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

Diagnosis: Dental Problems-Decay/Root involvement
Treatment: Dental/Orthodontic Procedure/ apicoectomy
The health plan denied the dental service as not medically necessary. 
The reviewer overturns the health plan determination in whole.

This is the case of a patient who presented to the dental provider for consultation on tooth #4. Initially, only one radiograph, a periapical image of tooth #4, was attached, which shows the tooth has been endodontically treated in the past. Initially, there was not enough clinical background information to make a determination. However, the independent reviewer was able to receive additional clinical notes and documentation. The current treatment plan is an apicoectomy of the tooth. The issue at hand is the medical necessity of the apicoectomy of the tooth.
This service of surgical access to root of bicuspid tooth, tooth 4; extra root for surgical access of tooth, Tooth 4; filling placed during root surgery, tooth 4; cyst removal, upper right quadrant is medically necessary. With the adequate clinical notes that have been received and reviewed by the independent case reviewer, the treatment was medically necessary. There is documented pain, and periapical radiolucency were present. Per the current evidence-based guidelines of the American Association of Endodontists, the service is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pregnancy/ Childbirth. 
Treatment: Home birth with an out-of-network provider. 

The insurer denied coverage for the home birth with an out-of-network provider. 

The denial is overturned. 

This is a female with no significant medical history requesting coverage for a home birth with an out-of-network provider. The pregnancy was reported as uncomplicated. The patient has been evaluated by a licensed provider and not found to have any risk or complication. The insurer had no in-network provider able to render the requested service. 

The patient meets all the insurer's policy requirements for a home birth with the out-of-network provider. Usually referral to an out of network provider is medically necessary if the services are not available from an in-network provider. The Plan stated that there was no in network provider available and since this patient meets the Insurer's criteria for a home birth, the requested services were medically necessary and eligible for coverage. 

The health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient. The home birth with the out-of-network provider is considered medically necessary. 

The carrier's denial of coverage for the home birth with an out-of-network provider is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Broken teeth; facial pain; headaches
Treatment: Crowns for teeth #s 17-32
The insurer denied the Crowns for teeth #s 17-32.
The denial is upheld. 

The patient is a male requesting benefits for crowns on teeth #s 17-32 to restore broken teeth, and to stop facial pain and headaches.

No, the crowns for teeth #s 17-32 are not medically necessary. 

While the patient has severe bruxism (grinding of teeth) that has caused breakage of his teeth, there is the thought that the wearing down of his teeth is also causing his facial pains and headaches. He is requesting a full mouth reconstruction with crowns on all lower teeth. 

Standard of care would include finding and trialing a therapeutic jaw position prior to placement of crowns. The goal would be a position that is comfortable for the patient and alleviates all or most of his problems (pain, headaches). Before new crowns are placed, it is a must that this comfortable jaw position is found and "tried out" for a while. Without this, it cannot be concluded that the treatment will stop this patient's grinding and the pain.  Also, the new crowns should be made to the properly established new bite so that the patient's comfort can continue while biting on the new crowns at the new position.

As of this time, medical necessity has not been established to allow for this much treatment (16 crowns); there is no evidence that this patient has trialed a new therapeutic jaw position. Therefore, placing new crowns is not the proper answer at this point, as the crowns are placed after a proper plan has been established.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male. He has a history of polysubstance abuse.  He presented to the ER (emergency room) with bilateral arm abscesses and possible needle stuck in right side of neck. He was s/p (status post) IV (intravenous) drug use in the neck one week prior.  

The patient's VS (vital signs) were as follows: Temperature 98.4, Pulse 101, respiration rate 19, blood pressure 117/77, pulse oximetry 99%. The patient's exam was remarkable for needle tracks in neck and arms, as well as induration in bilateral forearms. 

The patient's labs were as follows: WBC (white blood count) 8, H/H (hemoglobin/hematocrit) 11.8/37.3, Plt (platelets) 290, Na (sodium) 133, K (potassium) 4.9, BUN/Cr (blood urea nitrogen/creatinine) 15/.9. 

The patient's x-ray revealed foreign body near right sternomastoid area.  Urine toxicology was positive for cocaine and opiates.  Neck CT (computerized tomography) revealed radiopaque needle-like foreign body in superficial subcutaneous soft tissues of anterior neck.  

