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

Diagnosis: Oligodontia

Treatment: Implant placement (tooth numbers 2, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 3, 30, 31, 4, 5, 6, 7, 8 and 9) (code D6010 - surgical placement of implant body; endosteal implant)

The insurer denied coverage for implant placement (tooth numbers 2, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 3, 30, 31, 4, 5, 6, 7, 8 and 9) (code D6010 - surgical placement of implant body; endosteal implant).

The denial is upheld.

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants in areas as enumerated above.  The dentist is requesting implants over removable partial dentures presumably due to patients reported dysphagia and nausea. The insurer has denied the services stating that in their estimation endosteal implants are not the only appropriate treatment, and implant services are only covered when there is a documented medical condition that will be alleviated by the implants.  The insurer states that the medical records received do not demonstrate such a condition and therefore the endosteal implants and related services are considered not medically necessary, considered elective and therefore no benefit is available.  

Upon review of the objective documentation which primarily consists of panoramic radiograph, the patient exhibits an edentulous maxilla and oligodontia in the mandible. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include conventional removable dentures. Further the documentation provided does not support, justify, or substantiate the requested treatment.  Therefore, as removable dentures (full and partial removable) remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary.

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

Implant placement teeth:  #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13
#14, #15, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and 31 (code D6010 - surgical placement of implant body; endosteal implant) is not considered medically necessary for this patient.

The insurer's denial of coverage for implant placement (tooth numbers 2, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 3, 30, 31, 4, 5, 6, 7, 8 and 9) (code D6010 - surgical placement of implant body; endosteal implant) is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Digestive System
Pharmacy/Prescription Drugs

Diagnosis: GERD
Treatment: Carafate Suspension
The insurer denied the Carafate suspension. The health plan's determination is upheld. 

The patient is a female with gastroesophageal reflux disease (GERD). She is taking pantoprazole 40 milligrams (mg) twice daily and famotidine 40 mg twice daily, with persistent heartburn and reflux. Coverage is being requested for Carafate (sucralfate) suspension 1 g (gram) four times daily for the treatment of gastroesophageal reflux disease (GERD).

There is no documentation that the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects in this case.
The American College of Gastroenterology guidelines for the treatment of gastroesophageal reflux disease (GERD) recommend sucralfate for the treatment of GERD only in pregnancy. Additionally, the provided information does not substantiate clinical circumstances supporting an exception to the formulary, to use Carafate suspension rather than the formulary medication (sucralfate tablets). There is a lack of evidence to demonstrate that sucralfate suspension is safer or more effective than sucralfate tablets.
Per the Prescriber's Digital Reference, the sucralfate tablet is scored and may be cut into two pieces for ease of administration. Additionally, the reference states that the tablets can be made into the solution form "prepared just prior to administration by slowly dissolving a 1 gram tablet in 10 mL (milliliters) of distilled water, allowing to stand for 15 to 20 minutes"; this solution is then stable at room temperature for up to two weeks.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low hemoglobin, weakness, dizziness, intermittent
chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

This is a female who was sent to the emergency room by Hematology due to a hemoglobin of 4.4.  The patient reported weakness, dyspnea on exertion, intermittent chest pain, dizziness, fatigue, and abdominal pain.  The patient also had black tarry stools.  The patient was admitted and treated with intravenous one liter normal saline (NS) bolus, pantoprazole 80 milligrams (mg) intravenously, and four units of packed red blood cells (pRBCs). The patient was kept nothing by mouth (NPO).  The patient also received intravenous Ferrlecit.  Esophagogastroduodenoscopy (EGD) was positive for Los Angeles (LA) grade D esophagitis, candida esophagitis, hiatal hernia, and erosive gastroparesis.

No, the proposed inpatient admission was not medically necessary.
An inpatient admission was not medically necessary since the patient did not have active or ongoing gastrointestinal bleeding, did not require repeat procedural intervention, and did not require any surgical intervention.  In addition, the patient 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, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.

