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

Diagnosis: shortness of breath
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a girl who presented with fever, cough, and respiratory distress. She was well until a day prior to presentation when she developed a cough and breathing difficulty. Her symptoms progressed and she developed post-tussive emesis, abdominal pain, and decreased appetite. She was therefore brought to the emergency department for care.
In the emergency department, she was found to have severe respiratory distress. Her heart rate was 150 and respiratory rate was in the 30s-40s. She was found to have diffuse wheezes with decreased breath sounds at the lung bases and retractions. A chest x-ray was concerning for atypical pneumonia, and laboratory values revealed rhino/enterovirus infection. She was given 3 albuterol/Atrovent nebulized treatments as well as methyl prednisolone, terbutaline, and magnesium sulfate. However, she had only mild improvement, and therefore was admitted to the hospital for further care for status asthmaticus.

Inpatient Hospital Stay was medically necessary for this patient, due to the severity of her symptoms and the need for intensive treatment and monitoring.
This is a young girl who presented with status asthmaticus. She had severe respiratory distress with tachypnea and retractions at the time of presentation, and despite appropriate and aggressive treatment in the emergency department she continued to have significant symptoms. She required ongoing treatment with frequent bronchodilators (initially every 2 hours) as well as methylprednisone and intravenous fluids. This level of care requires an inpatient setting both for the administration of intensive therapies and for close monitoring.
The decision making at the time of admission for this patient was consistent with her young age, the presence of status asthmaticus with continued symptoms despite appropriate care, and the need for ongoing intensive therapies along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders - Psoriasis
Treatment: Pharmacy/Prescription Drugs - Simponi Aria Infusion
The Health Plan denied the Simponi Aria Infusion as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

This patient has a history of psoriatic arthritis and skin psoriasis. The patient has previously tried methotrexate, Remicade and Orencia. Currently he has been on Orencia with apparently good control of psoriatic arthritis, but not an ideal control for skin disease. The patient's treating rheumatologist wanted to switch the Orencia to Simponi Aria infusion. The patient has needle phobia and the patient's treating rheumatologist was concerned about the thrombosis risk with Xeljanz. According to the notes submitted for review, the patient has not had a thrombotic episode in the past. The request to approve Simponi Aria was denied, as Enbrel, Humira, and Xeljanz were the preferred agents.

The treatment with Simponi Aria is medically necessary for this patient, considering that the current treatment Orencia is not controlling the skin psoriasis very well.

Many biologicals and small molecules are approved for the treatment of psoriatic arthritis. Choice of medication is based upon patient preference including oral, injectable versus intravenous medication. Additionally, the patient's comorbidities affect the choice of medication. In the current case, this patient is reluctant to try injectable medication because of the fear of needles. The preferred medications, including Enbrel and Cosentyx are self-injectable medications. Xeljanz is also a preferred agent. Xeljanz is a slightly newer drug as compared to the other medications like Simponi Aria. There has been increasing concern about the safety of Xeljanz as more real-world data is available on the use of Xeljanz. The Food and Drug Administration (FDA) recently issued warnings about increased risk of serious heart-related events, cancer, blood clots, and death with Janus Kinase (JAK) inhibitors. Choice of Simponi Aria for the treatment of this patient is relatively safer and more likely to have patient adherence to the treatment, considering all these factors listed above including a better safety profile of Simponi Aria as compared to Xeljanz and that Simponi Aria is an intravenous (IV) medication, and the patient is reluctant to take the alternative Enbrel and Cosentyx because of the injectable nature of these drugs. The treating rheumatologist is concerned about thrombosis risk with Xeljanz. Simponi Aria has been shown to be effective for psoriatic arthritis and skin psoriasis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left shoulder Pain
Treatment: Physical therapy sessions (codes for 97140: manual therapy, 97110: therapeutic exercise, and 97032: electric stimulation-constant attendance)
The insurer denied coverage for physical therapy sessions (codes for 97140: manual therapy, 97110: therapeutic exercise, and 97032: electric stimulation-constant attendance).
The denial is upheld.

This is a patient who developed left shoulder pain after exercising.  Treatment included physical therapy.  Currently under review is the medical necessity for physical therapy sessions (codes 97140: manual therapy, 97110: therapeutic exercise, and 97032: electric stimulation-constant attendance).

The physical therapy treatment notes made available for review provide insufficient objective clinical information to support the medical necessity for the dates of service under review.  The clinical records do not establish the medical necessity of a structured outpatient physical therapy treatment program.  There is no documentation of a specific diagnosis or detailed clinical assessment.  This physician also agrees with the insurer regarding the lack of documentation regarding the services performed, areas of (modality) application and the requirement for one-on-one professional supervision to perform the intervention.  

