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

Diagnosis: Acute Kidney Injury (AKI)

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is an adult male patient with past medical history of pre-diabetes, hypertension, and high lipids who presented to the Emergency Room (ER) with complaints of dizziness, chills, loss of appetite and vomiting. The patient had recently had a ureteric stent placed. He was diagnosed with a urinary tract infection (UTI) and was noted to have high levels of potassium (K+), lactic acid, creatinine, and low blood pressure. A Foley catheter was placed for a distended bladder. The patient admitted for acute kidney injury (AKI), and he was given intravenous (IV) fluids and IV antibiotics. A computed tomography (CT) scan showed a left stent in place and a 3.6 millimeter (mm) left distal ureteral stone. The patient improved with treatment; his labs values and blood pressure also improved, and he was considered stable for discharge on oral antibiotics and outpatient Urology follow up. 

The insurer has denial coverage for the inpatient hospital admission as not medically necessary. They stated there were no notes stating that the patient did not get better after observation treatment and that the needed care could have been given in the ER or observation area.  
The appeal on behalf of the hospital is noted and read in detail. Per Milliman Care Guideline (MCG) Health (24th), the patient appears to meet several indications for admission to inpatient care. These included: hemodynamic instability (low blood pressure in ER of 75/57; increased lactic acid level, increased K+, creatinine = 4.16 [blood urea nitrogen (BUN) = 40]); urinary system finding that requires invasive procedure or places patient at higher risk for systemic illness (previous urologic surgery [stent placement], bladder emptying significantly impaired [neurogenic bladder, bladder outlet obstruction; patient was in retention in the ER and required Foley placement]); and acute renal failure (acute on chronic renal failure, it appears).

Therefore, based on the above, there was sufficient evidence to support that the hospital admission was considered medically necessary treatment for the patient's condition.

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

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

Diagnosis: Bipolar Disorder. 
Treatment: Inpatient Mental Health. 

The insurer denied coverage for inpatient mental health.	 

The denial is overturned. 

This is the case of an adult female patient who was admitted to this inpatient mental health treatment due to acute manic symptoms. She reportedly had racing thoughts, elated and irritable mood, labile affect, poor sleep, grandiosity, hypersexuality, pressured speech, mood instability, unlimited energy, limited insight and judgment, and poor functioning. The patient reportedly felt unstable. She had diagnosis of bipolar disorder and cannabis use disorder. She also was using cannabis and had a positive toxicology for tetrahydrocannabinol (THC). The patient reportedly had poor self-care. She reportedly had stress in her relationship with her mother. The patient reportedly had a history of past self-injurious behavior. She took Quetiapine, Bupropion, Gabapentin, and Xanax, and had electroconvulsive therapy (ECT). She was discharged after putting in a 72-hour letter regarding voluntary status. 
 
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and also that patients with severe agitation, aggression, psychotic symptoms, suicidal or homicidal plan or intent or attempts, manic episodes, severe major depressive episodes, or inability to adequately care for basic self-care needs are in need of hospital treatment. 

In this case this patient had reports of acute manic symptoms including racing thoughts, elated mood, labile affect, poor sleep, grandiosity, hypersexuality, pressured speech, mood instability, unlimited energy, poor functioning during the denial period and was not at her baseline and not able to care for her basic needs so she required 24-hour hospital treatment. The patient had ECT and took psychotropic medications due to her manic symptoms. She had reports of stressors at home and was also using cannabis and had a past history of self-injurious behavior. While presenting with acute manic symptoms she was considered unable to care for her basic needs and needed hospital treatment. Notes reported that she still had elated and irritable mood and labile affect though mood was better than previously, and she had fair self-care, partial insight and judgment, and less pressured speech so she was considered not a candidate for involuntary hospitalization. The patient reportedly put in a 72-hour letter, so she was discharged even though the recommendation was to continue hospital treatment to better target manic symptoms. Her symptoms were not considered severe enough to hospitalize her against her will. 

The medical records provided enough evidence to support that she required 24-hour hospital treatment. It did not appear that the health care plan acted reasonably or in the best interests of the patient. 

The insurer's denial of coverage for inpatient mental health treatment is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Migraines.
Treatment:  Botox Injection (100 UNIT).
The insurer denied the  Botox Injection (100 UNIT).
The denial is upheld.

