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

Diagnosis: Crohn's disease
Treatment: Capsule endoscopy
The insurer denied a capsule endoscopy.
The health plan's determination is overturned. 

This patient is a young female with a history of Crohn's disease. Her disease involves the small bowel. Her fecal calprotectin is elevated, suggesting active intestinal inflammation.

The capsule endoscopy is medically necessary. The use of video capsule endoscopy (CE) in the evaluation of Crohn's disease is consistent with the generally accepted practices and is recommended by the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). Per the NASPGHAN clinical report: "CE has become a key tool to assist in the diagnosis and management of pediatric Crohn disease. The diagnostic yield of CE for the diagnosis of Crohn disease has ranged from 6% to 70%. CE is also used to assess the extent of intestinal involvement and surveying for recurrence of Crohn disease after treatment or postoperatively. Studies have shown CE correlates well with other imaging modalities for Crohn disease with CE revealing good sensitivity compared with magnetic resonance enterography (MRE) and computed axial tomography enterography (CTE). Although the diagnostic yield varies significantly among studies, establishing the presence or absence of SB (small bowel) Crohn disease has played a major role in determining management strategy".
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart Failure
Treatment: inpatient hospital admission
The insurer denied coverage for inpatient hospital admission
The denial is upheld

The patient is an adult who has a history of hypertension, diabetes mellitus, anxiety and depression. The patient also has a history of polysubstance abuse and was on methadone maintenance. The patient presented to the emergency department (ED) with complaints of dizziness with near syncope while standing online for the methadone. No loss of consciousness was reported. The patient denied chest pain or shortness of breath.

At presentation to ED the patient was afebrile with stable vital signs, Temperature was 98.3 degrees Fahrenheit, Respiratory Rate 18, Heart Rate 72 and Blood Pressure 135/71. No orthostatic changes were noted. Oxygen saturation was 97% on room air. The patient had decreased breath sounds on lung exam. Heart sounds were normal. Lower extremity pitting edema was noted. Electrocardiogram (EKG) showed normal sinus rhythm. Troponins were negative. Chest X-ray showed bilateral pleural effusion. The patient was given intravenous (IV) Lasix.

White Blood Cell (WBC) count was 5.8, Hemoglobin 8.8, blood urea nitrogen (BUN)/ creatinine (Cr) 19/1.3. Head computed tomography (CT) was negative for any acute pathology. On admission the patient was ambulating and in no apparent distress.

This patient did not need acute inpatient hospitalization. The patient could have been observed while diagnostic studies were being done. The patient was stable after admission.

This patient could have been switched to oral Lasix and discharged home with cardiac medications and close follow up in the outpatient setting.

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 hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hirschsprung Disease
Treatment: Peristeen transanal irritation system
The insurer denied the Peristeen transanal irrigation system.
The health plan's determination is overturned. 

The patient is a male who was born with Hirschsprung disease who has ongoing issues with fecal incontinence that is impacting quality of life as he is having accidents in school. The patient has used home enemas in the past and is now being recommended for a Peristeen transanal irrigation system to better control his continence. The primary care team is requesting supplies for Peristeen transanal irrigation system.

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

Given the improvement in the continence the patient has received with the Peristeen transanal irrigation system as documented in the medical record, continuing this treatment is medically necessary and is beneficial for the patient for his incontinence. Although the patient's surgical team has not clearly described that the patient has failed home enema treatments. However, there is literature to support that a Peristeen transanal irrigation system can improve continence in patients with incontinence regardless of the underlying condition. In one study by Gordon et al., fecal incontinence and quality of life improved after three months and continued at the three year follow up after the use of Peristeen. Given the impact of incontinence and the improved results the patient has obtained with the early use of Peristeen transanal irrigation system, it appears to be in the patient's best interest to continue with this treatment.

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

Diagnosis: Abdominal pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This patient is an adult male who was admitted after he presented to the emergency room with a three-day history of worsening, intermittent, right lower quadrant abdominal pain. The patient was referred by the primary care provider. The pain was five out of ten (5/10) and sharp / stabbing. The patient had a total bilirubin of 2.4 but other labs were stated to be normal. Chest x-ray (CXR) was normal. Electrocardiogram (EKG) showed sinus bradycardia. Computed tomography (CT) of the abdomen showed no evidence of bowel obstruction or inflammatory bowel disease. However, there was new pneumobilia requiring surgery consult. In the emergency room, the patient was treated with piperacillin / tazobactam and intravenous fluids. Gastroenterology (GI) consult commented that the patient most likely had pneumobilia as a result of prior biliary instrumentation.

The proposed inpatient hospital admission was not medically necessary.

The patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, and did not require prolonged treatment with intravenous hydration or intravenous medications. In addition, the patient did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, did not have hepatic encephalopathy, did not have a prolonged prothrombin time or signs of liver failure, and did not have any complications such as intra-abdominal abscess or a surgical abdomen. The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who was admitted to the hospital with a chief complaint of "left arm heaviness". The patient denied any other neurologic deficits on presentation to the emergency department. She was admitted to the hospital for evaluation of a transient ischemic attack. On presentation to the emergency room, she had normal vital signs and normal laboratory studies. A computed tomography (CT) scan of the head and computed tomography (CT) perfusion scan of the head were unremarkable. A magnetic resonance imaging (MRI) scan of the brain was performed during the hospitalization which was negative for an acute ischemic stroke. The patient's medical history was significant for hypertension and atrial fibrillation. She was instructed to continue with rate control and Eliquis for secondary stroke prevention. The patient was subsequently discharge from the hospital. At issue is the medical necessity of an inpatient stay.

The patient was admitted to the hospital from the emergency room for evaluation of a transient ischemic attack. Transient ischemic attack is treated in observation status in the United States. This entity is defined as neurologic symptoms that resolved within 24 hours. The patient was noted to have some mild right arm heaviness on presentation. No clinically significant weakness was noted on the examination. On admission, the patient had normal vital signs, imaging, and laboratory studies. The MRI of the brain was negative for acute stroke. The patient did not have any significant cardiac arrhythmias, receive treatment for a stroke or transient ischemic attack. The patient was continued on all home medications for the treatment of hypertension, atrial fibrillation, and hyperlipidemia. The patient improved during the observation timeframe. There are no findings to support an acute inpatient admission for treatment of this patient's transient ischemic attack.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dental issues
Treatment: X-Rays, Facial and Gum Surgery on Tooth # 14 
The insurer denied X-Rays, Facial and Gum Surgery on Tooth # 14. The health plan's determination is upheld. 

This is a female with dental issues. Under review is the medical necessity of X-Rays, Facial and Gum Surgery on Tooth # 14. There is no clinical information provided.

X-Rays, Facial and Gum Surgery on Tooth # 14 are not medically necessary for this patient.
No clinical information was provided. In general, if a tooth is non-restorable, an extraction is indicated. Usually, a ridge augmentation is performed at the time of tooth removal to preserve the ridge for an implant. A membrane is indicated to prevent soft tissue infiltration into the bone graft. D4266 is not the correct code as this is the code for a membrane around a natural tooth. The appropriate code is D7956. A CT (computed tomography) would be indicated if an implant is planned but not for the tooth removal. As there is no clinical information provided, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who was transferred to the receiving hospital from an outside emergency department for evaluation of an acute stroke. The patient was exercising and developed generalized weakness, although it was later appreciated that he was weak on the right side. At the time of transfer, the patient only had slight facial asymmetry and there was no significant weakness appreciated in the limbs or on the right side. Following transfer, the patient underwent an evaluation for a stroke including imaging of the brain, blood vessels, and heart. Magnetic resonance imaging (MRI) of the brain showed multiple acute strokes involving the left posterior limb of the internal capsule and left posterior parietal subcortical white matter. The patient had no stenosis on an magnetic resonance angiography (MRA) of the brain. The patient's stroke was attributed to a cardioembolic source versus small vessel disease. The patient had a history of hypertension and he was on a beta blocker causing some bradycardia. For prevention of a stroke, the patient was treated with aspirin and a statin. The patient was subsequently discharged home with outpatient follow up. At issue is the medical necessity of an inpatient stay.

An acute inpatient admission at the receiving facility was not medically necessary.
The patient was transferred to the receiving facility for evaluation of a stroke; however, the patient did not have any significant neurologic deficits at the time of transfer. The patient was only noted to have a slight right facial droop. Any weakness in the arms or legs had resolved. The patient had already undergone a CT scan(computerized tomography) of the head and CTA (CT angiography)of the head and neck at the referring hospital. These were without any acute findings. At the receiving hospital, the patient underwent an MRI of the brain that confirmed an acute stroke. The patient was subsequently treated with the oral medications, aspirin and a statin. The patient did not require any complex rehabilitation or nursing needs as the patient did not have any significant neurologic deficits. The patient was continued on his home blood pressure medication and plans for cardiac monitoring were instituted to rule out any cryptogenic atrial fibrillation. The patient was subsequently discharged home.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #1

Diagnosis: Pelvic congestion syndrome.

Treatment: vascular embolization or occlusion.

The insurer denied coverage for vascular embolization or occlusion.

The denial is upheld.

The patient has a chief complaint of pelvic pain.  She was reportedly diagnosed with pelvic congestion syndrome. Ovarian vein studies revealed bilateral dilatation of ovarian veins with reflux. The treating physician requested coverage for outpatient surgery (37241 x 1). 
The insurer has denied coverage for outpatient surgery (37241 x 1). In a Final Adverse Determination letter, they stated that the patient reported severe lower abdominal pain related to pelvic congestion syndrome (PCS). The current role of vascular embolization or occlusion for PCS remains uncertain.

Two randomized clinical trials suggest that medical treatment with gonadotropin-releasing hormone agonists or synthetic progestins effectively decreases pain associated with pelvic congestion.

Other treatments for pelvic congestion syndrome, which have not been subjected to randomized clinical trials, include:

- Hysterectomy and bilateral salpingo-oophorectomy.
- Embolization of the ovarian veins with or without the internal iliac veins.
- Sclerotherapy.
- Surgical ligation of the ovarian vein. 
Efficacy of these treatments is supported only by observational data and case reports. 

