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

Diagnosis: Dental infection.
Treatment: inpatient admission.
The insurer denied an inpatient admission. 
The health plan's determination is upheld. 

This is a male who presented to the emergency room with a 5 day history of left facial swelling. The patient exhibited trismus and his temperature was 100.4 and white blood cell count was 18.5. The oxygen saturation was 97% on room air. A computed tomography (CT) scan did not indicate airway compromise. The patient was seen the following day by oral and maxillofacial surgery and an incision and drainage was performed at the bedside. Purulent drainage was obtained. 

An Inpatient hospital admission was not medically necessary.

Hospital admission criteria for a dental infection are threat to airways or other vital structures, need for general anesthesia, septic fever, marked swelling, need for inpatient control of a concomitant systemic disease, and need for intravenous antimicrobial treatment. Another study showed that risk factors for hospital admission were elderly patients with concurrent disease, elevated C-reactive protein level, and multiple-space infection in the maxillofacial area.

This patient had an elevated C-reactive protein level and a need for intravenous (IV) antibiotics. There was no need for general anesthesia as the treatment was handled with local anesthesia at the bedside. The patient was not elderly, did not have pre-existing conditions or a multiple-space infections. Antibiotic treatment is needed for orthognathic surgery patients and this treatment is routinely performed on an outpatient basis. Maxillofacial infections can be expected to heal well initially by removing the infection source and performing proper drainage. This can be accomplished at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing Tooth/Teeth
Treatment: Intravenous Moderate (Conscious) Sedation/Analgesia and Sinus Augmentation

The health plan denied: Intravenous Moderate (Conscious) Sedation/Analgesia and Sinus Augmentation
The determination is: Overturned

The patient is a female who is missing maxillary left posterior teeth. Her restorative dentist recommended that the best course would be to place osseointegrated implants similar to what had been done on the maxillary right side a few years earlier. The patient was referred to an oral and maxillofacial surgeon (OMS) for sinus augmentation under intravenous (IV) anesthesia.
At issue is the medical necessity of the intravenous moderate (conscious) sedation/analgesia and sinus augmentation.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of intravenous moderate (conscious) sedation/analgesia and sinus augmentation is medically necessary for this patient.
The use of osseointegrated implants is well within the standard of care for restoration of missing teeth and has previously been noted to be medically necessary. This is an extensive procedure that warrants IV sedation as being medically necessary under plan definition. The need for a sinus augmentation is medically necessary when there is insufficient bone to accommodate the placement of osseointegrated implants.
Of note, the patient had the same procedures done on the opposite side of her maxilla. The insurer denied the augmentation and sedation at that time - this was appealed by the patient, and the denial was overturned.
Therefore, intravenous moderate (conscious) sedation/analgesia and sinus augmentation is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity.
Treatment Saxenda.
The insurer denied Saxenda.
The determination is overturned.

This is a female patient with a history of obesity, gastroesophageal reflux disease (GERD), migraine, right hip pain, and anxiety. She is requesting coverage for Saxenda. A body mass index (BMI) of 41.2 is documented in an office visit note. Liraglutide (Saxenda) was prescribed. Receipts from the Get Slim Ultimate Fat Loss program are provided in the documentation for review. At issue is the medical necessity of Saxenda.

The requested health service/treatment of liraglutide (Saxenda) is medically necessary for this patient. Based on a review of the information provided the patient has met the criteria for approval of liraglutide (Saxenda). She has a body mass index (BMI) greater than 30, and in addition to counseling in her provider's office, she has participated for at least three months in a comprehensive weight management program. Therefore, based on the standard of care, as well as the peer reviewed literature and guidelines cited in the references, the liraglutide (Saxenda) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tardive dyskinesia
Treatment: Ingrezza 40 mg (milligrams) OR caps (capsules) 
The insurer denied coverage for Ingrezza 40 mg (milligrams) OR (capsules).
The denial is overturned.

This adult male reportedly had motor movements including lips and perioral area, jaw, and incapacitation due to abnormal movements and had tardive dyskinesia for over 1 year. It was reported that he had a diagnosis of Bipolar Disorder-severe with psychotic features and had multiple past psychiatric hospitalizations and suicidal ideation. It was reported that his doctor requested Ingrezza 40 mg (milligrams) per day to treat tardive dyskinesia.
  
