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

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a female who was sent to the emergency department (ED) by her cardiologist for workup of chest pain on exertion of several months duration. She had a history of hypertension, hyperlipidemia, and chronic kidney disease (CKD). Her private cardiologist had performed a stress test and, on that basis, had planned to perform a cardiac catheterization. The patient stated she was used to walking long distances but could now walk only one city block without getting chest pain. The patient was on isosorbide mononitrate (ISMN) and Toprol. The electrocardiogram (ECG) showed no ischemia. The troponin was normal. The patient was admitted. Repeat troponins were normal. Left heart catheterization was normal. She was discharged.

At issue is the medical necessity of the inpatient hospital admission.

The health plan's determination is upheld in whole.

The requested health service/treatment of inpatient hospital admission was not medically necessary for this patient.

The patient had an elective cardiac catheterization for worsening exertional chest pain. There is no clear indication in the documentation why the patient required inpatient hospital admission or why the patient required days in the hospital prior to the catheterization being performed. Based on the documentation it was reasonable to perform the diagnostic catheterization, but an inpatient hospital admission is not generally necessary for this procedure.

Therefore, the inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient presented to the emergency department (ED) via Emergency Medical Services (EMS) complaining of chest pain. En route to the ED, she received aspirin and sublingual nitroglycerin with partial relief. Her medical history was remarkable for hypertension and anemia.

An electrocardiogram showed sinus rhythm without acute changes. Her serum troponin I level was .06 nanograms/milliliter (ng/ml) and was .05 ng/ml when remeasured. The chest x-ray showed no acute pathology. The patient's brain (or B-type) natriuretic peptide (BNP) level was normal. The hemoglobin level was 8.7 grams/deciliter (gm/dl). The patient was admitted for a cardiac stress test. A third troponin level was unchanged. An echocardiogram was performed and was normal. The stress test was nondiagnostic due to a submaximal heart rate. 

The patient underwent myocardial perfusion imaging which was normal. The patient was seen by a gynecologist for reports of menorrhagia. A transvaginal ultrasound showed a uterine fibroid and a corpus luteum cyst on the right ovary. Outpatient follow-up was recommended. The patient was discharged. At issue is the medical necessity of the inpatient hospital stay.

Based on the documentation provided, an inpatient level of care was not medically necessary. The patient presented with complaints of chest pain that was thought to represent acute coronary syndrome (ACS). Accordingly, a lower level of care until ACS could be ruled-out was a reasonable approach. The patient was hemodynamically stable, with no ischemic electrocardiographic changes. The patient's serum troponin level was minimally elevated without a significant delta troponin. The patient did not require intensive monitoring or infusion of intravenous cardioactive medications. The care the patient received did not require an inpatient hospital admission and could have been provided under a lower level of care.

This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE)/American College of Chest Physicians (CHEST)/Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain. In addition, the 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes suggests that care could have been provided under a lower level of care as well.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD).
Treatment: Stiolto respimat inhalation spray.
The insurer denied Stiolto respimat inhalation spray.
The determination is upheld.

The patient has a medical diagnosis of chronic obstructive pulmonary disease (COPD) and is currently well controlled on Stiolto Respimat. The patient has previously tried and failed Spiriva Respimat, Incruse Ellipta, Breo Ellipta and cannot take dry powder inhalers due to a poor inspiratory capacity. The provider is requesting the continuation of Stiolto Respimat as the patient's COPD has been controlled with its use.

The patient has previously tried and failed the formulary alternative of Spiriva Respimat, Striverdi Respimat would not appropriate based on the class of medication and Anoro Ellipta is a dry powder inhaler, which the patient cannot effectively take. However, Bevespi would likely be as effective as the non-formulary drug, Stiolto Respimat inhalation spray.