From a physical medicine & rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, based on the enclosed clinical information available for review, physical therapy sessions (codes 97140: manual therapy, 97110: therapeutic exercise, and 97032: electric stimulation-constant attendance) were not medically necessary.

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

The insurer's denial of coverage for physical therapy sessions (codes 97140: manual therapy, 97110: therapeutic exercise, and 97032: electric stimulation-constant attendance) is upheld.  Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth pain, abscess and decay 
Treatment: D2740 Porcelain Crown, D2950 Core Buildup Including Pins, Tooth #6 
The insurer denied the D2740 Porcelain Crown, D2950 Core Buildup Including Pins, Tooth #6. 
The denial is overturned. 

The patient is a female. The request is for dental benefits for tooth # (number) 6, core build-up and porcelain crown. Per the provider's clinical findings, the patient presented with pain, abscess and areas of decay on mesial and distal aspect of tooth #6. The tooth had been previously endodontically treated (root canal). 

The health plan denied the claim because it "did not see any injury or decay to tooth #6." The provider appealed the claim based on the clinical findings and the proposed treatment plan. 

Yes, the proposed treatment of core build-up and porcelain crown on tooth #6 is medically necessary. 

As stated in the provider's clinical findings, the endodontist's report and the pre-op (checkup before the procedure), tooth #6 shows periapical translucency consistent with an infection. The post-op (checkup after the procedure) x-rays show that the tooth was endodontically re-treated (root canal) and decay removed. 

An endodontically (root canal) treated tooth has had the nerves and the blood vessels removed; the tooth tends to become brittle and is prone to subsequent fracture. 

The standard of care is for this tooth to be built-up to replace any structure loss as a result of decay or access during the procedure. A crown is then placed to restore form and function and aid in the prevention of any subsequent fracture. 

No, the health plan did not act reasonably, with sound medical judgement, or in the best interest of the patient. 

It is evident from the x-rays and reports submitted that this tooth has undergone root canal treatment. Core build-up and crown would be the optimal treatment to provide the most favorable prognosis and protection of this tooth. 

Not approving this treatment puts the patient's oral health and tooth at risk for possible fracture and eventual loss of this tooth.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, Abdominal Pain and Loose Stools.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. The patient had a prior history of hypertension and elevated cholesterol. The patient presented with the complaints of abdominal pain and fevers to 103. The patient reported that he developed this pain after eating barbequed meat. He developed left lower quadrant pain. He presented to his PCP (primary care provider) and was found to be febrile and directed to the emergency room.

On examination, the patient had left lower quadrant pain. He was mildly tachycardic. His sodium was 131. He had a normal white count. The patient was febrile to 102.9. The lactic acid was elevated at 2.2. The ALT (alanine aminotransferase) and AST (aspartate aminotransferase) were elevated at 2445 and 3418. An ultrasound was unremarkable, and a CT (computed tomography) scan showed possible cirrhosis. The patient was admitted for sepsis and acute hepatitis.

The patient received antibiotics and IV (intravenous) Tylenol. The patient received supportive care. Repeat CT (computed tomography) scan testing showed multiple hepatic masses concerning for cancer. The liver enzymes trended downwards. The patient was discharged with the plan for an outpatient work-up. 

No, the Inpatient admission was not medically necessary. The care as provided was medically appropriate, but not medically necessary at the level at which it was provided.
Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had a fever with elevated liver enzymes and abdominal pain without acute findings. He did not evidence a change in mental status, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such, the care could have been rendered at a lesser level.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite with gingival attachment loss.
Treatment:  D8080 Braces and D8670 Monthly Visit (x12), Pre-services.
The insurer denied the  D8080 Braces and D8670 Monthly Visit (x12), Pre-services.
The denial is overturned.

The patient is a male. The request is for dental benefits for orthodontic treatment (braces), monthly visits, pre-service.  Per the Provider's clinical assessment, the patient presents with skeletal class III-hypoplastic maxilla, asymmetric mandible-left side longer, moderate maxillary and mandibular spacing, right posterior crossbite, anterior crossbite with gingival attachment loss (mandibular canines).

The health plan denied the claim because the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) Index report, the score needed for approval for orthodontic treatment. The provider appealed based on the diagnoses that were determined after his clinical consultation.