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: Dental Caries

Treatment: for removal of tooth or tooth root, tooth 17

The insurer denied coverage for removal of tooth or tooth root, tooth 17

The denial is upheld.

Based on submitted documentation including dental progress notes and copy of panoramic radiograph, it appears that this patient presented for comprehensive dental care. In addition to recommending numerous endosteal implants, he also recommended extraction of a left mandibular molar tooth, presumably # (number) 17 which exhibited gross caries and would be non-maintainable. The insurer has denied the extraction stating that based on the records received, tooth #17 had previously been extracted. 

Based on the objective information provided for review, which is the panoramic radiograph, there is a grossly carious molar tooth in the left mandible. Dentist submitted the insurance claim form under the assessment that this carious molar represented tooth #17. The insurer has denied the claim stating that according to records tooth #17 was previously extracted and thus denied this service.

Based on review of the radiograph it appears most likely that the carious molar tooth is tooth #18 and not #17.

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient. It appears that tooth #17 had been previously extracted.
 
Based on the above, the medical necessity for the removal of tooth or tooth root, tooth 17 is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, Vomiting and Belly Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female. She presented to the hospital with the complaints of nausea, emesis and abdominal pain. The patient underwent a full, acute admission. The patient has a history of episodes of cannabinoid-induced hyperemesis syndrome.

The patient's vital signs were stable on presentation. The patient also reported a fall from the bed. The patient had a negative head CT (computed tomography). The patient received supportive care including anti-nausea medication and IV (intravenous) hydration.

No, the Inpatient admission was not medically necessary. While the treatment is medically appropriate, the level at which the care was provided was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had a cannibinoid hyperemesis syndrome; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 Diabetes. 
Treatment: Continuous glucose monitoring device - A9276x180, A9277x2. 

The insurer denied the Continuous glucose monitoring device - A9276x180, A9277x2. 
The denial is overturned. 

The patient is a female with type 2 diabetes on multiple insulin injections per day complicated by severe hypoglycemia. Her A1C (glycated hemoglobin) is 8.9%. The request for continuous glucose monitoring device is under review. The prior request was denied. The attending physician is appealing this determination. 

Yes, the requested continuous glucose monitor is medically necessary. 

This patient has type 2 diabetes on multiple daily insulin doses. She has hyperglycemia based on an elevated A1C (glycated hemoglobin) of 8.9%. She also has a history of severe hypoglycemia. Continuous glucose monitoring has been shown to improve glucose control for patients with type 2 diabetes on insulin therapy [1, 2]. The American Diabetes Association clinical guidelines support the use of continuous glucose monitoring in this clinical situation of history of severe hypoglycemia. Without continuous glucose monitoring, this patient will be at risk of worsening hyperglycemia, as well as future episodes of severe hypoglycemia, which can cause seizures and be life-threatening. Therefore, the requested continuous glucose monitor is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. 
The requested continuous glucose monitor was denied and is medically necessary. Therefore, no, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services. 
The insurer denied G-POEM. 
The denial is overturn. 

The patient is a female with type 1 diabetes mellitus complicated by gastroparesis. She has had nausea and vomiting, early satiety, bloating, and abdominal pain. She has had hospital admission for diabetic ketoacidosis related to gastroparesis. Gastric emptying study showed 58% retention at 4 hours, and SmartPill showed delayed gastric emptying greater than 7 hours. She has failed antiemetic medications, prokinetic medications (including metoclopramide, prucalopride, and erythromycin), acid reflux medications, and two pyloric injections of botulinum toxin with transient improvement. The subject under review is gastric per-oral endoscopic myotomy (G-POEM) for the treatment of the patient's gastroparesis.