Stiolto is a combination long-acting beta-agonist (LABA) and long-acting muscarinic antagonist (LAMA) inhaler. Of the remaining formulary alternatives Striverdi Respimat would not be appropriate as it is only a LABA inhaler and Anoro Ellipta is a dry powder inhaler, which the patient cannot effectively take. However, Bevespi is a combination LABA/LAMA in the same class as Stiolto Respimat. Also, Bevespi is not a dry powder inhaler but rather a pressurized metered dose inhaler, which would be suitable for a patient with a poor inspiratory capacity. The patient has not tried Bevespi and there is no documented contraindication to its use. In addition, there were no references (Pubmed search) to support the requested Stiolto Respimat as being more effective compared to the formulary alternative of Bevespi. Therefore, Bevespi would likely be as effective as the non-formulary drug, Stiolto Respimat inhalation spray.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma, RSV (respiratory syncytial virus)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned

The patient is a toddler aged male with known autism and known intermittent asthma. The patient developed a cough for three days prior to developing shortness of breath and worsening increased respiratory effort when presenting to the emergency department. The patient demonstrated a decrease in oxygen saturation to 89%(percent) on room air, increased heart rate, and was respiratory syncytial virus (RSV) positive. The patient required oxygen support and bronchodilators as well as intravenous steroids. The patient was discharged once he was able to demonstrate a comfortable respiratory condition at baseline.

The proposed inpatient hospital admission was medically necessary.

The patient had a developing cough for three days, and presented with a decrease in oxygen saturation with an asthma exacerbation secondary to a respiratory syncytial virus (RSV) infection. Due to the underlying known mild asthma, the patient demonstrated worsening respiratory condition as well as hypoxia and increased respiratory effort that required rapid and a multi-pharmacologic treatment plan. As the patient demonstrated an increased respiratory effort with a decrease in oxygenation in the face of respiratory syncytial virus infection and a worsening asthma exacerbation, the patient required this inpatient stay for appropriate care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Migraine Headache Disorder.
Treatment: Botox Treatment.
The insurer denied the request for Botox Treatment.
The health plan's determination is overturned.

The patient is a female with chronic migraine headaches. Treatment with Botox is the subject of this review. The drug was denied because the patient has not tried and failed multiple oral preventative medications. However, records indicate that the patient has not responded to Gabapentin, Amitriptyline, Sertraline, Metoprolol, Labetalol, or Cyclobenzaprine for the prevention of migraine headaches. The denial of Botox was appealed.

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

Yes, the requested service/treatment of Botox treatment is medically necessary for the patient. The patient has chronic migraine headaches. Chronic migraine is a Food and Drug Administration (FDA) approved indication for treatment with Botox. The FDA and manufacturer do not require that a patient has failed any first-line therapies prior to Botox therapy. However, the information supplied for review indicates that the patient has tried and failed Labetalol, Metoprolol, Gabapentin, Amitriptyline, Sertraline, and Cyclobenzaprine. This includes a number of first line and second-line oral preventative therapies. These have been ineffective.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gender dysphoria
Treatment: CPT (Current Procedural Terminology) codes 21122 (osseous genioplasty) and 21125 (reconstruction of lower jaw with prosthetic)
The insurer denied coverage for CPT codes 21122 (osseous genioplasty) and 21125 (reconstruction of lower jaw with prosthetic)
The denial is upheld

The health plan acted reasonably and with sound medical judgment.

The patient has gender dysphoria, and additional facial feminization surgery is requested. While generally appropriate for patients with severe gender dysphoria, this particular patient has already had two previous gender affirming chin surgeries. Photos do not demonstrate a chin appearance that is obviously outside the range of feminine appearance. The letter from the  Psychologist states: "The patient has begun to experience a significant and impairing degree of gender dysphoria about her facial features as she ages and as the fat distribution in her body changes. Specifically, now she is in need of multiple facial feminization procedures including but not limited to brow lift, facelift, fat graft, and work on her forehead, eyelids, and lips." The letter indicates that the patient's issues are primarily related to facial aging, and the letter does not specifically mention chin appearance as a source of dysphoria. In view of the fact that the patient has already had two chin feminizing procedures and the photos do not show that the chin is overtly masculine in appearance, the request is not medically necessary.

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 CPT codes 21122 (osseous genioplasty) and 21125 (reconstruction of lower jaw with prosthetic) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Extensive caries tooth #27
Treatment: D2751 white glass with metal crown, tooth 27
The insurer denied coverage for D2751 white glass with metal crown, tooth 27
The denial is overturned.
 
