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

Diagnosis: Deep Vein Thrombosis

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission

The denial is overturned.

This patient has a past medical history of hyperlipidemia, fibroids, breast cancer (lumpectomy and radiation) and a recent hysterectomy. She presented to the emergency department (ED) after experiencing 2 days of left arm and bilateral lower extremity swelling. The patient denied pain, fever, chills, chest pain, or shortness of breath. Her blood pressure was 130/82 and heart rate was 79 beats per minute. She was in no apparent distress on examination. The physical examination was unremarkable except for bilateral lower extremity swelling and nonpitting edema. The Doppler study of the left upper extremity revealed a nonocclusive thrombus in the mid and distal left brachial vein.  The cephalic vein demonstrated an occlusive thrombus. The remaining left-sided venous structures were unremarkable. The lower extremity venous Doppler studies were unremarkable. The patient was admitted, and Vascular Surgery was consulted. The patient was discharged the following day in stable condition.

The patient had major pelvic surgery, a total abdominal hysterectomy a few days prior to admission and was now found to have a left upper extremity deep vein thrombosis (DVT). As such, she needed anticoagulation and was placed on Lovenox. It is entirely reasonable to admit this patient for bleeding complications as it is only 48 hours after major surgery. The inpatient hospital admission is considered medically necessary for this patient

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 the inpatient hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis Vulgaris
Treatment: Otezla

The insurer denied coverage for Otezla.
The denial is overturned.

The patient has a history of psoriasis vulgaris.  She has been on Otezla for a few years.  Her disease is stable on her current regimen of Otezla with clobetasol.  The request is for continuation of Otezla therapy.  The use of Otezla is medically necessary in this patient as it represents a continuation of therapy.  The patient has been successfully treated with Otezla for a few years without any reported side effects or complications.  

It would not be proper to discontinue a treatment which has proven effective and well tolerated by the patient after a few years of treatment.  Otezla is FDA (Food and Drug Administration) approved for the treatment of moderate to severe Psoriasis.  The use of Otezla is approved under the supervision of the requesting physician and provider. 

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

Based on the above, the medical necessity for Otezla is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligodontia, maxilla and mandible.

Treatment: Implant placement for tooth 7, 8, 9, 10.

The insurer denied coverage for implant placement for tooth 7, 8, 9, 10.

The denial is upheld.

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants in areas as enumerated above.  The dentist is requesting implants over removable partial dentures presumably due to patients reported dysphagia and nausea. 

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in the maxilla and mandible. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include conventional removable dentures. 

In this case the removable partial denture in the maxilla would be entirely tooth borne, the most stable and retentive of all removable appliances. Further the documentation provided does not support, justify, or substantiate the requested treatment.  Therefore, as removable partial dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary.

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

The implant placement for teeth 7, 8, 9, 10 is not considered medically necessary for this patient.

Uphold denial of coverage for dental implants as not medically necessary, as an appropriate alternative standard of care treatment would be conventional removable denture and the medical documentation provided does not substantiate a limitation that would preclude the patient using a removable partial denture. Therefore, as other acceptable alternative treatments are appropriate, and the documentation provided does not support the recommended treatment this renders the endosteal implants and associated services not medically necessary.

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

The insurer's denial of coverage for implant placement for tooth 7, 8, 9, 10 is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: foot ulcer.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a male with a medical history of hypertension and insulin dependent diabetes mellitus who was admitted for a right lower extremity infected foot ulcer, despite outpatient antibiotics, with persistent symptoms of foul smell, purulence and swelling. He was found to have a diabetic skin ulcer with superimposed infection (methicillin-susceptible staphylococcus aureus (MSSA) bacteria) requiring debridement and bone biopsy in the operating room. He was treated with intravenous antibiotics with subsequent conversion to oral antibiotics based on the infectious disease consultants recommendations.

The Inpatient Hospital Admission was medically necessary for this patient.
This patient was admitted for a right lower extremity infected foot ulcer, despite outpatient antibiotics, with persistent symptoms of foul smell, purulence and swelling. As per the clinical documentation, the patient was afebrile, hemodynamically stable, with a respiratory rate of 20 breath per minute. He had an oxygen saturation of 99% on room air, and was not in any distress but was found to have a purulent erythematous ulcer on the medial aspect of the right foot with mild swelling. He was given antibiotics (Ceftriaxone and Flagyl) and started on his insulin regimen with glucose monitoring. On computed tomography (CT) of the foot he was found to have skin ulceration and soft tissue swelling adjacent to the first metatarsophalangeal joint. The patient was seen by podiatry and determined to require operative management. He was taken to the operating room for debridement of the wound and bone biopsy. The culture results demonstrated wound infection with methicillin sensitive staphylococcus aureus (MSSA) bacteria. He was subsequently discharged home on oral antibiotics for the wound with outpatient follow-up. Based on the diabetic skin ulcer with superimposed infection requiring debridement in the operating room, the Inpatient Hospital Admission was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligodontia.