Evidence in the published peer-reviewed medical literature investigating the use of embolization for pelvic congestion syndrome (PCS) exists primarily in the form of small case series and cohort studies with mixed results. 

The optimal diagnostic approach for PCS-related pelvic pain remains unclear, and controlled trials comparing medical and interventional treatments are urgently needed for PCS-associated pelvic pain.  Additional well-designed randomized controlled trials are needed to evaluate the safety and effectiveness of embolization therapy as a treatment for PCS.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes.

Vascular embolization or occlusion does not need approval from the appropriate regulatory bodies for this diagnosis. 

Due to lack of scientific evidence of health improvement, it is unknown if this patient is a good candidate for vascular embolization or occlusion.

The vascular embolization or occlusion is not the best available treatment for this patient at this time.

The adverse risks are increased over standard treatment/services.

The requested service is unlikely to be more beneficial than any of the standard treatments/procedures for this patient.

In summary, the denial of vascular embolization or occlusion and coverage for the requested service / treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who presented to the emergency department (ED) with right lower abdominal pain. Her evaluation in the emergency department (ED) identified normal vital signs, normal lab data and a computed tomography (CT) scan that showed equivocal findings for appendicitis. She was admitted to the hospital with the diagnosis of abdominal pain to monitor for possible appendicitis. A pelvic ultrasound showed a right ovarian hemorrhagic cyst. A gynecology consultation was obtained and outpatient follow up was proposed. The patient remained afebrile with normal vital signs throughout her hospitalization. She was discharged home. At issue is the medical necessity of an inpatient stay.

The available medical record does not support the medical necessity of the requested acute inpatient hospitalization.
The records indicate that this patient presented to the emergency department (ED) on the evening with complaint of right lower abdominal pain. Her evaluation in the ED identified normal vital signs, normal lab data and an equivocal CT scan for appendicitis. She was monitored overnight. A pelvic ultrasound identified findings of a hemorrhagic right ovarian cyst. The patient remained clinically stable with regard to lab and vital signs data. Following completion of a gynecology consultation, the patient was deemed to be stable for discharge home with outpatient follow up.
The records submitted do not support the medical necessity of this inpatient admission. The care provided during this time could have reasonably been rendered with a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Gender Identity Disorder.
Treatment:  Estradiol Valerate 40mg/ml (milligrams/milliliter).

The insurer denied Estradiol Valerate 40mg/ml.  The health plan's determination upheld. 

This is a patient being treated with estradiol valerate for the treatment of gender identity disorder. The patient's provider provided a letter of support for this appeal. The letter states that since switching to a pill form of estrogen, the patient has struggled to consistently adhere to the medication regimen and has been having regression of physical changes. The provider also feels that in their opinion a transdermal patch would not be optimal for the patient due to "her history of sensitive skin reactions to topically applied agents and personal care products." Therefore, the provider requests the injectable estrogen formulation be approved. The plan denied coverage for the requested medication because it is non-formulary. Formulary alternatives to the requested medication include estradiol tablets and estradiol patches.

The formulary drugs available for treating the patient's gender dysphoria have not been proven to be ineffective or have adverse effects. The decreased response to oral estrogen is documented as due to nonadherence with the regimen, not a failure to achieve target levels of serum estradiol. The formulary also contains a transdermal estrogen patch which has not been tried; prior sensitivity to other products is not a contraindication to a therapeutic trial.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chest pain
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This woman presented to the emergency department (ED) via Emergency Medical Services (EMS) complaining of two days of constant left-sided pleuritic chest pain that was exacerbated by movement. En route to the ED, she was treated with aspirin. Her past medical history was remarkable for hypertension, asthma and recent COVID-19 infection. In the ED, her blood pressure was 127/86 with a heart rate of 91 beats/minute. Her room air oxygen saturation was 100%. Her physical exam was unremarkable. An electrocardiogram showed sinus rhythm without acute changes. Her serum troponin level was normal and remained normal when re-measured. Chest X-ray showed no acute pathology. Her D-dimer level was normal. The patient was treated with acetaminophen and ketorolac. She was admitted to the hospital. 

Based on the documentation provided an inpatient hospital admission was not medically necessary.
This woman presented with atypical symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under "observation" status. This approach has been shown to be both safe and effective and is in accordance with current guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and monthly visits.
The insurer denied the Braces and monthly visits.
The determination is overturned.

This is a female patient with a Class II Division 2 malocclusion with maxillary and mandibular crowding. She has a 5-millimeter (mm) overjet and 8 mm overbite. She is treatment planned for 36 months of orthodontics to correct her malocclusion. At issue is the medical necessity of braces and monthly visits.

There is a significant relationship between patients with a deep overbite and the development of incisor wear. (1) This patient has a 100 percent (%) deep bite. If left untreated this will worsen and cause restorative problems. (2) This can also lead to periodontal problems in the future (3) that will be more invasive to correct than the orthodontic problem she currently has. Orthodontic treatment is medically necessary.