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

This patient with a past medical history of hypertension, hyperlipidemia and ethyl alcohol (ETOH) abuse who had a cerebrovascular accident (CVA) previously.  An evaluation, including a transesophageal echocardiogram demonstrated a patent foramen ovale, which was thought to be a contributing issue.  Patient was referred for elective transcatheter patent foramen ovale (PFO) closure.  The procedure was uncomplicated; patient was admitted overnight and discharged the following day without significant event.  The HP determination of medical necessity is upheld in whole.  The procedure was elective and uncomplicated.  The patient was discharged the following day after an uncomplicated stay.  The care of this patient was appropriate at a lower level of care, which would include an overnight stay.  There were no clinical, procedural, hemodynamic, laboratory, telemetry or post procedural issues that warranted an inpatient level of care.  The post-procedural monitoring required for this patient involved nothing additional to the standard of care provided to patients undergoing an uncomplicated transcatheter PFO closure such as this.  Post procedure care is routinely provided to these types of patients at a lower level.  Therefore, the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: skeletal Class lll -Hypoplastic Maxilla, Vertical Growth Pattern, Permanent Dentition, Moderate Maxillary Crowding, Moderate Mandibular Crowding, and Anterior Crossbite with Gingival Attachment Loss (mandibular left canine). Crossbite of Individual Anterior Teeth when Clinical Attachment Loss and Recession of the Gingival Margin
 
Treatment: Comprehensive Orthodontic Treatment

The insurer denied the Comprehensive Orthodontic Treatment.  The denial was reversed. 

This is young male patient who presented to his orthodontist for Orthodontic treatment evaluation. The orthodontist recommended comprehensive orthodontics due to Class III malocclusion, anterior crossbite with gingival attachment loss (mandibular canine), moderate maxillary and mandibular crowding. The orthodontist has completed the HLD index which revealed only 12 points on review.

It is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.

Based on the above, the medical necessity for Comprehensive Orthodontic Treatment of the Adolescent Dentition (D8080) is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of hypertension, chronic obstructive pulmonary disease (COPD), and melanoma. The patient presented to the hospital with complaints of shortness of breath, palpitations, and leg swelling with an eight-pound weight gain.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient had no significant pulmonary edema, persistent hypotension, uncontrolled tachycardia, ischemic events or thromboembolic episodes. The patient could have been cared for at a lower level of care with discharge on 7/25/18 as there was no complications and resolution of all symptoms at that time.
Appeal type: Medical necessity
Decision: Upheld

The patient had begun receiving physical therapy treatment following a right shoulder surgery. The patient had had twenty sessions corresponding to 3 skilled physical therapy treatment modalities. At issue is the use of CPT 97140.

The health plan's determination is upheld. The physical therapy in question was not medically necessary. The three modalities on the date of service are sufficient to address his needs. The use of CPT 97140 was not medically necessary to treat this patient.
Appeal type: Medical necessity
Decision: Overturned

This is a patient without a personal history of cancer. She has a family history of breast cancer in her maternal grandfather, paternal aunt, and paternal cousin. She has been recommended to undergo genetic testing using breast cancer antigen (BRCA) MyRisk panel. 

The health plan's determination of medical necessity is overturned. Based on national criteria, including criteria from the National Comprehensive Cancer Network (NCCN), and Society of Gynecologic Oncology, patients with either a first- or second-degree relative diagnosed with male breast cancer, such as this patient, meet criteria for BRCA genetic testing.
Appeal type: Medical necessity
Decision: Upheld

The patient suffered a near complete amputation of his left thumb and ring finger on a table saw with additional fractures and lacerations t left digits number 2 and 3. He was evaluated at Facility A and transported via air ambulance to Facility B. The health plan denied the air ambulance transport as not medically necessary. The health plan's determination is upheld. The air medical transport was not medically necessary. While the patient needed transport to a higher level of care, similar ground transport would only have been 12 minutes more and the patient was stable enough to be transported by ground. Further the patient was not transported to the nearest facility with hand surgery.
Appeal type: Medical necessity
Decision: Overturned

The patient was prescribed bilateral compression garments (stockings) for her lower extremity lymphedema. The Compression Stockings were denied by the health plan.