Yes, the proposed treatment of orthodontic therapy (braces), monthly visits, pre-service is medically necessary.
As supported by the documentation submitted, the patient presents with both a posterior crossbite (right side) and an anterior crossbite bilaterally (mandibular canines). In a crossbite situation, the upper teeth are inside or lingual to the lower teeth; this is the opposite of the normal relationship of the upper and lower teeth.  This abnormal relationship can cause difficulty with chewing, proper speech, and can eventually lead to more shifting of the dentition.

No, the health plan did not act reasonably, with sound medical judgement and in the best interest of the patient.
If these conditions are not treated, the consequences of decreased proper function as it relates to proper speech, chewing, and the shifting of the teeth will only lead to more complications of the patient's dentition over time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Painful chewing.
Treatment: D6010 Implant Placement Tooth 4, 5, 12, 13, 19.
The insurer denied the D6010 Implant Placement Tooth 4, 5, 12, 13, 19.
The denial is overturned.

The patient is a female. The request is for pre-service for implant placement (D6010) teeth #4, 5, 12, 13, 19.

Per the Provider's clinical exam, the patient is complaining of pain upon chewing, defective filling on teeth. The patient has difficulty wearing partial dentures due to gag reflex. The patient suffers from dysphagia and nausea as a result of dentures.

Implant placement was suggested to improve function. The Health plan denied the claim because it is not considered medically necessary. The Provider appealed the case based on the diagnoses and the patient's condition.

Yes, the proposed treatment of implant placement (D6010) is medically necessary.
The x-rays support that this patient is in need of these five teeth being replaced. All teeth act to keep the other teeth within the arch as well as the opposing arch in place. As detailed in the Provider's letter, this patient has had a failed history of partial denture use due to her hypersensitive gag-reflex. The patient is unable to tolerate the placement of an upper partial.

Implant placement is the standard of care to restore function in a case where a partial is not an option. Therefore, the requested health service is medically necessary.

No, the health plan did not act reasonably, with sound judgement and in the best interest of the patient.
Based on the circumstances of this patient, if the patient is left untreated the complications that arise from the missing teeth will only be compounded over time and lead to further problems of the patient's dentition over time.

Increased difficulty chewing, shifting and drifting of teeth, pain upon chewing, inadequate mastication can lead to digestive issues.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent Syn 300.
The insurer denied the Dupixent Syn 300.
The denial is upheld.

The patient is a male with history of atopic dermatitis. He has failed topical steroids and tacrolimus ointment. His provider is requesting approval for Dupixent.

No, the treatment with Dupixent is not medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Atopic dermatitis is a chronic difficult-to-manage condition that can cause significant psychosocial and physical impairment. There is no gold-standard treatment for this condition. Despite a rising prevalence, effective and safe therapeutics for patients with moderate-to-severe AD (atopic dermatitis) are limited due to toxicity and side effects.

Although Dupixent is FDA (United States Food and Drug Administration)-approved for atopic dermatitis, this patient has not failed both of the health plan's formulary preferences of tacrolimus ointment and Eucrisa.

The patient has not failed the step therapy of both Eucrisa and tacrolimus; he has only failed topical steroids and tacrolimus, but not Eucrisa. Eucrisa would be an appropriate treatment option prior to Dupixent, as its safe, immunosuppressive properties function well to reduce the inflammatory response in atopic dermatitis patients, and thereby alleviate symptoms. It is widely used and is considered safe and effective medications when properly managed.
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 with a history of alcohol and opioid abuse. He presented for detox. He drinks 2-6 packs of beer per day and uses 3 bags of heroin IV (intravenous) daily. He has nausea, vomiting, diarrhea, abdominal pain, anxiety, tremors, agitation, and sweating.

The patient's vital signs were as follows: Temperature 97.8, pulse 92, respiration rate 18, blood pressure 132/81. The patient's exam revealed COWS (clinical opiate withdrawal scale) 8 and CIWA (clinical institute withdrawal assessment) 10. CBC (complete blood count) and BMP (basic metabolic panel) unremarkable.

The patient was admitted with plan of CIWA (clinical institute withdrawal assessment) and methadone protocol.

On day two, the patient's vital signs were stable. CIWA (clinical institute withdrawal assessment) 6. COWS (clinical opiate withdrawal scale) 8. The plan was to continue management with methadone and CIWA (clinical institute withdrawal assessment) protocol.

On day three, the patient's vital signs were stable. CIWA (clinical institute withdrawal assessment) 0. COWS (clinical opiate withdrawal scale) 0. The plan was to continue current management.

On day four, the patient's vital signs were stable. The plan was for transfer to rehab on day five.

On day five, the patient was discharged to rehab.