The patient is a female. She who has been under the care of providers for migraine headaches. Her history is also notable for cervicalgia and an unspecified brain tumor (thought to be a sub-ependymoma of the fourth ventricle).  Onset of the patient's neck pain following a fall down stairs and a head injury. The patient's migraines were described as being "throbbing, pulsating, nagging over the pack of the head with radiation to the neck with photophobia and hyperosmia".

The patient has previously had trials of ibuprofen, Tramadol, escitalopram, duloxetine, cyclobenzaprine, TPIs (trigger point injections) and ONBs (occipital nerve blocks). At a follow-up visit, the patient reported daily headaches, and approximately 12-15 migraines/month. Migraines were said to last six to eight hours in duration. The patient's migraines were said to have worsened in the three months preceding the appointment. Medications used by the patient at the time of the visit included escitalopram 20 mg (milligrams), Vitamin B12 and Vitamin D3. At the time of the visit, her treating provider recommended to progressing to treatment with Botox for migraine prophylaxis.  A request was made of the patient's health plan for coverage of Botox injections.

No, the requested Botox is not medically necessary.
In this case, the patient is noted to have a history of chronic migraine headaches. The patient is only noted to have trialed one drug that is recognized in authoritative literature for migraine prophylaxis (duloxetine). The patient is not noted to have tried any other validated therapies for the prophylaxis of their migraine headaches to date.

The generally accepted standards of practice in the prophylaxis of chronic migraine are to trial patients on multiple oral prophylactic drugs prior to a trial of Botox. In this case, the patient has not had trials of such drugs.  She is not readily noted to have any FDA (United States Food and Drug Administration)-listed contraindications to the use of other classes of prophylactic therapies for migraine headache at this time (aside from anti-depressants, which are precluded due to possible drug-drug interaction).  The patient otherwise does not have any listed contraindications to a trial of CGRP (calcitonin gene-related peptide)-based agents for migraine prophylaxis.
The health plan denied the request for Botox noting that the patient had not had adequate trials of at least two oral prophylactic medication classes, or a trial of a CGRP (calcitonin gene-related peptide) inhibitor drug.

It should also be noted that Botox is not otherwise identified as being "more effective" than other prophylactic medications for chronic migraine (for example, see Frank et al). In this setting, it cannot be concluded that it would be expected that the requested drug would result in superior clinical outcomes when compared to the plan's formulary drugs. For these reasons, the request would not be considered to be medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Decompensated Systolic Congestive Heart Failure (CHF)

Treatment: hospital admission

The insurer denied coverage for hospital admission.

The denial is upheld.

This is the case of an adult male patient with a past medical history notable for congestive heart failure , left ventricular systolic dysfunction with ejection fraction (EF) 20% (percent), mitral valve replacement, and atrial fibrillation. He presented to the hospital with a 3-day history of worsening shortness of breath and orthopnea. He reported that his symptoms were similar to those he had experienced prior to his mitral valve surgery. The patient was found to have respiratory distress and hypoxia requiring oxygen supplementation. The troponin levels were borderline, but not diagnostically positive for myocardial ischemia or infarction. Blood pressure was 160/103 with a heart rate between 88-120. The rhythm was atrial fibrillation. His oxygen saturation in the Emergency Room (ER) was 96% on room air. The patient was admitted with acute decompensated systolic CHF. He was started on intravenous (IV) Lasix. An echocardiogram was performed, showing EF of 25%, mean mitral valve gradient of 5 millimeters of mercury (mmHg), and at least moderate mitral regurgitation. He was transitioned to oral Lasix 40 milligrams (mg). He was also started on Entresto and spironolactone. Amlodipine was discontinued. The patient was cleared for discharge home with outpatient follow-up appointments. 

The patient was admitted with symptoms of CHF. His care could have been rendered under observational status. There was clinical CHF supporting necessity of observational care, while inpatient admission status was not met due to lack of severity of disease or comorbidities. There was no evidence of myocardial ischemia, hemodynamic instability, electrolyte abnormalities, hypoxemia, or other indications to substantiate medical necessity for acute inpatient admission status for the dates under review. Per Milliman Care Guidelines (MCG) 24th Edition Guideline Heart Failure: Observation Care the patient's care could have been provided under observational level of care. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

Inpatient admission was not medically necessary for this patient.

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

Diagnosis: Excess Skin

Treatment: Hip lift and abdominoplasty (procedure code 15834 and 15847) and full hospital admission

The insurer denied coverage for a hip lift and abdominoplasty (procedure code 15834 and 15847) and full hospital admission.

The denial is upheld.