The request for endoscopic peroral pyloromyotomy (G-POEM) is supported as likely to be more beneficial than any standard treatment or treatments for the patient's gastroparesis. There have been over a dozen published studies reporting the results of G-POEM for the treatment of gastroparesis at multiple centers, with multiple etiologies for gastroparesis (including diabetes mellitus, postsurgical, idiopathic, and postinfectious); clinical success was reported in 68-90% of patients (Mekaroonkamol, et al.; Podboy, et al.). Multiple studies showed improvement in or complete normalization of gastric emptying study findings, which supports the improvement in patient-reported symptom indices - improvement in gastric emptying study was reported in 67-100% of patients across 8 studies, and normalization in gastric emptying study was reported in approximately half of patients (with a range of 0% to 75%) (Podboy, et al.). Additionally, unlike prior treatments for gastroparesis, G-POEM has a similar mechanistic surgical analogue (surgical pyloromyotomy) with proven efficacy. There are likely to be significant benefits to performing G-POEM rather than laparoscopic pyloromyotomy, given that surgery is significantly more invasive. A retrospective study of 60 patients comparing endoscopic with surgical pyloromyotomy (30 patients each) found that both groups had similar and significant improvement in subjective measures and in objective performance on gastric emptying study, and noted that G-POEM resulted in significantly shorter length of stay (1.4 versus 4.6 days, probability [p]=0.003), shorter operative time (34 minutes versus 99 minutes, p less than [<] 0.001), less estimated blood loss, and a trend towards lower complication rate (3.3% versus 16.7%, p=0.09) with only surgical patients experiencing surgical site infection, pneumonia, and unplanned intensive care admission (Landreneau, et al.). These findings are consistent with published meta-analyses (Kamal, et al.; Mohan, et al.). For these reasons, the request for G-POEM is supported as likely to be more beneficial than any standard treatment or treatments for the patient's gastroparesis.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services. 
The insurer denied G-POEM. 
The denial is upheld. 

The patient is a female who has diabetic gastroparesis. She was treated with metoclopramide and erythromycin in the past and has also responded to intra pyloric botulinum toxin injections. She is currently on domperidone with some improvement in her gastroparesis symptoms. The attending provider would like to treat her gastroparesis with the gastric per-oral endoscopic myotomy (G-POEM) procedure.

The G-POEM procedure is not likely to be more beneficial than any standard treatment or treatments for the patient's condition.
Gastroparesis is a complex, debilitating dysmotility disorder with challenging symptom management. A diagnosis of gastroparesis is based on objectively delayed gastric emptying in the absence of mechanical obstruction. Medical options are limited, and the only medication approved by the Food and Drug Administration (FDA) for treatment of gastroparesis is metoclopramide, although other agents are frequently used off label. With this caveat, first-line treatments for gastroparesis include dietary modifications, antiemetics and promotility agents, although these therapies are limited by suboptimal efficacy and significant medication side effects. Treatment of patients that fail first-line treatments represents a significant therapeutic challenge. Recent advances in endoscopic techniques have led to the development of a promising novel endoscopic therapy for gastroparesis via endoscopic pyloromyotomy, also referred to as gastric per-oral endoscopic myotomy or per-oral endoscopic pyloromyotomy. G-POEM demonstrates an exciting potential therapeutic addition to a limited armamentarium and may ultimately be a safer option than many of the medical options currently available. However, more investigation is needed to identify optimal candidates, including a standardized approach to pre- and post-operative testing, developing a standard endoscopic approach and further studies into the physiologic effects of G-POEM. G-POEM may be an excellent candidate for a subgroup of gastroparesis patients with pyloric dysfunction; however, standardization and data are needed to ensure that this procedure is best positioned to help those patients who may most benefit from pyloric intervention. A multi-center international trial on the use of G-POEM for gastroparesis by Vasoughi and colleagues found that G-POEM is a safe procedure but showed only modest overall effectiveness in the treatment of refractory gastroparesis. Further studies are required to identify the best candidates for G-POEM; unselective use of this procedure should be discouraged. There is not enough evidence to show that the long-term results of this requested service are better than other treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services. 
The insurer denied G-POEM. 
The denial is upheld. 