The patient's CIWA (clinical institute withdrawal assessment) was 2.  The patient was admitted with plan of care for IV (intravenous) antibiotics, methadone and surgery consultation.    

The patient's vital signs were stable. There was no surgical intervention.  The plan was to continue antibiotics, discontinue methadone, continue Ativan.  The patient left AMA (against medical advice).  

No, the Inpatient admission was not medically necessary.

This patient with a history of IVDU (intravenous drug use) was admitted for IV (intravenous) antibiotics for cellulitis. The patient was hemodynamically stable and afebrile.  The patient remains hospitalized for IV antibiotics.  

Indications for inpatient care of cellulitis include the following: Severe infection; suspicion of deeper or rapidly spreading infection; tissue necrosis; marked systemic toxicity or worsening symptoms that do not resolve after 24 to 48 hours of therapy; or patients with underlying risk factors or severe comorbidities.  This patient does not meet criteria for inpatient admission.  The patient did not have evidence of severe infection, spreading infection, tissue necrosis or systemic toxicity.  In addition, the patient did not have severe comorbidities nor had the patient failed outpatient therapy.  The requested Inpatient admission was therefore not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Periodontal disease

Treatment: Dental deep gum and root cleaning to all 4 quadrants (D4341)

The insurer denied coverage for the dental deep gum and root cleaning to all 4 quadrants (D4341).

The denial is overturned. 

This is a female patient who presented to the dentist for care, with identification of periodontal disease in all four quadrants. Recommended treatment was four quadrants of scaling and root planing given multiple areas of 7 millimeter (mm) pocketing. The insurer denied scaling and root planing as requested stating in summary that the information provided does not offer sufficient basis for the requested services such as bone loss or radiographic calculus indicative of periodontal disease. 

In this case, as regards documentation of the periodontal status, in particular the patient's periodontal charting and radiographs, it is evident that there is a level of periodontal disease where there is root surface exposure and alveolar bone loss. All four quadrants exhibit multiple areas of 7 mm pocket depths. Appropriate treatment would be the recommended scaling and root planing to address any ongoing periodontal issues.  This would be the standard of care treatment given the alveolar bone loss and level of periodontal disease as documented on the clinical and radiographic findings. As such these services are considered dentally necessary.

The dental deep gum and root cleaning to all four quadrants (D4341) are considered medically necessary for this patient.

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

The carrier's denial of coverage for the dental deep gum and root cleaning to all 4 quadrants (D4341) should be overturned. The medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Infectious Disease
Pharmacy/Prescription Drugs

Diagnosis: HIV
Treatment: Egrifta
The insurer denied Egrifta. The health plan's determination is overturned. 

The patient is a male with human immunodeficiency virus (HIV). Egrifta was prescribed for HIV-associated lipodystrophy. The patient was treated with this medication for a year with notable reduction in abdominal circumference, abdominal distention, and abdominal girth. The patient stated that the lack of access to this medication after a lack of authorization had a deleterious effect on his physical well-being with emotional stress and disruption of sleep pattern. His waist circumference increased to 111 centimeter (cm) from 106 cm with a waist: hip ratio of 1.13.

A formulary exception is indicated in this case.
Egrifta is Food and Drug Administration (FDA) approved for treatment of HIV-associated lipodystrophy, which the documentation supports that this patient has. The patient responded well to this medication and had an increase in waist circumference when it was discontinued. In addition, there is no formulary alternative provided and none that is FDA approved for treatment of HIV-associated lipodystrophy. In summary, a formulary drug would be ineffective and would not be as effective as the requested Egrifta.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Periodontal disease

Treatment: periodontal scaling and root planing- all quadrants

The insurer denied coverage for periodontal scaling and root planing- all quadrants.

The denial is overturned.

This is a female patient who presented to the dentist for care, with identification of periodontal disease in all four quadrants. Recommended treatment was four quadrants of scaling and root planing given multiple areas of pocketing. The insurer denied scaling and root planing as requested stating in summary that the information provided does not offer sufficient basis for the requested services such as bone loss indicative of moderate to severe periodontal disease.