The health plan's determination is overturned. The compression stockings are medically necessary for this patient. Per the documentation submitted, the patient has lymphedema in both legs. The patient has attempted to use a compression wrap, but it has proven to be cumbersome, and does not allow the patient to wear normal shoes. In this case, compression stockings are the standard medical treatment available. They have been found to be safe and effective for both primary and secondary lymphedema and is the most practical treatment for use during the day under clothing and while wearing shoes.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #3

The patient is a female patient with a diagnosis of right knee pain, swelling and limited range of motion due to an injury two years prior when she attempted to push her car in the snow and hyperextended her knee.  A magnetic resonance imaging (MRI) identified a large, full thickness cartilage injury of her central-lateral patella with a large cartilage flap present.  Her surgeon is recommending an osteochondral allograft implantation and to perform an unloading tibial tubercle osteotomy to improve her patellofemoral biomechanics and protect the cartilage repair site. 

Based on the review of literature, this treatment proposal-osteochondral allograft transplantation and tibial tubercle osteotomy, is the best treatment option for the patient.  Non operative options such as physical therapy, nonsteroidal antiinflammatory drugs (NSAIDS), and injections have not been proven to have a biologic effect and minimal effects on symptoms. Surgical debridement of chondral lesions is not recommended.

The use of osteochondral allograft transplantation for patella injuries has been documented as successful in peer reviewed literature.  In a study by Gacitelli et al, they found that "patellar allografting survivorship was 78.1% at 5 and 10 years and 55.8% at 15 years.  Among the 20 knees (71.4%) with grafts in situ, the mean follow-up duration was 9.7 years (range, 1.8-30.1 years).  Pain and function improved from the preoperative visit to latest follow-up, and 89% of patients were extremely satisfied or satisfied with the results of the osteochondral allograft [OCA] transplantation."  Thus, there is evidence to support the use of osteochondral allografts.  The additional use of tibial tubercle osteotomy (TTO) for these patients is also well supported.  As far back at 1976, Maquet et al found that a 2cm elevation of the tibial tubercle offset loads by 50%.  Thus, there is clinical and biomechanical support for this procedure. 

Based on the records, the proposed surgery is the best option for this young, healthy patient with an isolated cartilage injury in her patella.  This is the most likely procedure to provide short and long term improvement in symptoms and is likely to be more beneficial than other treatment options. 

The carrier's denial of coverage for the osteochondral allograft, knee, open, right knee (code 27415) should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #2

The patient is female with a diagnosis of right knee pain, swelling, and limited range of motion due to an injury that happened when she was pushing her car in the snow.  The patient hyperextended her knee resulting in an immediate onset of knee pain and an inability to bear weight.  The patient underwent an MRI, which revealed a large, full-thickness cartilage injury of her central lateral patella with a large cartilage flap present.  The provider noted that the patient had undergone non-operative management including anti-inflammatory medication and a home exercise program.  The patient was having difficulty working.  The patient was now unable to exercise and was having pain with simple ambulation and stairs.  The surgeon requested an osteochondral allograft implantation.
 
There are multiple articles that support Osteochondral Allograft transplantation in the knee for decreased pain and increased function.  Gracitelli et al reported 89% of patients satisfied or extremely satisfied with their outcome (Fresh Osteochondral Allograft Transplantation for Isolated Patellar Cartilage Injury, AJSM. 2015. 43(4):879-884.)  Mirzayan et al also reported significant improvement in functional outcomes, relief from pain, activity level (Bipolar Osteochondral Allograft Transplantation of the Patella and Trochlea. Cartilage. 2018 Sep 3:  1947603518796124.)  In a young patient with a low body mass index (BMI), the osteochondral allograft has very predictable results and frequently the tibial tubercle osteotomy is required to address concomitant anatomic abnormalities and to off load the cartilage surface that was just implanted.  The procedure does not need final approval from the appropriate regulatory bodies for this diagnosis.  

