The patient underwent a TAVR (transcatheter aortic valve replacement) with placement of a Sapinen valve. Post-procedure peak gradient was 12 mm Hg. The patient was discharged home with a plan for outpatient follow-up.

There is no evidence that the 33361 - transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach is likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease.

The patient is a male with reported aortic stenosis. His peak to peak aortic gradient on invasive hemodynamic assessment was 12 mm Hg in the setting of normal LV (left ventricle) systolic function, which is not consistent with severe aortic stenosis. The TEE data did not report the valve area or aortic valve gradients. The provider writing the report did not report findings supporting the diagnosis of severe aortic stenosis.  The peak gradient of 12 mm Hg measured in the cath lab, in a patient with a normal EF, is not consistent with severe aortic stenosis.  The findings of the TEE do not document anything to support the diagnosis either.  Therefore, the data does not support the diagnosis of severe aortic stenosis, and therefore there is no evidence that the requested health service or procedure is likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Aortic stenosis
Treatment: 33361 - Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach
The insurer denied the 33361 - Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach.
The denial is upheld.


The health plan should cover the 33361 - transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach.

The patient is a male. He has severe symptomatic aortic stenosis with low gradient. The patient's echocardiogram demonstrates severe aortic stenosis.

The patient has severe symptomatic aortic stenosis with low gradient, which would be an indication for aortic valve replacement. The echocardiogram demonstrates severe aortic stenosis, and his admission due to syncope would warrant treatment of his valve immediately.

The 33361 - transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach is likely to be more beneficial.

TAVR in low and intermediate risk patients has a lower one-year mortality than surgical aortic valve replacement. The morbidity is also lower than surgical aortic valve replacement.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD/asthma Exacerbation

Treatment: inpatient admission

The insurer denied coverage for the inpatient admission. The denial is upheld. 

This patient is a male with history of nonalcoholic steatohepatitis, morbid obesity, gastroesophageal reflux disease, hypertension, osteoarthritis, asthma/chronic obstructive pulmonary disease (COPD) who presented to the Emergency Department (ED) with complaint of wheezing. The patient had recent hospitalizations for same conditions. At presentation to the ED, the patient's vitals showed: temperature 98, blood pressure 160/90, respiratory rate 20, heart rate 84, and oxygen saturation 97%. On exam, the patient was in no acute distress, speaking full sentences; lung exam revealed bilateral rhonchi; cardiovascular system was unremarkable. The patient was noted to be alert and oriented with peak expiratory flow (PEF) of 170 (baseline not known). The patient's white blood cell (WBC) count was 10.4 K, electrolytes were within normal limits, and the patient's influenza screen was negative. The patient's chest x-rays revealed no acute infiltrates. The patient was treated with intravenous (IV) steroids, bronchodilators and magnesium. 

The patient was admitted to hospital for COPD/asthma Exacerbation. As per admitting H&P note, the patient's vital signs were: temperature 97.3 F heart rate 97 respiratory rate 20 blood pressure 156/84 mm Hg. The patient was in not in acute distress, and the patient's lung exam revealed bilateral rhonchi. The patient's arterial blood gas (ABG) showed pH 7.40, pCO2 49, pO2 82, base excess 30, oxygen saturation of 95%. As per Pulmonology consult and evaluation, the recommendation was to taper steroids, add inhaled corticosteroid, and continue with bronchodilators for the patient's care. 

Based on the review of the medical record, the patient remained afebrile and hemodynamically stable after admission. The patient was awake and alert, tolerating oral intake and maintaining acceptable oxygen saturations. Based on literature review, the patient did not need acute inpatient hospitalization. The patient could have been placed in observation status while diagnostic testing and treatment were initiated. The patient was stable for discharge on oral steroids, bronchodilators and inhaled corticosteroids and his other maintenance medications with close follow up in outpatient setting after a period in observation status. Thus, inpatient admission was not medically necessary for this patient.

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

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

Diagnosis:  Maxillary Crowding and Mandibular Crowding, and Anterior Crossbite with Gingival attachment loss  

Treatment: Braces (comprehensive orthodontic treatment)  

The insurer denied braces (comprehensive orthodontic treatment).  The denial was reversed.  

This is a female patient who consulted an orthodontist for orthodontic treatment.  An evaluation was performed that included lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images.  An HLD index was performed that revealed crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  Orthodontic treatment was recommended.  

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.  Each of these peer reviewed articles concludes 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.  