The patient is a female under evaluation and management for gastroparesis. She has had gastric emptying scans which confirm delayed gastric emptying. The patient has underlying diabetes and a neurogenic bladder along with comorbid depression. The patient has post-prandial bloating along with abdominal pain and nausea. The patient has previously/currently been tried on antiemetics including metoclopramide, erythromycin and domperidone. Prucalopride was not particularly helpful. The patient has had Botox A injection into the pylorus with temporary partial relief of symptoms. The patient uses medical marijuana twice daily for symptom improvement.
The patient's provider has recommended a gastric per-oral endoscopic myotomy (G-POEM) of the pyloric sphincter as definitive treatment. The subject under review is whether the requested service is likely to be more beneficial than any standard treatment.

The requested treatment is not likely to be more beneficial for this patient. Gastroparesis is a syndrome of delayed gastric emptying in the absence of a mechanical obstruction, which usually presents with symptoms of nausea, vomiting, early satiety, bloating, or upper abdominal pain. Most cases of gastroparesis are idiopathic, diabetic, or postsurgical. Initial management of gastroparesis consists of dietary modification, optimization of glycemic control and hydration, and pharmacologic therapy with prokinetic and antiemetic medications such as have been tried with this patient. Patients who are refractory to medical therapy may require a gastrostomy (G) or gastro-jejunal (G-J) tube placement for hydration and nutrition. For many years, a reduction in pyloric muscle resting tone has been an additional target of treatment. Surgical pyloroplasty has been performed historically although success was very modest. Recently Botox injection into the pylorus has been performed although 2 randomized trials showed this therapy to be no better than placebo. Endoscopic pyloromyotomy is a new approach to this issue. Currently there are several large cohort studies looking at G-POEM which are not controlled and therefore subject to bias. A very recent meta-analysis of these studies has even been done and does not include randomized controlled studies.[3] The long-term benefit relative to a sham procedure remains unknown and there is concern that patients actually could develop even more symptoms from G-POEM including bile reflux.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedures. 
The insurer denied braces and monthly visits x 12. 
The denial is overturned. 

The patient in question is a male with a buccal (reverse) crossbite on #5 and a deep bite. He has severe maxillary and mandibular crowding. He presents with a skeletal Class I malocclusion. He is treatment planned for 30-36 months of orthodontics with extraction of four first premolars, but treatment was denied due to lack of medical necessity. The subject under review is the medical necessity for braces and monthly visits x12.

The health plan's determination is overturned.

If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For these reasons treatment is deemed medically necessary. Because tooth 5 is in buccal crossbite, it has no antagonist. As a result, it is extremely likely that this tooth will over erupt. Once this overeruption occurs, it is very difficult to treat. (1) Buccal crossbite (also known as scissor-bite in the literature) can also negatively affect mandibular growth and should be treated as early as possible to eliminate the potential growth disturbance. (2)
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal Uterine and Vaginal Bleeding

Treatment inpatient hospital stay

The insurer denied coverage for inpatient hospital stay

The denial is upheld

The patient had a history of abnormal uterine and vaginal bleeding, anemia. The patient presented to the hospital for a planned surgical procedure. The patient was admitted status post laparoscopic hysterectomy with bilateral salpingectomy for extended monitoring. She was discharged with follow up with her Gynecologist in two weeks.

The surgery was without complication. Postoperatively the patient was doing well with no complaints.

There are many ways of doing a hysterectomy. The trend has been towards less invasive procedures. Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions.  Laparoscopic hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary.  According to Milliman Care Guidelines, Inpatient and Surgical Care 24 Edition, Laparoscopic hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure. Inpatient stay may be needed for:

. Surgical complications (bladder ureter or bowel injury or hemorrhage)
. Conversion to abdominal hysterectomy
. Complex surgery (staging of endometrial cancer)
. Wound complications
. Comorbidities

This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. Post operatively, the patient was stable. Nothing in the operative report or the progress notes suggested any serious problem that warranted admission. Please note that laparoscopic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital stay is not considered medically necessary for this patient.

Based on the above, the medical necessity for the inpatient hospital stay is not substantiated. The insurer's denial is upheld.