The patient is an appropriate candidate based on her age, the location of the isolated defect, and the failure of other nonoperative measures.  The treatment proposed, the osteochondral allograft (27415) in conjunction with the tibial tubercle osteotomy are the best available treatment options at this time.  Given the documentation provided, this reviewing physician agrees with the requesting provider.  This patient has had three years of nonoperative treatment with a cartilage defect that is impacting her function.  The described defect is too large for an abrasion chondroplasty or microfracture and those results are inferior to the requested service.  The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for the osteochondral allograft, knee, open, right knee (code 27415) should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Osteochondral injury to retropatellar surface

Treatment: Osteochondral allograft, knee, open, right knee (code 27415)

The insurer denied coverage for osteochondral allograft, knee, open, right knee (code 27415). The denial reversed.

Reviewer#1 

This patient is a female who has been followed complaining of right knee pain which occurred after pushing her car in the snow suffering hyperextension of the knee.  Magnetic Resonance Imaging (MRI) scan has shown a large chondral lesion to the patella.  The patient has had increasing knee pain particularly with stairs, squatting and prolonged sitting.  A repeat MRI scan has shown a large full-thickness cartilage injury of the central lateral patella with a large cartilage flap present.  The patient has not improved with nonoperative management including medications and home exercises.  She is unable to work because of knee pain.  The doctor has recommended surgery in order to prevent progressive patellofemoral compartment arthrosis.  She is not a candidate for patellofemoral resurfacing.  The doctor suggests osteochondral allograft implantation with healthy mature articular cartilage.  It is noted that there are no other repair or restorative procedures that will be effective.  The doctor notes several literature references supporting benefits/efficacy of the proposed surgery.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.  This patient has an osteochondral injury to her retropatellar surface.  In an active patient, this type of injury is difficult to treat with no well proven treatment options available.  This reviewer agrees that she is not a candidate for patellofemoral arthroplasty and that the osteochondral lesion is too large to consider autograft.  The only viable treatment option for this type of injury is an osteochondral allograft.  While results of this procedure are variable, the end result will be better than what the patient is presently experiencing, and the allograft procedure may well lessen the chance of developing patellofemoral osteoarthritis in the future.

The osteochondral allograft does not need final approval from appropriate regulatory bodies for this diagnosis.  The patient is a good candidate for an osteochondral allograft, knee, open, right knee (code 27415).  There are no other treatment options available.   Having failed conservative treatment, and in view of the fact that her osteochondral lesion is too large for an autograft procedure, the only remaining viable procedure would be to consider an osteochondral allograft.

The osteochondral allograft for the right knee is felt to be the best available treatment for the patient. 
  
The requested service is likely to be more beneficial than any other treatments for this patient.  The procedure is likely to improve the patient's health outcome and is likely to lessen the chance for patellofemoral arthritis in the future.  

The carrier's denial of coverage for the osteochondral allograft, knee, open, right knee (code 27415) should be reversed.
Appeal type: Medical necessity
Decision: Overturned

Other/Sepsis
Inpatient hospital stay

This patient underwent ultrasound guided biopsy of the prostate. Subsequent to the biopsy, the patient developed systemic signs of sepsis including fever, and chills. Diagnostic workup included blood and urine cultures, both positive for E. Coli. The organism was resistant to levofloxacin and gentamicin. Patient was admitted for intravenous resuscitation, and antibiotics. The health plan's determination of medical necessity is overturned in whole. The treatment the patient received was appropriate based on history, exam and supporting lab studies. The patient presented with signs consistent with sepsis following a transrectal prostate biopsy manifested by fever and chills. The blood and urine cultures were positive for E.coli. Patient received intravenous ceftriaxone and vancomycin. Length of stay was 2 days. The standard of care was met by the treating physicians and hospital. 
According to current literature, Infection is the most common complication of prostate biopsy with fluoroquinolone resistant Escherichia coli having a prominent role. Reported rates of infectious complications range from 0.1% to 7.0%, and sepsis rates range from 0.3% to 3.1% depending on antibiotic prophylaxis regimens. Bacteria causing infection are found in the rectum before biopsy and are seeded into the prostate, bladder and/or bloodstream by the hollow core biopsy needle traversing the rectum into the prostate/bladder. Cultures obtained from the rectum immediately prior to biopsy have demonstrated a fluoroquinolone resistant colonization rate of 10% to 22%, and a fourfold increased risk of infection has been noted in men colonized with fluoroquinolone resistant organisms. Any patient who presents with a fever after prostate biopsy should be assessed for sepsis and not be offered fluoroquinolones Empiric intravenous treatment with carbapenems, amikacin or second and third generation cephalosporins can be considered until culture sensitivities are known. 