The reviewer disagrees with the decision to deny coverage for Ingrezza (Valbenazine) 40 mg per day to treat this patient's tardive dyskinesia as Ingrezza (Valbenazine) is an FDA (food and drug administration) approved medication for treatment of tardive dyskinesia.  According to the Journal of Clinical Psychiatry "FDA (food and drug administration) Approved Medication to Treat Tardive Dyskinesia" by Dr. McEroy, it states that there are only 2 FDA (food and drug administration) approved medications to treat tardive dyskinesia and they are for Ingrezza (Valbenazine) and Austedo (Deutetrabenazine). Ingrezza was approved by the FDA (food and drug administration) in 2017. Both Ingrezza (Valbenazine) and Austedo (Deutetrabenazine) are vesicular monoamine transporter 2 inhibitors (VMAT3) that act by decreasing abnormal dopamine functioning. It was also reported that other medications have been used off label to treat tardive dyskinesia including tetrabenazine which was on the insurer's recommended drug list, amantadine, clonazepam, ginkgo biloba, lithium, and botulism toxin. Not only is the requested medication, Ingrezza, FDA (food and drug administration) approved for the treatment of tardive dyskinesia, but it was considered medically necessary treatment for this patient as his tardive dykinesia motor movements interfered with his ability to eat certain foods and interfered with speech. The recommended preferred medication on the plan's formulary list was not one of the only two approved FDA (food and drug administration) medications to treat tardive dyskinesia. Tetrabenazine is FDA (food and drug administration) approved for the treatment of Huntington's Disease related chorea movements and not tardive dykinesia. As a result, the recommendation is to approve coverage for Ingrezza (Valbenazine) 40 milligrams per day to treat this patient's tardive dyskinesia. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Ingrezza 40 milligrams (mg) OR caps (capsules) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Complex regional pain syndrome (CRPS).
Treatment:  Spinal Cord Stimulator.

The insurer denied the Spinal Cord Stimulator.  The denial is overturned.

The patient is an adult female with complex regional pain syndrome (CRPS), who underwent a spinal cord stimulator (SCS) trial with paddle electrodes and sustained greater than 50% improvement. The patient was then recommended for placement of permanent spinal cord stimulator and generator last year.

The proposed treatment is medically necessary.

This patient has complex regional pain syndrome (CRPS), which is an appropriate indication for a spinal cord stimulator (SCS). The patient has attempted an adequate trial of nonsurgical management, and the spinal cord stimulator trial provided a significant benefit. In this setting, the next most appropriate step is to place a permanent system, which is what was done. This is the most appropriate management option.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ovarian cyst
Treatment: inpatient stay
The insurer denied an inpatient stay. 
The health plan's determination is upheld. 

The patient is a female who presented to the emergency department with left lower quadrant pain. The patient had a medical history remarkable for a prior episode of ovarian torsion requiring surgery. Her imaging demonstrated a left sided 5.2 centimeter ovarian cyst. 

The inpatient hospital admission was not medically necessary. The time in the hospital was to assess what clinical action should be taken (surgery, antibiotics, or discharge). The patient underwent pain control measures, but otherwise no interventions beyond the assessment of the need for surgery were done. This type of clinical decision-making stay in the hospital can be done at a lower level of care. She was not receiving any significant interventions during that time. The progress notes demonstrated a resolution of pain and no additional diagnoses revealed. There was nothing to suggest that there was ongoing concern for infection or other serious problem. The inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior cruciate ligament (ACL) deficient knee
Treatment: Arthroscopy of the knee, procedure code 29879
The insurer denied coverage for arthroscopy of the knee, procedure code 29879.
The denial is overturned.

The medical records were consistent for the diagnosis of anterior cruciate ligament (ACL) deficient knee. The patient had recurrent episodes of instability. The patient likely tore the ACL prior to this recent injury. The clinical status reported by the physician was significant for an abnormal physical examination. There was hyperextension and a + (positive) Lachman/drawer sign. There was confirmed pathology. This type of injury would not likely respond to non-operative management. Based upon functional limitation and confirmed pathology, surgery would be appropriate and necessary. The micro fracture procedure would be necessary as the operative report described the abnormality. It would not be standard of care to leave the lesion. The physician provided all procedures as necessary with satisfactory documentation.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for arthroscopy of the knee, procedure code 29879, is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Shoulder pain.
Treatment:  Shoulder procedure (procedure code 29805).