The treatment is not medically necessary. The initial consultation note indicates that the patient's excess skin causes him anxiety. He "denies rashes, changes in exercise tolerance or difficulty using the bathroom." The records do not include any primary care provider (PCP) documentation of skin fold rashes or health related problems due to the excess skin. According to the MCG (Milliman Care Guidelines), 25th Edition, Panniculectomy, panniculectomy surgery is medically necessary if the skin folds are causing rashes or difficulty with activities of daily living despite medically supervised treatment. The records do not document complications from the pannus, rashes or difficulties with activities of daily living. The treatments are cosmetic body contouring procedures with the primary intent to improve appearance. The patient is likely to derive emotional benefit from the surgery, but his physiologic health will not be improved.

There was not sufficient evidence to support that a hip lift and abdominoplasty are medically necessary treatments for the patient's condition.

The health care plan did act reasonably, with sound clinical judgment, and in the best interest of the patient.

The insurer's denial of coverage for a hip lift and abdominoplasty (procedure code 15834 and 15847) and full hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke.

Treatment: Inpatient emergency admission.

The insurer denied coverage for inpatient emergency admission.

The denial is overturned. 

This female patient has a history of anemia and uterine fibroids

The patient is a female with a past medical history of anemia and uterine fibroids. She presented to the Emergency Department (ED) with new onset stuttering. The patient had a headache rated 6/10. The temperature was 101.3 Fahrenheit. A code stroke was called. The patient was evaluated by Neurology. She was stuttering on examination. There was no motor or sensory deficit on examination and no pronator drift. The computed tomography (CT) of the head and CT angiography (CTA) of the head and neck were unremarkable. The patient was treated with acetaminophen, aspirin, fluids, antibiotic, and Crestor. The urinalysis revealed a urinary tract infection (UTI). The patient was given packed red blood cells (PRBC) for a low hemoglobin. She was admitted for acute stuttering as stroke versus stroke mimic. The patient was to undergo a magnetic resonance imaging (MRI) and MR angiography(magnetic resonance angiography), echocardiography, cardiac monitoring, rehabilitation, and a continued fever work-up. Neurosurgery was consulted for xanthochromia found on the lumbar puncture. The recommendation was for possible cerebral angiogram. The CT scan of the spine and thoracic echocardiogram were within normal limits. The patient was stabilized and discharged.

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

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

Diagnosis: Shoulder pain
Treatment: Joint Surgery (29806-incision of shoulder joint capsule using and endoscope and 29807-repair of shoulder socket cartilage using an endoscope) 
The insurer denied the joint surgery (29806-incision of shoulder joint capsule using and endoscope and 29807-repair of shoulder socket cartilage using an endoscope). 
The denial is upheld. 

The patient is a male with right shoulder pain. He was initially evaluated the previous year. He had reported eight shoulder dislocations. He was referred for an MRI (magnetic resonance imaging) arthrogram and found to have a labral tear. He reportedly was treated with ice, heat, rest and anti-inflammatories. He reportedly could not obtain other services due to COVID. He underwent shoulder surgery.

No, the surgery was not medically necessary.

The applicable criteria are AIM (Anthem, Inc. Medical) Clinical Guidelines. These are generally accepted guidelines in the Orthopedic community. The AIM Clinical Guidelines criteria were not fulfilled.

Per the guidelines criteria for Arthroscopic or Open Procedures for Chronic Shoulder Instability/Laxity, Capsulorrhaphy (Bankart procedure) may be considered medically necessary when ALL of the following criteria are met:
1) History of a shoulder dislocation, MET 2) Positive apprehension/relocation test, MET 3) Shoulder pain and/or instability which interferes with age-appropriate activities of daily living, MET 4) MRI demonstrates at least ONE of the following: a) Bankart/labral lesion b) Hill Sachs lesion MET c) Capsular tear 5) Failure of at least 12 weeks of conservative management (unless has multiple dislocations during management) NOT MET.

The patient did not receive three months of conservative treatment (stabilization/strengthening exercises). Therefore, the procedure would not be indicated. The reported rest and medication would not be considered sufficient. It would be important to provide a course of PT (physical therapy) prior to surgical intervention.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: Cimzia 400 milligrams (mg) / 2 milliliters (mL) Syringe Kit.
The insurer denied the Cimzia 400 milligrams (mg) / 2 milliliters (mL) Syringe Kit.
The denial is overturned.

The patient is a female with psoriasis for whom Cimzia is requested. She has tried and failed various topical medications. She used Ilumya with excellent results for two years but had to stop due to insurance coverage changes.

