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

Diagnosis: Back Pain.
Treatment: Pain injection (pain management) (64483x2).
The insurer denied the Pain injection (pain management) (64483x2).
The denial is overturned. 

The patient is a male with lumbar radiculopathy who has failed conservative treatment.  He has had epidural steroid injections in the past with greater than 75% relief. He has not had an injection in over a year.

Yes, the proposed treatment with Pain injection (pain management) (64483x2) is medically necessary.

The patient is a male with lumbar radiculopathy who has failed conservative treatment.  Per the notes, the patient has failed physical therapy (PT) and chiropractic care. He has been taking various medications.  He has had epidural steroid injections in the past with greater than 75% relief for about two months.  He has not had an injection in over a year.  Magnetic resonance image (MRI) does show severe neural foraminal stenosis at L5-S1(lumbosacral joint, is the transition region between the lumbar spine and sacral spine in the lower back), where the injection is recommended. His exam is consistent with his symptoms. Given that he has failed conservative treatment, has imaging findings that are consistent with his exam which correlate to lumbar radiculopathy, that he has had a good response to epidural steroid injections (ESIs), and has not had one in over one year, the requested procedure is medically necessary.

Refusing the procedure can lead to escalation of medications, such as opiates, which have not been shown to be effective in the long-term, or can lead to more invasive options with surgery. Surgery carries greater risk, and offers no guarantees.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and Shortness of breath. 
Treatment: Inpatient hospital service.

The insurer denied coverage for the inpatient hospital service.  The denial is upheld.

This is a female patient with a history of hypertension (HTN), immunocompromising disease, schizoaffective disorder, depression, and gastroesophageal reflux disease (GERD) who presented to the Emergency Department (ED) with complaints of worsening left-sided chest pain and shortness of breath. The patient also complained of some dry cough. The patient's vital signs in the ED were: temperature (T) 100.1 F (Fahrenheit), blood pressure (BP) 134/90, heart rate (HR) 110, respiratory rate (RR) 18, and oxygen (O2) saturations 99% on room air (RA).  The patient was in no acute distress (NAD). The patient's lungs were clear to auscultation. The patient's cardiovascular system (CVS) and neurological exam was unremarkable. The patient was alerted and oriented with no focal finding on exam. The patient's white blood cell (WBC) count was 7600, hemoglobin was 8.5, blood urea nitrogen (BUN)/Creatinine ratio was within normal limits, sodium was 139, and potassium was 3.3. The patient's troponin was negative. The patient's electrocardiogram (EKG) showed normal sinus rhythm (NSR). There were no acute changes. The patient's chest X-ray showed no acute infiltrate. The patient's D-Dimer was 246.  The patient's computed tomography angiography (CTA) was negative for pulmonary embolism (PE); small left upper lobe (LUL) infiltrate was noted. 

This patient was admitted with the diagnosis of rule out acute coronary syndrome (ACS) and pneumonia. The patient remained stable after admission. The patient was afebrile and hemodynamically (HD) stable. The patient was not hypoxic on RA. Myocardial infarction (MI) was ruled out.  The patient was seen by Infectious Diseases (ID) and Psychiatry for history of hearing some voices. The patient was treated with antibiotics for possible pneumonia. Psychiatry adjusted her medications. The patient was subsequently discharged home.

Based on the review of the medical record and literature, this patient did not need acute inpatient hospitalization. The patient was stable to be placed in observation status (which could be for up to 48 hours) while diagnostic testing and treatment were initiated.  The patient could have been discharged home after a period in observation. The patient was afebrile and hemodynamically stable. The patient was not hypoxic, and did not have a MI or PE. The patient was tolerating oral intake, and there was no history of failure of outpatient treatment/management. The patient's pneumonia was mild. The patient was in no acute distress. 

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 hospital service should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: pericardial effusion.
Treatment: inpatient hospital admission.
The insurer is denied coverage for inpatient hospital admission.
The denial is overturned. 