No, the Inpatient admission was not medically necessary.
This patient with a history of polysubstance abuse was admitted for detox from alcohol and opioids. The patient was hemodynamically stable and afebrile. He has normal oxygenation. He did not have tachycardia. His exam was unremarkable for physical signs of withdrawal. The patient did not have active comorbid conditions. The patient was admitted with plan for monitoring and CIWA/COWS (clinical institute withdrawal assessment/clinical opiate withdrawal scale) protocols. He rapidly resounded to treatment based on CIWA/COWS (clinical institute withdrawal assessment/clinical opiate withdrawal scale) reports. The patient was clinically stable and did not have findings of severe withdrawal. He did not have symptoms that required an acute inpatient level of care. He had not failed management in a lesser level of care.

Therefore, given the above, the inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical insufficiency
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female.  She presented to the hospital during pregnancy for placement of a prophylactic cerclage, due to history of cervical insufficiency.  The cerclage was placed under spinal anesthesia without complications.  There is no documentation of postoperative complications and she was discharged from the post anesthesia area.  However, the facility placed a claim for a hospital admission day contending that the patient was discharged a day later.

The health plan contends that the admission was not medically necessary because the procedure was uncomplicated and the care could be accomplished at observation level of care.  The facility contends that inpatient level of care was warranted due to need for IV (intravenous) fluids, cervical cerclage procedure, monitoring of voiding status, and pain management and cites MCG (Milliman care guidelines) 25th edition, Clinical Indications for Inpatient Care, outpatient observation failed.

No, the inpatient admission was not medically necessary.

The records document an uncomplicated transcervical cerclage procedure.  This procedure is typically performed on an outpatient basis under a spinal anesthetic and patient is discharged from the PACU (post anesthesia care unit), as was the case for this patient.  Inpatient admission would only be necessary if the surgical or anesthesia course were complicated.  In addition, the documentation states that the patient was discharged on the day of surgery and was not admitted to the inpatient service, but was discharged from the PACU (post anesthesia care unit).  Therefore, she was not even admitted to the hospital.

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

Diagnosis: Glaucoma
Treatment: Combigan 0.2-0.5% OP SOLN
The insurer denied the Combigan 0.2-0.5% OP SOLN
The denial is upheld

The patient is a female with primary open angle glaucoma for whom coverage of branded Combigan (brimonidine / timolol) is the subject of review. Coverage was previously denied as it was not identified why the patent could not use the individual components of this medication (brimonidine 0.2% and timolol 0.5%) which are on the preferred drug list. Upon appeal, it is identified that the patient previously tried and failed latanoprost, timolol 0.25% and Rhopressa. Intraocular pressures were adequately reduced when the patient was switched to Combigan 0.2%-0.5% and Rocklatan to simplify the patient's regimen. Pharmacy claims are identified for timolol 0.5% and brimonidine 0.2%.

No, the requested Combigan is not established as medically necessary.
In this case, there is no documentation provided as to why fixed combination Combigan is medically necessary over the concomitant use of the individual components (brimonidine and timolol). While its convenience may improve compliance, Combigan is not established as safer or more effective. Pharmacy claims have been identified for the individual components. No records are provided to document failure or intolerance to these individual medications.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Musculoskeletal/Orthopedic. 
Treatment: Surgical Services. 
The insurer denied the Intracept Procedure. 
The denial is overturned.

The patient in question is a male with an eight-year history of low back pain. Prior microdiscectomy relieved radicular pain but failed to relieve axial low back pain. He has failed physical therapy (PT), lumbar epidural steroid injections (LESI) x 2 and nonsteroidal anti-inflammatory drugs (NSAIDs) over a period of greater than (>) 6 months. Magnetic resonance imaging (MRI) reveals Modic-type (I or II) degenerative endplate changes at lumbar (L)2, L3, L4, L5 and sacral (S)1. It is reported that there is no dynamic instability on plain radiography. There are no reported radicular symptoms. The axial low back pain significantly impacts the patient's activities of daily living (ADLs) and ability to work. The subject under review is whether the Intracept procedure is likely to be more beneficial for the patient than standard treatment for the patient's condition.

There is level I/II evidence that basivertebral nerve (BVN) radiofrequency ablation (Intracept) results in significant reduction in pain and improvement in function when compared to patients who received sham procedure and standard therapy. As the patient in question has failed standard conservative therapy over > 6 months and has Modic I/II type endplate changes at L2, L3, L4, L5 and S1, BVN radiofrequency (RF) ablation is a reasonable intervention and based upon evidence in the medical literature the patient is likely to benefit more from this therapy than other treatments.