Based on the submitted documentation which includes copies of pretreatment full mouth series and two periapical radiographs, narrative letter from the dentist, and insurer correspondence, it appears that this patient presented to the dentist for comprehensive dental care. Extensive caries was noted on tooth #27 extending into the pulp chamber. Endodontic therapy was recommended and completed with additional recommendation of full coverage crown restorations on this tooth. The insurer has denied the full coverage crown stating that the service is not medically necessary as the documentation did not demonstrate medical need to support the treatment. The patient is appealing the decision.

Upon review of radiographs, it supports the recommended treatment. Review of pretreatment radiograph indicates a large carious lesion affecting #27 in continuity with the pulp chamber. Endodontic therapy would be required and was completed as per additional periapical radiographs. There is ample coronal structure remaining after the endodontic therapy. This tooth will have adequate residual coronal structure for support of crown and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be placement of crown on an endodontically treated tooth which would have an excellent long-term prognosis with the recommended treatment.

Reverse denial and approve coverage for dental crown for teeth #27 as medically necessary as the radiographic documentation supports this service, and this service would be a standard of care in general dental practice.

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 D2751 white glass with metal crown, tooth 27 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, anxiety, depression and osteoarthritis
Treatment: Personal Care Aide services a total of 168 hours/week, Consumer Direct, 1 Client
The insurer denied coverage for Personal Care Aide services a total of 168 hours/week, Consumer Direct, 1 Client
The denial is overturned

This is a patient with a history of Alzheimer's disease, anxiety, depression and osteoarthritis. According to the most recent Uniform Assessment System (UAS), via interactive video teleconference the patient lives with spouse. Cognitive skills for daily decision making is moderately impaired and the patient was alert and oriented to 2 identifiers with periods of confusions, is able to make needs known. The patient's daughter and family assist with the medications. The patient requires maximal assistance for meal preparation, and ordinary housework. Extensive assistance for managing medications, bathing, personal hygiene, dressing upper body, and dressing lower body. No fall reported in last 90 days. The patient's physician is requesting an increase in personal care aide (PCA) services due to Alzheimer's disease progression.

The medical records show progression of disease and increasing inability to perform basic activities of daily living (ADL's). Recent correspondence and letters of support were provided. The documentation was that of a worsening mental status with associated combativeness and hallucinations. There were reports of incontinence. There were reports of inability to specifically care for herself on several levels. There was documentation of inability of husband to provide these needs. She would be a risk for falls and possible aspiration.  The previous nursing assessment does not adequately describe the current condition. The services would thus be warranted. 

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

Based on the above, the insurer's denial must be overturned. 

The medical necessity for Personal Care Aide services, Consumer Direct, 1 Client a total of 168 hours/week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission.
The denial is overturned.
 

This patient is an adult with a history of hypertension, coronary artery disease, status post (s/p) percutaneous transluminal coronary angioplasty (PTCA), diabetes, and gastroesophageal reflux disease (GERD). The patient presented to the emergency department (ED) with complaints of shortness of breath (SOB) and bilateral lower extremity (LE) edema for 2 weeks. Vital signs were as follows: temperature 98.1 degrees Fahrenheit, heart rate 94, respirations 20, blood pressure 147/84, and oxygen saturation 98% (percent) on 4 liter nasal canula. The patient was noted to have rales on the lung exam. Pitting LE (left extremity) edema noted. The white blood cell (WBC) count was 6.5. The patient had an acute kidney injury with elevated Blood urea nitrogen/Creatinine (BUN/Cr) 29/2.49. The B-type natriuretic peptide (BNP) was elevated to > (greater than) 5000 from a baseline of 223. Troponins were also elevated. A Chest x-ray (CXR) revealed pulmonary congestion and signs of volume overload. The patient also had > 100 WBC on urinalysis and was treated with intravenous (IV) Ceftriaxone for a urinary tract infection (UTI).

The patient's presentation was consistent with decompensated heart failure. The patient was treated with IV Lasix with close monitoring of electrolytes, intake and output, and BUN/Cr. Myocardial infarction (MI) was ruled out. The patient required telemetry heart monitoring. An echocardiogram revealed a decrease in ejection fraction (EF) to 31%. The patient gradually improved with IV diuretics and oxygen. The patient was subsequently discharged home on after 5 days of hospitalization. Given the patient's presentation, the admission and length of stay (LOS) was appropriate.