It is evident that the patient exhibits a significant 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 claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care.  In this case, the clinical circumstance does meet insurer and plan criteria to justify 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 braces (comprehensive orthodontic treatment) is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope, Facial trauma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

This is a female patient with a past medical history of hypertension and hyperlipidemia.  The patient was brought to the Emergency Department (ED) by the Emergency Medical Services (EMS) following a fall. The patient's National Institutes of Health Stroke Scale (NIHSS) score was 2. The patient did not recall the fall. The patient did not recall symptoms prior to the fall. The patient's speech was mildly dysarthric. There was left facial asymmetry. The patient's face and lip were significantly swollen and there was periorbital ecchymosis. There were no drifts or focal limb weakness. There were deficits to light touch bilaterally. The patient had difficulty performing heel-to-shin testing due to uncomfortable positioning. The patient's vital signs revealed a blood pressure of 180/100, and a respiratory rate of 24. 

The patient's electrocardiogram (EKG) revealed bradycardia. The patient's maxillofacial computed tomography (CT) scan revealed a small left periorbital edema, hematoma, and small hematoma in the left cheek with surrounding edema and mild paranasal sinus inflammation. The patient's magnetic resonance imaging (MRI) of the brain revealed mild microvascular ischemic disease. The patient was admitted for diagnosis of syncope, stabilized and discharged.

Based on the review of the medical record and literature, the admission was medically necessary. This patient had syncope with focal neurological signs including facial droop/asymmetry and mild dysarthria. This would be considered a high-risk stratification. Thus, inpatient admission was medically necessary for this patient.

The carrier's denial of coverage for inpatient admission should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  COPD; Cardiovascular disease; Hypertension.
Treatment:  Personal Care Assistance (PCA) Services.

The insurer denied the Personal Care Assistance (PCA) Services.  The denial is overturned. 

The patient is an male.  He has a history of severe COPD (chronic obstructive pulmonary disease), dependent on supplemental home oxygen, cardiovascular disease and hypertension.  Due to impairments related to these conditions, he requires assistance for completion of some of his activities of daily living (ADLs).  An appeal review was requested for potential approval of Personal Assistance Services to offer increased ADL support.

This is a male with a history of severe COPD, dependent on supplemental home oxygen, cardiovascular disease and hypertension.  Due to impairments related to these conditions, he requires assistance for completion of some of his activities of daily living (ADLs).  Documentation from the patient's provider confirms that, due to the patient's severe COPD and numerous comorbidities, he requires assistance for completion of some of his activities of daily living.  Hence, the recent denial of Personal Assistance Services is not appropriate and not sufficient to meet the patient's current needs.  For these reasons, the proposed treatment Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea (OSA)

Treatment: CPT code E0486 Obstructive Sleep Apnea (OSA) oral appliance

The insurer denied coverage for CPT code E0486 Obstructive Sleep Apnea (OSA) oral appliance.

The denial is overturned.

Based on the review of the medical record, this was a female patient who was diagnosed with obstructive sleep apnea (OSA) based on a polysomnography (PSG) sleep study. The patient wished to have her OSA treated by Oral Appliance Therapy using a custom-fitted Mandibular Advancement Device.   

Obstructive Sleep Apnea (OSA) is a common sleep disorder affecting millions of Americans. Symptoms include excessive daytime sleepiness, nonrestorative sleep, morning headaches, fatigue and lack of energy. Untreated sleep apnea can lead to motor vehicle accidents, hypertension, cardiovascular and neurological events. Treatment of OSA includes weight loss when appropriate, PAP devices, and oral appliance therapy. Patients with mild OSA are often intolerant of PAP and are commonly and effectively managed with oral appliance therapy.

The usual metric for sleep apnea severity is the Apnea-Hypopnea Index (AHI). This metric represents the sum of both Apnea Events and Hypopnea events. The definition of Apnea events is straightforward; it is an event is defined as cessation of breathing for 10 seconds or more. The definition of a "hypopnea" is somewhat looser, including a change in airflow with either sleep arousal or oxygen desaturation; the latter may be scored with a 3% or 4% criterion. There are additional respiratory events that may be scored on a sleep study which may not be recognized the AHI metric. These include RERA events-respiratory effort related arousals. These events reflect the increased respiratory effort of breathing through a narrow but open upper airway, without oxygen desaturation but with sleep disruption. The American Academy of Sleep Medicine (AASM) guidelines in it's 2017 position paper recommends including these events in sleep apnea severity scoring.

Based on the review of the medical record and literature, the patient has been correctly identified as having mild sleep apnea. In addition, applying a 3% metric, the hypopnea scoring criteria may bring the AHI in the OSA range. Thus, oral appliance therapy would be medically appropriate for this patient.