The insurer denied coverage for shoulder procedure (procedure code 29805).  The denial is upheld.

This is the case of a patient with a history of seronegative rheumatoid arthritis (RA), dyslipidemia, resolved hypercalciuria, osteoporosis, and rotator cuff tear status post (s/p) right shoulder repair in the past. The patient was evaluated for seronegative RA. The patient presented for a second opinion due to continued joint pain affecting functional status. The patient is followed by pain management services and taking Humira and Methotrexate (MTX). The patient's physical exam showed acromioclavicular (AC) joint tenderness in bilateral shoulders and right shoulder with positive Apley. Multiple magnetic resonance imaging (MRI) do not show synovitis or inflammatory specific arthritis and atypical features of RA. The patient underwent a shoulder arthroscopy with rotator cuff, shoulder acromioplasty/decompression. 

There was no indication for operative management. The records show a chronic pain pattern to multiple joints. A specific diagnosis was never established. The important issues were a traumatic event earlier in the year. Bilateral shoulder complaints were made. The physical examination showed full motion to both shoulders. There were multiple positive provocative signs for pathology with indistinct clinical correlation. The operative report did not show specific abnormalities (such as tendonitis). The pathology report did not show a pathology. Nevertheless, the indication for surgery was "pain and need for biopsy." The facts are that surgery is recommended only if a pain generator has been defined and failed to improve with conservative treatment. These criteria were not met. There was one report of a physical therapy visit. There were no injections of cortisone given. Treatment with an injection of cortisone would help in treating inflammation and defining the source of pain (such as synovitis). There were no extenuating circumstances to support the surgical procedure. Several National Guidelines were not met. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for shoulder procedure (procedure code 29805) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

This is an adult with a past medical history which includes hyperlipidemia, hypertension, benign prostatic hyperplasia, marijuana use, and stroke with loss of function in the right arm that has recovered. He presented to the hospital after a syncopal episode at home, after an evening walk. His blood pressure immediately before the episode was 90/60. He subsequently suddenly lost strength, started speaking oddly, went limp and lost consciousness briefly as witnessed by family. When he tried to stand, he continued to feel dizzy and was brought to the emergency department (ED) via ambulance. At the time of evaluation, he was diaphoretic.

In the ED, Blood pressure remained low at 95/68. Fluids were given. A Canadian Syncope Score was calculated at 2.

Notes indicated that vagal syncope appeared likely, no further workup was warranted, and outpatient cardiology follow-up was appropriate after discharge. Neither the ED physician who evaluated him, nor the cardiologist who performed his consultation, anticipated any more than a brief hospitalization under observation status. There was no indication that a prolonged hospitalization was anticipated, and in fact, none was necessary - the patient was ultimately discharged to home on the same calendar day that he was admitted, after a brief focused workup. 

A prolonged (2 midnight) hospital stay was neither expected nor completed. His chest pain was moderate risk and, in the context of his recent CT (computed tomography) angiogram and his subsequent evaluation, adequately worked up. His diagnoses of vagal syncope and hypotension as his presenting concerns, were low-risk findings and there was no indication for further hospitalization. This was particularly true as the vagal episode appeared to be a direct consequence of a recent dose change in his antihypertensive medications, a problem which was easily corrected.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: congestive heart failure, hypertension and dementia
Treatment: Personal care aide (PCA) services 7 days x (times) 12 hours x 2 shifts, for a total of 168 hours per week.
The insurer denied coverage for Personal care aide (PCA) services 7 days x 12 hours x 2 shifts, for a total of 168 hours per week.
The denial is overturned.
 
This is an elderly patient with medical problems that include congestive heart failure, hypertension and dementia.  The patient lives alone in a 1-bedroom apartment.  The patient's son is temporarily taking care of her daily when the personal care aide (PCA) is not available and also staying overnight to provide assistance.  The insurer approved PCA services 12 hours/day, 7 days/week and the request is for PCA services 7 days x (times) 12 hours x 2 shifts, for a total of 168 hours per week.

According to the Uniform Assessment System (UAS) report the patient's cognition is described as severely impaired.  She is totally dependent for performing Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  She requires maximal assistance for bathing, personal hygiene, bed mobility, dressing, locomotion and toilet transfer/use.  The patient is frequently incontinent of bladder and occasionally incontinent of bowel.  She is totally dependent for ambulation (wheeled by others in a manual wheelchair) and requires limited assistance for eating.  