This female patient has a history of  hypertension, hyperlipidemia, hypothyroidism, and myomectomy. The patient presented to the Emergency Room (ER) with complaints of 10 out of 10, abdominal pain. The patient was given 2 liter (L) intravenous (IV) normal saline (NS) bolus and 4 milligrams (mg) of morphine. The patient was admitted to the coronary care unit (CCU) with a pericardial effusion. In the ER, the patient's heart rate and blood pressure were elevated. The patient's complete blood count (CBC) was within normal limits (WNL). The patient's chest computed tomography (CT) angiogram revealed a large, stable pericardial effusion. The patient's CT scan of the abdomen and pelvis revealed cholelithiasis and colonic diverticulitis. The patient was admitted to medicine for further care. The patient was initially kept on nothing-by-mouth (NPO) and pain management was provided. The patient was given 20 mg of intravenous (IV) Pepcid twice a day (BID). The patient was given morphine, Tylenol, and Motrin as needed (PRN). The patient was also given lactulose and suppositories. The patient had 3 small bowel movements and was passing gas. The patient's abdominal pain persisted until the second day of admission. The patient's pain improved with each bowel movement. The patient's pericardiocentesis was done and there was 800 milliliters (ml) of serous fluid. The patient's echocardiogram revealed a left ventricular ejection fraction of 55-60% and a large pericardial effusion. The patient's chest X-ray revealed no pneumothorax. The patient's electrocardiogram (EKG) revealed sinus rhythm with T wave inversions in V1-V5. 88 micrograms (mcg) of daily (QD) Synthroid was continued throughout the admission. The care plan was implemented and the patient's condition stabilized. The patient was discharged. 

Based on the review of the medical record and literature, full hospital admission was medically necessary for this patient. The patient was admitted with abdominal pain and was found to have a pericardial effusion with echocardiographic evidence of tamponade (i.e., right ventricle collapse). While this patient's abdominal pain did not present as an acute abdomen, with surgical indication, hemodynamic compromise, or evidence of peritoneal signs, this patient required pericardiocentesis, which was medically necessary and appropriate. This procedure, and the post-procedure monitoring with pericardial drain output monitoring, required inpatient level of care and hospitalization. This care was not appropriate for a lower level of care.

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

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

Diagnosis: Syncope; Acute infarct in the brain.
Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.  The denial is overturned. 

This male patient has a past medical history of syncope three years prior to presentation.  The patient presented to the Emergency Department (ED) with a syncopal episode.  The patient was brought in by Emergency Medical Services (EMS). Per EMS report the family was there to assist him to the floor.  He reported his neck pain was somewhat different from his chronic neck pain.  He denied chest pain, shortness of breath, dizziness, lightheadedness, fever, productive cough, and palpitations.  He did not remember the entire event but noted he was not on the ground for long.  He was a current some day smoker.  The physical examination revealed a blood pressure of 138/80.  He had a normal rate and rhythm and normal pulses.  He had normal heart sounds.  He was alert and oriented to person, place, and time.  His mood was normal and his behavior was normal.  The patient was stable.  The twelve-lead electrocardiogram (ECG) revealed flattening T waves and left ventricular hypertrophy.  The patient was admitted to telemetry / Cardiology for a syncope work-up.  The patient was to undergo treatment with a computed tomography (CT) of the head, CT of the cervical spine, urinalysis, and intravenous (IV) fluids. The CT of the head revealed multiple lacunar infarcts. The magnetic resonance imaging (MRI) of the brain and magnetic resonance angiography (MRA) of the head and neck confirmed an acute infarct in the right putamen and caudate nucleus. The patient also had chronic infarcts in the left caudate nucleus, right thalamus, and bilateral pons. The echocardiogram was normal. Per Neurology, the infarcts were possibly cardioembolic given their distribution, and the recommendation was an implantable loop recorder (ILR) and a 30-day Holter monitor. The ILR was placed and the patient was subsequently discharged in stable condition.

The inpatient admission is medically necessary for this patient. The patient was admitted to the hospital because syncopal episode. His head MRI confirmed an acute infarct in the right putamen and caudate nucleus, and there were chronic infarcts in the left caudate nucleus, right thalamus, and bilateral pons.  His new infarct is considered most likely from embolic origin.  His inpatient admission is medically necessary.

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

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

Diagnosis: Dental Problems.

Treatment: D5212 Mandibular Partial Denture- Resin Based (Including Retentive/Clasping Materials, Rests, and Teeth) Lower Arch.

The insurer denied coverage for D5212 Mandibular Partial Denture- Resin Based (Including Retentive/Clasping Materials, Rests, and Teeth) Lower Arch.

The denial is overturned. 

This is a female patient who presented for evaluation and comprehensive dental care.  The recommended treatment was for a mandibular removable partial denture to restore function. The insurer has denied these services stating that there is adequate posterior occlusion and therefore the services are deemed not medically necessary.  