Treatment D6010 surgical placement of implant body: endosteal implant (Tooth #8, #18, #19, #20, #28, #29, #30, #31).

The insurer denied coverage for D6010 surgical placement of implant body: endosteal implant (Tooth #8, #18, #19, #20, #28, #29, #30, #31).

The denial is upheld.

Based on review of the submitted documentation which includes copy of panoramic radiograph, handwritten notes, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants in the areas as enumerated above.  The dentist is requesting implant over removable partial dentures presumably due to patients reported difficulty eating. The insurer has denied the aforementioned services stating that in their estimation endosteal implants are not the only appropriate treatment, and implant services are only covered when there is a documented medical condition that will be alleviated by the implants. The insurer states that the medical records received do not demonstrate such a condition and therefore, the endosteal implants and related services are considered not medically necessary, considered elective and therefore no benefit is available.  

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in the maxilla and mandible. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include conventional removable dentures. In this case the removable partial denture in the mandible would be entirely tooth borne, the most stable and retentive of all removable appliances. Further the documentation provided does not support, justify, or substantiate the requested treatment   Therefore, as removable dentures (partial removable) remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary.

Dental implants are not medically necessary, as an appropriate alternative standard of care treatment would be conventional removable dentures and the medical documentation provided does not objectively substantiate a limitation that would preclude the patient using removable full and partial dentures. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the D6010 surgical placement of implant body: endosteal implant (Tooth #8, #18, #19, #20, #28, #29, #30, #31) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment: Inpatient level of care

The insurer denied coverage for an inpatient level of care.

The denial is upheld.

This is a patient who was seen in the emergency department after an episode of syncope. When initially evaluated, she was unresponsive but subsequently improved. There was no visualized seizure activity. There was no evidence of orthostasis. A head computed tomography (CT) scan revealed evidence of an empty sella but was otherwise normal.

She was admitted to the intensive care unit and underwent magnesium supplementation intravenously. Her workup was significant only for mildly elevated thyroid stimulating hormone. A brain magnetic resonance imaging (MRI) was not performed. An electroencephalogram (EEG) was ordered and there was no evidence that it was performed.  She was seen by Neurology, who believe that she had syncope and not seizures.

She was transferred from the intensive care unit (ICU) to a general medical service patient floor. No further seizures were noted. She was discharged later that day.

The patient had an episode of loss of consciousness. An acute intracranial structural abnormality required exclusion as did seizures. Per Shen et al, and Ropper et al, an acute intracranial event can be ruled out through a CT scan. If ongoing seizures are suspected, routine EEG may also be performed (Ropper et al). The patient otherwise regained consciousness and did not have any evidence of a cardiac arrhythmia. There are no hemodynamic abnormalities, and no evidence of hypotension or hypertension, requiring cardiac or neurological monitoring. She had no comorbidities, such as no coronary artery disease, seizures, autonomic dysrhythmia. Mental status was normal after recovery from the loss of consciousness and there was no documentation of any concern that it would recur. She did not require any intravenous medications or hydration that could not be performed enterally. There was no documented indication for any frequent hemodynamic, pulmonary, or other medical monitoring. Any neurological monitoring could have been performed in the emergency department while in observation, with discharge occurring once an acute intracranial abnormality and seizures have been ruled out. Therefore, the inpatient admission was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment in the best interest of the patient. The inpatient admission is not considered medically necessary for this patient. 

The insurer's denial of coverage for inpatient level of care is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Missing teeth
Treatment: Implants For Teeth 5,10,12,13,14,15,18,19, 20, 30 and 31
The insurer denied the Implants For Teeth 5,10,12,13,14,15,18,19, 20, 30 and 31
The denial is overturned, in part

The patient is a female. The request is for dental benefits for implant placement for teeth #5, 10, 12, 13, 14, 15, 18, 19, 20, 30, 31.

Per the Provider's dental clinical summary, the patient has a failed partial denture history. She has a severe gag reflex, and she is unable to wear conventional partial dentures.

The health plan denied the claim because it was not medically necessary, and per their guidelines, they only approve implants when there is only one missing tooth in the arch, must have adequate bone and space for placement.

Yes, in part. The requested health service is medically necessary, in part.
Specifically, as it pertains to teeth #(number)s  5, 10, 12, 13, 14, 15, the implant placements are medically necessary. However, as it pertains to teeth #s 18, 19, 20, 30, 31, implant placements are not medically necessary.

As evident on the x-rays, the patient is missing teeth #s 5, 12, 13, 14, 15, and #10 is fractured and needs to be replaced.