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

Based on the above, the medical necessity for CPT code E0486 Obstructive Sleep Apnea (OSA) oral appliance is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer /Prostate cancer
Treatment: Radiation therapy
The insurer denied of Proton beam radiation therapy
The denial is upheld in whole

This patient with a rise in prostate-specific antigen (PSA) to 7.25 Nanograms per milliliter, (NG/ML). The patient  has a past medical history of hypertension. The patient  had prostate biopsies that revealed a Gleason 6 adenocarcinoma. The patient  was staged with no evidence of regional nor distant metastases. Radiation therapy was recommended as definitive treatment and proton beam approach is requested.
No, the requested treatment of proton beam radiation therapy is not considered medically necessary for this patient.
The use of Proton Beam radiation therapy as definitive treatment for prostate cancer has medical literature with relatively short follow up with proton beam therapy as monotherapy for prostate malignancies. These studies show equivalent control rates to other types of radiation therapy for the shorter follow up periods. There are also retrospective studies with large numbers of patient that have shown worse gastrointestinal (GI) side effects as compared to photon beam radiation therapy with intensity modulated radiation therapy (IMRT).
There is a lack of randomized studies regarding proton beam radiation therapy alone as treatment for prostate cancer that shows equivalent outcome or any improvement over other forms of radiation therapy such as photon IMRT. Until the current randomized trials ongoing are published in peer reviewed medical literature, this treatment for prostate cancer is considered investigational and not a standard of care treatment option.
Therefore, the Proton beam radiation therapy is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Leg Swelling and tachypnea
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female.  At the time of admission to the hospital, she had a past medical history significant for gastroesophageal reflux disease (GERD), varicose veins, and arthritis.  The patient presented with worsening leg swelling and tachypnea. 

The patient was hemodynamically stable. Electrocardiogram (ECG) revealed normal sinus rhythm with left axis deviation. Labs were significant for mildly elevated troponin. She was admitted for suspected non-ST segment elevation myocardial infarction (NSTEMI). The chest x-ray revealed mild pulmonary vascular congestion. Computed tomography (CT) angiogram of the chest was performed in the ER(emergency room) and was negative for pulmonary embolism. Repeat troponin was also mildly elevated. The patient was seen in consultation by Cardiology. Echocardiogram was obtained to assess wall motion, and the patient was found to have normal systolic function.  Lower extremity Doppler scan was negative for deep vein thrombosis (DVT). The patient was discharged home with a plan for outpatient follow-up.

Yes, the proposed treatment was medically necessary.

The patient presented for evaluation of edema and tachypnea and was found to have elevated serum troponin level. She was admitted to inpatient level of care for suspected acute coronary syndrome (ACS). The ECG was unrevealing for ACS but was abnormal. Appropriate work-up was performed. The patient's troponin trended down, and the patient was stable clinically, and thus the decision was made to discharge the patient. Given this presentation, suspicion for an acute coronary syndrome in the setting of elevated cardiac enzymes/troponins, it would be consistent with the current standard of care that this patient be managed in an inpatient setting, rather than ER observation unit, and therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System
Inpatient Hospital

Diagnosis: ruptured arteriovenous malformations 
Treatment: acute inpatient rehab hospital stay 
The insurer denied the acute inpatient rehab hospital stay. The health plan's determination is overturned.

The patient is a male who was admitted to acute inpatient rehabilitation due to left sided hemiparesis. He has a complicated past medical history. He had a ruptured arteriovenous malformations (AVM) and underwent clipping. Subsequently, the AVM ruptured again and required partial embolization. He presented for venous approach intervention of AVM. Following completion of the procedure, it was noted that the patient had new left-sided hemiparesis. Under review is the Acute Inpatient Rehab Hospital Stay.

The acute inpatient rehab hospital stay is medically necessary and appropriate for this patient. He continues to require multiple therapy disciplines, he was participating in 3 hours of therapy, 5x/week, he was progressing yet not at a level of independence to be discharged and he continued to require physician oversight secondary medical complexity of aneurysm repair.

Physical therapy weekly progress note stated that patient had met goal of supine to sit with head of bed (HOB) flat and without bedrails with close supervision. He had required contact guard assist (CGA) for sit to stand. He required CGA for bed to wheelchair transfers. He "ambulates 50 feet with no AD, (+) ankle-foot orthosis (AFO) donned to left lower extremity (LLE) and Mod A (moderate assistance) for balance and proximal trunk stability." He was also ambulating 4 steps with MINA (minimal assistance) and use of unilateral handrail (noted that patient had 4 steps to enter his building and then elevator to home).
At this time, the patient was progressing in all his goals, participating in at least 3 hours of therapy/day, 5 days/week, and was still not at a safe level for discharge. Therapy, appropriately, continued. Team interdisciplinary conference noted that patient was able to transfer CS/CGA with use of quad cane. Gait improved with comment that "Patient ambulates 100 feet with a small base quad cane (SBQC) + AFO donned on LLE and MinA to CGA" and then decreased assistance to CGA and increased distance to 150'. Transfers also improved to close supervision. He was fitted for a custom AFO which allowed him to ambulate with MODI (modified independent). Family training was appropriately completed and services stopped.