In this case, it is evident that there is a level of periodontal disease where there is root surface exposure and alveolar bone loss. All four quadrants exhibit multiple areas of 6 millimeters of pocket depths. Appropriate treatment would be the recommended scaling and root planing to address any ongoing periodontal issues. This would be the standard of care treatment given the alveolar bone loss and level of periodontal disease as documented on the clinical and radiographic findings. As such, these services are considered dentally necessary.

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

Based on the above, the medical necessity for the preservice request for periodontal scaling and root planing- all quadrants is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foot Ulcer.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is a male with history of metastatic prostate cancer, type 2 diabetes mellitus, diabetic foot ulcers, atrial fibrillation, recent toe amputation who presented to the hospital for evaluation of post-operative wounds on both feet and a fever. Vital signs were temperature 97.5 F, blood pressure (BP) 141/84, pulse 87, respirations 18, and pulse oximetry 98% on room air. Physical examination revealed complete amputation of both 3rd toes with exposed necrotic tissue and foul-smelling odor. Abnormal laboratory values included white blood cell count (WBC) 11.8, hemoglobin 10.5 and hematocrit 32.4. The patient was admitted and started on intravenous antibiotics. The patient was seen by Plastic surgery, Infectious disease, Vascular surgery and Endocrinology. The patient underwent bilateral foot ulcer debridement and vac placement. The patient returned to the operating room (OR) for flap and skin graft. The patient was then discharged to rehab facility.

The inpatient hospital stay was not medically necessary. This patient presented to the hospital with bilateral foot wounds and required intravenous antibiotics. The patient was also taken to the operating room for surgical debridement, wound vac placement and skin graft/flap. As of the date in question, the patient was afebrile with a stable wound. There was no evidence of an active infection at that point. The patient was tolerating diet and pain was controlled. There were no further plans for surgical intervention. The patient did not have any further inpatient needs. 

This patient was clinically stable after the surgical procedure. The patient met discharge criteria. The patient did not have any clinical needs that required continued inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foreign Body Ingestion
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of developmental delay and swallowed a foreign object on the day of presentation. She was reportedly pointing to her lower neck saying it was uncomfortable. She had no drooling. She was brought to the emergency room (ER) where initially on chest x-ray (CXR), a coin was seen in the upper esophagus. The patient then gagged and the object moved into her stomach. On the second x-ray, the object looked to be multiple coins or magnets stuck together in the stomach. The patient was otherwise healthy, with no vomiting and no respiratory distress. On exam, her vital signs were stable, with no acute findings. Lab results were unremarkable. She was transferred from the ER to the endoscopy suite with a plan for an esophagogastroduodenoscopy (EGD) with foreign body removal. Four (4) hours post arrival to the ER, the patient was taken to the endoscopy suite and had foreign bodies (3 pennies) removed by gastroenterology (GI). After 2 hours in recovery, the patient was discharged home from the post-anesthesia care unit (PACU) in stable condition.
At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary for this patient.

This patient presented with a history of foreign body ingestion. Serial x-rays showed progression of a coin like structure from her esophagus into her stomach. The appearance of the foreign body changed and there was then concern for the presence of magnets in her gastrointestinal tract. Magnets potentially can cause serious complications including intestinal obstruction and perforation. Given the increased risks associated with magnet ingestion, the child was emergently taken to the endoscopy suite and had 3 pennies removed. The patient recovered quickly and fully and was discharged safely from the PACU. This child did not experience any complications and was treated adequately in the emergency setting and then went on to have a procedure performed that is usually done as a same day outpatient procedure. She did not require an inpatient level of care to safely manage her medical condition. The patient had stable vital signs and was never described to be in distress. She had no complications nor did she need out of the ordinary monitoring or care after the procedure. Emergency care followed by an emergent outpatient procedure would not constitute the need for inpatient level of care. Inpatient stay was not medically necessary. This patient's presentation was not acute nor did she require any care that would necessitate inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite.
Treatment: Braces.
The insurer denied the braces. The denial is overturned. 

The patient is a male. The request is for orthodontic benefits.

Yes, the proposed orthodontic treatment is medically necessary. 

The patient has a deep, impinging overbite with soft tissue damage on the palate. This is an "automatic qualifier" according to the handicapping index scale.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations.
Treatment: Inpatient admission.
The insurer denied coverage for the inpatient admission.
The denial is upheld. 