The patient's ADL (Activities of Daily Living) status has declined over the prior 90 days.  She was hospitalized due to a fall and rib fractures.  She was subsequently admitted to a skilled nursing facility. Her cognitive and functional abilities have modestly declined when compared to the older UAS (Uniform Assessment System) reports.

The patient's clinical condition and functional deficits are at a level and unpredictable as to require the requested PCA (personal care aide) 7 days per week, 24 hours per day split shift.  Of particular concern is her essentially bed bound status, risk of pressure ulcers and development of joint contractures.  She requires routine repositioning in bed at least every 2-3 hours.  Based on the clinical records, a live-in PCA is unlikely capable of obtaining approximately 5 hours of uninterrupted sleep over the course of a 24-hour shift.  This physician would agree that attention to the patient's functional needs is more appropriately provided and maintained by the requested PCA services 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Personal Care Aide (PCA) services, 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Full hospital admission
The insurer denied the full hospital admission.
The determination is overturned.

This is a male patient with a history of asthma. His presenting complaints were a cough and congestion, wheezing, and shortness of breath. His symptoms began a week prior and he was treated with doxycycline and dexamethasone as an outpatient for a diagnosis of bronchitis. On arrival to the emergency department the patient's vital signs were blood pressure 147/87, heart rate 81, respiratory rate 20, with oxygen saturation 95 percent (%). The physical exam was unremarkable. Lab results were notable for leukocytosis. Radiology was unremarkable. In the emergency department (ED), the patient was given steroids and nebulizer therapy; on reassessment, the patient exhibited persistent wheezing and shortness of breath. He was admitted to an inpatient level of care for treatment and monitoring of an asthma exacerbation.

At issue is the medical necessity of inpatient stay. The inpatient stay was medically necessary.

The patient presented with an acute asthma exacerbation that had failed outpatient management by his primary care doctor. He had severe symptoms that were affecting his activities of daily living. Initial treatment in the emergency department also failed to alleviate his persistent wheezing and shortness of breath. Although he did not demonstrate hypercapnia, respiratory failure, or other dangerous signs he was at high risk of further clinical decompensation. An inpatient level of care would have been the best site in which to monitor the patient carefully and continue therapy for an asthma exacerbation. The inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: left elbow injury 
Treatment: inpatient stay
the insurer denied the inpatient stay. The health plan's determination is upheld. 

This case describes a female patient who sustained a left elbow injury while hiking. She was evaluated and plain radiographs revealed a displaced left elbow proximal ulna fracture and comminuted radial fracture. She underwent surgical fixation of the ulna fracture and radial head replacement. The surgery was completed successfully with no documented complications. 

The inpatient hospital admission was not medically necessary for this patient. The provided records document that this patient sustained a left elbow injury that required surgical intervention. According to the records, the surgery was completed successfully with no documented complications. This entailed open reception and internal fixation of a left proximal ulna fracture and a radial head replacement. This intervention was consistent with the current standard of care and the recommendations of the current peer-reviewed orthopedic literature as documented by Flynn and colleagues in the Instructional Course Lectures of the American Academy of Orthopedic Surgeons in 2022. The patient had normal vital signs and lab values after the operation. There was no documentation of post-operative bleeding complications, infection, or nerve or vessel damage. In addition, the progress notes clearly document that there were no signs of post-operative compartment syndrome. Therefore, based upon the provided records and the recommendations of the peer-reviewed literature, the inpatient hospital admission was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal bleeding
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The health plan's determination is upheld. 

The patient is a female who presented to the emergency room (ER) with a complaint of heavy menstrual bleeding. Her hematocrit was 18 on presentation. She had been treated two weeks prior with tranexamic acid at another ER visit for bleeding. She received one unit of blood in the ER and was then admitted to the hospital for a second unit. She was also treated with oral progesterone. 

Inpatient admission was not medically necessary in this case. The patient was not unstable at any point, and there was no documentation of heavy bleeding. Her vital signs were within normal range for her entire stay. There is no mention in the ER or on the floor of the patient being unstable or having acute bleeding. The patient did have a low hematocrit, and transfusion was necessary. With that said, transfusions are routinely conducted at a lower level of care. Furthermore, the patient was in the hospital less than 24 hours. There was no justification for an inpatient level of care.