Yes, the proposed treatment with Cimzia is medically necessary.
Per the plan requirements, the patient has not tried and failed, or the patient is a candidate to try, at least a three-month trial of phototherapy. 

The medical records indicate this patient has psoriasis and is currently completely clear on Ilumya, per office visit. The appeal letter indicates the patient is in process of starting a family and phototherapy is contraindicated.

Even though narrowband ultraviolet-B (NB-UVB) and broadband ultraviolet-B rays have not shown to cause fetal abnormalities or premature deliveries, there are concerns that they could create a deficiency in serum folate levels.  Psoralen plus ultraviolet-A (PUVA) phototherapy should be avoided due to a few cases where premature labor and fetal abnormalities resulted.

Most oral therapeutic options are either not safe to take during pregnancy or there is limited data; these include methotrexate, ciclosporin, acitretin, and apremilast.

When it comes to considering biological therapies, there is also limited data. However, antitumor necrosis factor (anti-TNF) inhibitors are supported as a safe option during pregnancy if a patient is experiencing severe psoriasis symptoms. This includes etanercept, infliximab, adalimumab, and certolizumab pegol.

Per the published peer reviewed literature, the data on safety in pregnancy supports use of tumor necrosis factor (TNF) alpha inhibitors, such as Cimzia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior Crossbite.

Treatment D8080 braces and D8670 monthly visit.

The insurer denied coverage for D8080 braces and D8670 monthly visit.

The denial is upheld.

The dental director states that the Handicapping Labio-Lingual Deviation (HLD) index is 14. The provider states that the patient automatically qualifies as there is an anterior crossbite. In order to qualify with an anterior crossbite, there must be clinical attachment loss and recession of the gingival margin. There is no crossbite evident and no clinical attachment loss and recession of the gingival margin evident on the photographs. The different gingival levels are due to the malposition of the teeth and not due to recession. 

Per An Introduction to Orthodontics, one or more of these dental traits that would have an adverse effect on the longevity of dentition, indicating high need for correction:

1)	Increased Overjet.
2)	Increased traumatic Overbites.
3)	Anterior crossbites causing decreased periodontal support.
4)	Unerupted impacted teeth (where there is danger of pathology).
5)	Crossbites associated with mandibular displacements.

Per the clinical records, the patient does not meet the requirements. There is no increased overjet, traumatic overbite, anterior crossbite, impacted teeth or crossbites associated with mandibular displacements.

The guidelines for braces are not met.

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visit is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraines

Treatment outpatient procedure codes 64405 x (times)1 and 64450 x1, occipital nerve injections

The insurer denied coverage for outpatient procedure codes 64405 x1 and 64450 x1, occipital nerve injections

The denial is overturned

This is an adult female with a history of migraines and occipital neuralgia. She presented to the Neurologist's office for evaluation of migraines. An electromyogram (EMG) had not confirmed radiculopathy. Magnetic resonance imaging (MRI) of the brain revealed a possible Chiari I malformation. It was otherwise negative. The patient reported 2-3 debilitating headaches per month. The treating practitioner recommended an occipital nerve block to treat migraines. 

Souzdalnitski et al. (1) reviewed the role of occipital nerve block in occipital neuralgia and stated: "Occipital nerve block (ONB) allows blockade of nociceptive afferent fibers distributed over the occipital region, vertex, sides of the head, as well as upper cervical region, which is known to interact with the trigeminal complex. ONB may provide acute headache relief, abort an intractable headache cycle, or serve as part of prevention strategies for occipital neuralgia, migraine, cluster headaches, and other common headache disorders; ONB typically provides rapid pain relief, lasting days to weeks and months. ONB can be performed blindly or with ultrasound guidance. They are technically simple and well tolerated by patients and, if accurately performed, are remarkably safe."

Similarly, Jung et al. (2) advocates the use of occipital nerve block for treatment of occipital neuralgia and it is part of the diagnostic process (3) supported by clinical practice classification guidelines.

This adult female has both migraine without aura and occipital neuralgia.  She has pain in the occipital region that is different from her migraine pain. She has symptomology that is indicative of occipital neuralgia and on physical exam, tenderness over the left greater and lesser occipital nerves. 

The requested procedure is medically reasonable and necessary. 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 the outpatient procedure codes 64405 x1 and 64450 x1, occipital nerve injections is substantiated. The insurer's denial is overturned.