Upon review of the documentation (in particular the panoramic radiograph), the patient exhibits oligodontia in the maxilla and mandible regions. Review of the remaining dentition on radiograph indicates a level of moderate periodontal alveolar bone loss corresponding to periodontal disease and a severely periodontally compromised right mandibular molar.  There are less than 8 teeth in posterior occlusion.  However, the patient's teeth that would be support for the removable partial denture are stable and would be adequate abutment teeth.  This treatment of a removable partial denture is a standard of care in dental practice for this clinical circumstance.  As this is a covered service and indicated for restoration of function and occlusal stability, the partial denture is considered medically/dentally necessary, and meets the insurer's criteria for approval.

Overturn denial and approve lower partial denture as partial dentures are designed for use in this clinical circumstance, are a covered service for this patient, are a standard of care in general dental practice and would be an appropriate treatment to restore function and occlusal stability.

D5212 mandibular partial denture- resin based (including retentive/clasping materials, rests, and teeth) lower arch is considered medically necessary for this patient. 

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

The carrier's denial of coverage for D5212 Mandibular Partial Denture- Resin Based (Including Retentive/Clasping Materials, Rests, and Teeth) Lower Arch should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient in is a male. He was sent to the emergency department by his primary physician.  He had anemia with symptoms of dizziness for two to three weeks.  Outpatient CBC (complete blood count) revealed a hemoglobin of 6.5g/dl (grams per deciliter).  He had chronic dyspnea on exertion that had worsened just before this ED (emergency department) visit.

Notably, the patient had no cardiovascular symptoms, and on initial evaluation, he had unremarkable vital signs. He was noted to have been transfused twice in the past to treat anemia.  Physical exam and ECG (electrocardiogram) were both unremarkable.  Hemoglobin as measured in the emergency department was 6.9g/dl (grams per deciliter).

The patient was admitted for transfusion.  He was noted to have a history of coronary artery disease and had two stents placed in the past.  He was admitted and treated with packed red blood cell transfusion.  He was discharged the following day.

No, the Inpatient admission was not medically necessary.

This patient required transfusion due to identification of symptomatic anemia.  Hemoglobin was 6.9g/dl (grams per deciliter), and he was noted to have a history of cardiovascular disease, though he was not having any active cardiovascular symptoms at the time he was initially evaluated.  He had a normal ECG (electrocardiogram).  While he needed transfusion, acute care inpatient admission was not medically necessary in this case.  He could have been safely transfused without admission to the hospital.  This is because he had no hemodynamic instability, active coronary ischemia or active bleeding.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left-sided headache with left arm pain.
Treatment: Inpatient admission.
The insurer denied coverage for the inpatient admission.
The denial is upheld. 

This is a female patient who presented to the Emergency Department (ED) with complaints of a left-sided headache with left arm pain.  The documentation indicated that the patient has a past medical history that includes attention deficit hyperactivity disorder (ADHD).  The patient reported that she was woken from sleep by sudden onset of the left frontal headache.  The patient indicated that when she looked in the mirror her right eyebrow was drooping.  The physician indicated that the patient's behavioral health history included borderline personality disorder as well as schizophrenia, bipolar disorder, drug overdose, polysubstance abuse, and a prior history of hepatitis C all of which the patient failed to report during initial evaluation.  The patient's physical examination revealed that the patient was slightly anxious.  The patient did have mild to moderate sensory loss with minor facial palsy.  The recommendation was made for the patient to undergo laboratory and diagnostic studies.  The laboratory studies did not provide any significant findings.  The patient's computed tomography (CT) scan revealed no acute intracranial pathology.  The patient also underwent a CT angiogram revealing a normal examination.  The patient's chest X-ray revealed no acute pulmonary disease.  The physician indicated that the patient likely had a migraine.  The patient was admitted for further treatment.  The patient had a neurology consult but did not reveal any significant findings.  The patient was discharged the following day.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. This patient presented to the Emergency Department (ED) with headache and arm pain/tenderness, ipsilateral to side of headache. Acute neurologic deficits that would qualify this patient for acute stroke intervention were absent. Neuroimaging was benign, as was imaging of the right arm. Concern for a neurologic diagnosis that required inpatient management was not stated clearly. 

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

The medical necessity for the inpatient admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder (chronic migraines). 
Treatment: Pharmacy/Prescription Drugs (Botox). 

The insurer denied Pharmacy/Prescription Drugs (Botox) for medical necessity.  The denial was upheld.

This is a female who was prescribed Botox to treat chronic migraines. 200 units of Botox were administered. An office note indicates that headaches, neck pain and right foot pain were overall better. Current medications were Namenda, candesartan, Ajovy and Botox. She was willing to taper off Namenda. Botox 200 units was administered. 