This is a female patient with a past medical history of hypertension, hyperlipidemia, and diabetes mellitus who presented to the Emergency Department (ED) complaining of palpitations. The patient indicated that she was diaphoretic at the onset of her palpitations. The patient denied chest pain and shortness of breath. The patient reported that her son witnessed her going in and out of consciousness; however, she did not fall.  The patient's physical examination revealed that her palpitations resolved. The patient was alert and oriented and was in no acute distress.  

The patient's cardiovascular examination revealed a normal rate and regular rhythm. The patient's blood pressure was 175/96 with a pulse of 120 beats per minute. The patient's oxygen saturation was 99%. It was recommended that the patient undergo laboratory diagnostic studies. The laboratory studies revealed a lactate of 2.5. The patient's troponin was negative and it was recommended that the patient be admitted to rule out neurological etiologies and undergo further evaluation. It was recommended that the patient should be observed however the patient did not wish to be observed given her son could not stay with her overnight. The patient continued to be monitored and underwent a computed tomography (CT) scan of the brain. There were no significant abnormalities noted on the CT. The patient did have a small focus of encephalomalacia seen to the right frontal corona, however it was considered to be due to old ischemic, hemorrhagic or inflammatory insult to the brain. The patient's chest X-ray was negative, and she continued to receive treatment. The following day it was recommended that the patient continue with treatment but no further abnormalities were noted. The patient did not have any further significant adverse events and it was recommended that the patient be discharged on day 4 of admission with instruction to follow-up as outpatient.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient presented with complaints of palpitations. The documentation does not detail that the patient had any evidence of syncope as well as neurological symptoms or cardiac symptoms. The work-up revealed encephalomalacia which was not acute. The documentation indicated that this finding was likely an old ischemic event. The submitted notes do not detail any findings needing an inpatient level of care and admission. The patient could have been observed and treated as well as undergone additional work-up in an outpatient setting. Therefore, as per review of the Milliman Care Guidelines for this patient's clinical presentation, 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.

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: Braces
The insurer denied the braces. 
The denial is overturned. 

The patient is a male. The request is for orthodontic benefits.

Yes, the Braces are medically necessary. The patient has a deep, impinging overbite with damage to the soft tissue of the palate. This is an automatic qualifier according to the handicapping index scale.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low AMH level
Treatment: In vitro fertilization
The insurer denied the In vitro fertilization. 
The denial is upheld. 

The patient is a female. She presented interested in fertility preservation. She did not have a diagnosis of infertility as she had just stopped her contraception. She reported a low AMH (anti-mullerian hormone) level (0.65). 

The patient underwent IVF (in vitro fertilization), though it is unclear from the submitted material how many IVF (in vitro fertilization) cycles she had, and she has currently one euploid embryo frozen. The patient is requesting coverage for additional IVF (in vitro fertilization) cycles.

No, the In vitro fertilization is not medically necessary.

According to ASRM (American Society for Reproductive Medicine), infertility is defined by the failure to achieve a successful pregnancy after 12 months or more of appropriate, timed unprotected intercourse or therapeutic donor insemination. Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after six months for women over age 35 years.

This patient does not have infertility as she never tried and failed to conceive. She presented for fertility preservation through embryo freezing and she had just stopped her birth control method (NuvaRing). As such, this patient does not have any sickness or injury that requires treatment. 

IVF (in vitro fertilization) for this patient is not medically necessary as the patient does not have a diagnosis of infertility. IVF (in vitro fertilization) is being requested for fertility preservation. The patient may not need to preserve her fertility. She could try conceiving naturally when she is ready to get pregnant. Please note that fertility preservation in this patient is an elective procedure. The patient does not have any malignancy or medical condition that would lead to an inability to reproduce in the future. 

Note that studies have shown clearly that a low AMH (anti-mullerian hormone) does not mean infertility, and patients with low AMH (anti-mullerian hormone) can conceive easily when ready to conceive.

In the absence of a diagnosis of infertility, additional IVF (in vitro fertilization) cycles are not medically necessary as supported by current medical literature and any applicable diagnostic/treatment guidelines. 

This patient already has a euploid frozen embryo. If she is interested in conceiving, she could proceed with transfer of this embryo.  The odds of conception and live birth with a euploid embryo are excellent. 

In summary, in the absence of a diagnosis of infertility, additional IVF (in vitro fertilization) cycles are not medically necessary.