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

The insurer's denial of coverage for hospital admission and inpatient level of care is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epilepsy
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is upheld. 

 
This case involves a child with a history of epilepsy who presented to the emergency department (ED) complaining of a witnessed seizure. In the ED, triage notes stated both that the patient had no head strike/head trauma, but also documented that according to the patient's mother that the patient fell back, hit his head, and bit his tongue during the witnessed seizure. The seizure reportedly happened while at the supermarket with the patient falling onto concrete. The patient had a prescription for Keppra 100 mg (milligrams)/mL (milliliter) oral solution at 0.25 mL orally 2 times a day. According to the patient's mother, the seizure lasted 2 to 3 minutes with claims that the patient was compliant with medication per emergency medical services (EMS). The patient's vital signs were stable, and they were alert and oriented x (times) 3. Laboratory values were relatively unremarkable. The computed tomography (CT) of the head was unremarkable. A CT of the chest showed diffuse bilateral airspace disease compatible with pneumonia.  

The patient was subsequently admitted for possible aspiration pneumonia status post seizure. The physician felt that the patient could not be safely discharged home and required further management. The patient was admitted, and he was discharged later that evening.  

The Milliman Care Guidelines have indicated that the patient did not meet criteria for admission pertaining to seizure activity. The CT of the head was unremarkable, and the patient had no further seizures during observation and was alert and oriented x3. As for the pneumonia due to possible aspiration, the Milliman Care Guidelines have stated that admission is indicated for 1 more the following to include aspiration pneumonitis associated with an acute event that requires inpatient care. However, while it was noted that the patient had concerns following chest x-ray for pneumonia, there was no evidence of hemodynamic instability, hypoxemia, persistent dyspnea or tachypnea despite observation care, altered mental status, severe persistent dehydration, failure of outpatient treatment, uncompensated respiratory acidosis, the inability of the patient to protect or unclear the airway, and no indication that the patient was receiving chronic custodial care or skilled nursing facility care or aspiration has failed or cannot be provided. The evidence was that the patient had a history of seizures, had a witnessed seizure, for which he responded favorably to observational care, and did not have persistent symptoms that cannot be managed on an outpatient observational basis related to the possible aspiration pneumonia.  

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, diabetes mellitus, hypertension, depression, and osteoarthritis
Treatment: Increase personal care aide (PCA) hours from 7 days per week, 12 hours per day to 7 days per week, 2 - 12 hours per day
The insurer denied coverage for the increase in personal care aide (PCA) hours from 7 days per week, 12 hours per day to 7 days per week, 2 - 12 hours per day
The denial is upheld.
 
This is a patient with a history of dementia, diabetes mellitus, hypertension, depression, and osteoarthritis. According to the most recent Uniform Assessment System (UAS) the patient lives alone in a 1-bedroom apartment, has poor mental capacity due to dementia, cognitive skills for daily decision making is severely impaired, the patient is alert and oriented (A+O) x 1, with periods of confusion. The patient requires total dependence for meal preparation, and ordinary housework. Maximal assistance was needed for managing medications, bathing, and dressing the lower body. One fall was reported in the last 30 days. She was observed to ambulate with unsteady gait and fair balance. She is frequently incontinent of bladder and bowel but with some control. These are similar to the prior UAS. Limited assistance with bed mobility and eating was needed. No skin issues noted. Wandering was present but not exhibited in the last 30 days. The physician is asking for an increase in hours of home care service for the patient due to rapidly deteriorating cognitive, physical health and functional status, based upon clinical findings.

The records show no specific change in medical condition. The patient has not required visits to the emergency department (ED) or hospitalization. There were no reports of recent falls. She had access to two family members who could respond at night. There were no reasons provided why she required a person at bedside while she slept. Her assistance for activities of daily living had been met. The most recent nursing assessment confirmed the status. 

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 increase personal care aide (PCA) hours from 7 days per week, 12 hours per day to 7 days per week, 2 - 12 hours per day is not substantiated.