Literature confirms the rate of infectious complications associated with prostate biopsy is increasing. Therapy is initiated with broad spectrum intravenous antibiotics, but not a quinolone, and maintained until such time as therapy may be tapered pending outcomes of the cultures and the patient stabilizes clinically.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the hospital with palpitations, dyspnea, nausea, and chest tightness for almost 24 hours. The patient had been using cocaine and alcohol the night prior to admission. The patient had a history of asthma. An electrocardiogram (ECG) in the emergency department (ED) showed supraventricular tachycardia at 220 beats per minute (bpm). The patient was given intravenous (iv) adenosine, the arrhythmia terminated, and the patient went into sinus tachycardia. Urine testing showed tetrahydrocannabinol and cocaine. Troponin was within normal limits.
The patient was admitted to the hospital. Echocardiogram was normal. Nuclear stress test was normal. The patient was discharged 3/25/19. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient hospital admission was not medically necessary for this patient. The patient had a very rapid supraventricular tachycardia (SVT) in the setting of excessive alcohol and cocaine lasting for several hours prior to entering ED and which caused multiple symptoms. The ED appropriately treated the arrhythmia with iv adenosine with restoration of sinus rhythm. It was reasonable to observe the patient for several hours after conversion but that could have been performed at a lower level of care. Further testing including echocardiography and stress testing could have been performed as an outpatient, or at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with chronic hypertrophic adenotonsillitis and moderate obstructive sleep apnea. Per the anesthesia note, the child had no pertinent medical history. He underwent an uncomplicated adenotonsillectomy . There is no documentation of any postoperative complications. Vital signs were stable. There are no notes indicating that the child was admitted overnight. The health plan's determination of medical necessity is upheld.
There were no clinical indications for admission. There were no documented health issues that required admission. There were no complications noted. There were no perioperative concerns.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Malocclusion and deep impinging overbite
 
Treatment: Orthodontic care

The insurer denied the orthodontic care. The denial was reversed.

This patient presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to skeletal Class I malocclusion, moderate mandibular crowding, excessive overjet and deep impinging overbite.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required.  

It is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

The D8080 (braces) are considered medically necessary for this patient.  The carrier's denial of coverage for braces (D8080) is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: Braces

The braces are medically necessary.

The patient has a crossbite (reverse bite) between teeth #s 7 and 27.  This "anterior crossbite with gingival attachment loss" is an "automatic qualifier" for orthodontic benefits, according to the Handicapping Index report.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cough and hemoptysis

Treatment: Inpatient admission, IV medications, isolation precautions

The insurer denied inpatient admission. The denial was reversed.

The patient presented to the ER via ambulance after a four-day history of cough and hemoptysis. The patient was homeless and living in a shelter. His past medical history included heart failure, with a left ventricular ejection fraction of 15-20%. He was admitted for sepsis secondary to community acquired pneumonia, and exacerbation of congestive heart failure secondary to medication non-compliance. Treatment included IV antibiotics and IV diuretics. An acid-fast bacillus (AFB) culture was obtained and the patient was placed in isolation due to concern for tuberculosis (TB). The culture showed no growth and he was discharged on.

The patient was admitted for sepsis and to rule-out TB. His other co-morbidities include alcohol use disorder; a non-ST elevated MI in 2018 and coronary artery disease. Milliman Care Guidelines (MCG) indicate an inpatient admission for pneumonia is warranted if the patient is demonstrating signs of hemodynamic instability. Based on the patient's clinical presentation on admission, he was at risk for decompensation due to presenting symptoms, his diagnostics of a chest x-ray that revealed bilateral upper lung airspace disease, his lab values that revealed a BNP of 7,836, and his co-morbidities. He required a seven-day course of antibiotics. He required isolation precautions until AFB smears returned with a negative result.  His heart failure exacerbation is demonstrative of both hemodynamic instability and a worsening of co-morbid conditions; requirements for admission under MCG guidelines for pneumonia. His diagnosis of pneumonia is indicative of a precipitating cause for admission under the MCG heart failure guidelines. 
Therefore, the inpatient admission was considered medically necessary for this patient.