A letter of medical necessity from the patient's neurologist indicates that the patient had been receiving Botox every three months. She had previously tried and failed Keppra, amitriptyline, and Calan. 

155 units of Botox were approved for four sessions. This is a total of 620 units of Botox. The additional 180 units (or 45 units per session) have not been approved. This is the subject under review.

The health plan's determination is upheld in whole.

No, the additional Botox units are not medically necessary for this patient.

Under specific review is the dosing of Botox. The issue was dosing of 200 units versus 155 units. Botox is United States Food and Drug Administration (FDA) approved at a dose of 155 units. There is evidence-based, positive clinical trial data at a dose of 155 units. The safety and the improved efficacy of higher doses has not been established in the medical literature. Therefore, the higher dosing is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glycogen Storage Disease, Type III. 
Treatment: Physical Therapy. 

The insurer is denied coverage for Physical Therapy. 

The denial is overturned. 

The patient is male with a past medical history of glycogen storage disease, type III and hepatomegaly/transaminitis.  The records noted the patient was at risk for hypoglycemia and was gastrostomy tube (GT) dependent.  The patient had global developmental delay, seizure disorder, and pelviectasis.  The patient's Managed Care Summary noted the patient/caregiver required training in the home environment for maximal learning and carryover.  The patient status/function will deteriorate without skilled intervention. He required maximal assistance for transfers and transportation and was medically fragile.  There was a lack of accessible transportation.  It was difficult and taxing to leave the home.  It was noted that the patient will continue to benefit from home physical therapy services to address impairments in standing balance, motor planning and coordination and to improve trunk and extremity muscle strength to improve mobility and posture control and improve safety and level of independence in mobility at home.  He ambulated with a waddling gait.  The patient's lower extremities were in external rotation with decreased swing and wide base of support with lacking heel strike and push-off pattern.  He could tolerate short distance walking but his endurance was low.  The patient's mother had to carry him when he had to go to doctor appointments. The patient's stairs negotiation was moderately challenged by his poor ability to control and support 1-leg standing activities. He compensated through step-2 pattern and ascending/descending steps sideways holding onto the rail with both hands.  With home physical therapy, the patient had clinically improved and was walking with decreased compensatory movements with correction cues with improvements in lower extremity swing.  The request was made for continued physical therapy 3 times a week. 

Continuation of services is considered medically necessary for this patient. These services are indicated to clinically improve the patient's balance and gait. Currently, the patient ambulates with a waddling gait pattern, wide base of support, with lack of heel and push off. The patient can only tolerate short distance walking at this time. As per literature review, continuing physical therapy (PT) at frequency of 3 times/week for 4 weeks (12 visits total) followed by re-evaluation to determine if the patient can be progressed to full home exercise program, is considered medically necessary for this patient. 

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

The carrier's denial of coverage for physical therapy sessions should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration. 

Treatment: Acute Inpatient Stay.

The insurer denied coverage for the acute inpatient stay.

The denial is upheld. 

This patient is a female child who was brought to the hospital due to poor oral intake in the setting of 2-days of fever. As per the history of present illness, the patient was seen the previous day for fever of 1 day duration and partial sepsis work up. The patient was noted to be dehydrated, but the patient's parent refused intravenous (IV) fluids at that time. The parents returned to the hospital because the patient drank only one ounce in the past 20 hours and had scant wet diapers that were "very dry". The patient's mother had a telehealth visit with the primary medical doctor (PMD) who recommended taking the patient to the Emergency Department (ED). On examination, the patient had slightly mottled extremities but was well-perfused. The patient's vital signs were: temperature 103.8 and heart rate 195 initially. The patient's labs included: white blood cell (WBC) 14,000, platelet count 401,000 and unremarkable differential count that were within normal limits; the patient's bicarbonate level was decreased from 26 the previous day to 22 but was not abnormal. The patient's blood urea nitrogen (BUN) and creatinine levels were normal. The patient's urine specific gravity of 1020 was consistent with minimal to mild dehydration. The reason for admission given is a concern for dehydration as well as refusing oral intake. In the disposition note it is stated that there is inadequate oral intake, unable to take enough to maintain hydration. 

Per current literature on management of dehydration in children, and using the Children Hospital of Philadelphia (CHOP) clinical pathway, a trial of oral rehydration following a bolus of IV fluids should be the management of minimal to mild dehydration, especially as there were no ongoing fluid losses (i.e., there was no ongoing diarrhea). This could have been tried in the ED with a period of monitoring at the observation level of care. 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 medical necessity for the Acute Inpatient Stay is not substantiated. The insurer's denial should be upheld.