If the patient is unable to wear a denture due to extreme gag reflex and the teeth that are missing do not lend themselves to be replaced by fixed bridgework, then the only option for restoration of function is implant placement.

With respect to teeth #s 18, 19, 20, 20, 31, the patient currently has fixed bridgework replacing teeth in those areas. There is no information in the dental clinical summary as to why these need to be replaced. There is not any overt gross pathology evident from the x-rays that would dictate implant placement for these teeth.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in part.
The patient is missing five teeth on the maxillary (upper arch), four of these teeth are in the upper left posterior area such that the patient has no premolars or molars present to be able to effectively chew on the left side of the mouth.

Since the patient is unable to wear a partial denture, and the missing teeth do not allow for the configuration of a fixed bridge, there is no other alternative but implant placement.

By not approving this treatment, the patient will continue to have reduced function and the inability to chew on the left side of the mouth, this will eventually lead to increased stress on the dentition on the right side of the mouth as well as drifting of the teeth both inter and intra arch.

As it pertains to teeth #s 18, 19, 20, 30, 31, there is no information submitted that supports the removal of the existing fixed bridge prosthesis to be replaced by implants.
Appeal type: Medical necessity
Decision: Upheld

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

The patient presented with abdominal pain, flank pain, and vomiting. She was having chills but at the time of admission was afebrile. There was no abdominal rebound or guarding. A computed axial tomography (CAT) scan showed fat stranding in the upper abdomen and it was not clear if she had gastroenteritis or pancreatitis. The lipase was 25 and the amylase was 16. Intravenous (IV) hydration and pain medications were given. Her symptoms improved and she was able to tolerate a diet. 

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG (Milliman Care Guidelines) M-05) include hemodynamic instability, peritoneal signs, an inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

Clinical indications for admission for Gastroenteritis (MCG M-170) include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration, severe electrolyte abnormalities, or an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had gastroenteritis and improved with IV hydration. She did not meet MCG criteria for admission for either Undiagnosed Abdominal Pain or Gastroenteritis. She could have been treated with observation status. An inpatient hospital admission was not medically necessary.

The health care plan acted reasonably, with sound medical judgement 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: Formulary Exception
Decision: Overturned

Diagnosis: Chronic atrial fibrillation.
Treatment: Formulary exception for Eliquis.

The insurer denied the Formulary exception for Eliquis.  The denial is overturned.

The patient is a female with chronic atrial fibrillation. She is being treated with anti-coagulation per guidelines. She was initially treated with Coumadin, and switched to a NOAC (non-vitamin K oral anticoagulant) (DOAC [directly acting oral anticoagulants]), Eliquis. This was well tolerated, but Xarelto is the preferred NOAC (non-vitamin K oral anticoagulant) on formulary. The patient is on Primidone, which interacts with Xarelto. The request was made to allow coverage of Eliquis.

Yes, the health plan should cover the Formulary exception for Eliquis.
Eliquis is appropriate and the best drug in this clinical situation. The preferred formulary Xarelto would have potential complications in this patient due to her use of Primidone.

The health plan has determined that NOAC (non-vitamin K oral anticoagulant) drugs have advantage over Coumadin by including Xarelto as an option. Eliquis was well tolerated and is the appropriate substitute for formulary drug.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral Knee Pain. 
Treatment: Current procedural terminology (CPT) code 97110, PT (physical therapy) for 2 additional visits. 

The insurer denied coverage for current procedural terminology (CPT) code 97110, PT for 2 additional visits. 
The denial is upheld. 

The patient has bilateral knee pain. Treatment included physical therapy.  Under review is the medical necessity of CPT code 97110, physical therapy (PT) for 2 additional visits.
Based on the enclosed clinical information available for review, current procedural terminology (CPT) code 97110, physical therapy (PT) for 2 additional visits were not medically necessary.  The physical therapy treatment notes provide insufficient objective clinical evidence to support the medical necessity of the services provided.  The clinical records do not demonstrate the medical necessity of continuing a structured out-patient physical therapy treatment program from beyond the 3 physical therapy visits approved.  This physician would also agree, the medical records do not demonstrate improvement can be expected within a reasonable time frame, services are needed to maintain, prevent, or slow a decline in condition, and the skill of a therapist is needed to manage, carry out, or set up a safe and effective treatment program.  The patient should be functionally independent performing a home exercise program at the conclusion of the approved 3 physical therapy visits. 

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based). 

From a physical medicine and rehabilitation/pain management perspective as well as within a reasonable degree of medical certainty, current procedural terminology (CPT) code 97110, physical therapy (PT) for 2 additional visits was not medically necessary. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 
	
Based on the above, the medical necessity for the current procedural terminology (CPT) code 97110, physical therapy (PT) for 2 additional visits is not substantiated. The insurer's denial is upheld.