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

Diagnosis: Transient ischemic attack. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This case involves an adult who had a history of hypothyroidism, tobacco abuse, and alcohol abuse who presented to the emergency room complaining of facial numbness. Upon arrival, the patient was alert and oriented to person, place, and time. She had a steady gait and was neurologically intact in all 4 extremities. She had facial symmetry and her pupil's equal round reactive to light (PERRL). She claimed to have facial numbness since the day prior and denied any headache, dizziness, or neurological issues. She was documented as having clear speech, full range of motion, and equal strength in all extremities.  Her vital signs were stable, and her Glasgow Coma Score was 15. The triage notes were negative for facial droop and the patient was able to follow all commands. She complained of dizziness with intermittent neck pain. The plan of care included evaluation by a cardiologist and neurologist for dizziness along with magnetic resonance imaging (MRI) of the brain. The emergency department notes stated that symptoms had somewhat resolved while the patient was evaluated. On physical examination, the patient had mild to moderate sensory loss, feeling a pinprick that was less sharp or dull on the affected side, although she was aware of being touched. The physician indicated National Institutes of Health (NIH) stroke scale of 1 indicating a minor stroke. The patient was admitted for further work-up. On further assessment, the determination by neurology was that the patient had a possible migraine variant. She remained on inpatient status. 

The Milliman Care Guidelines (MCG) state that when there are concerns for transient ischemic attack, admission to inpatient care may be indicated when the patient is hemodynamically unstable, when there are focal neurologic signs recurring, there are findings on brain imaging that require inpatient care, the patient has altered mental status, cardiac arrhythmias of immediate concern, or as clinically significant cardiac or vascular disorders identified that require inpatient care. Admission may also be indicated for severe hypertension with systolic blood pressure greater than 180 mmHg (millimeters of mercury) or distally blood pressure greater than 120 mmHg, or greater than 95th percentile for age, gender, and height +30 mmHg in pediatric patients. Admission may be indicated for prolonged cardiac telemetry monitoring needs, suspected vasculitis, pregnancy, or when parenteral anticoagulation is required. 

The information provided for the review did not support that the patient met these criteria and could have had her care safely and effectively rendered at a lower level of service to include observation or outpatient. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Splenic infarction. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

The patient is an adult with past medical history of congenital aortic disorder, dyslipidemia who presented to the emergency room (ER) with abdominal pain and nausea. Her vital signs and laboratory were unremarkable except for mild leukocytosis. A computed tomography (CT)/ultrasound (US) showed possible splenic infarct. She was placed on heparin drip. She was seen by vascular surgery and hematology. No interventions were recommended. She was discharged home on Eliquis. 

The splenic infarct showed in imaging would be considered venous thromboembolism (VTE). In this case, the patient required anticoagulation therapy, heparin drip for a newly diagnosis of VTE. Therefore, the requested hospital admission was medically necessary. 

Per Milliman Care Guidelines (MCG), "Initial inpatient care needed for anticoagulation therapy, as indicated by ALL of the following: 

- Temporary subtherapeutic anticoagulation unacceptable because of high short-term risk of venous or arterial thromboembolism due to 1 or more of the following: 
- Venous thromboembolism newly diagnosed or within past 12 months 
- Underlying malignancy 
- Patient with mechanical cardiac valve 
- Underlying thrombophilia (hypercoagulable state, e.g., protein C or protein S deficiency, antithrombin deficiency, antiphospholipid antibodies) 
- Patient at temporary high risk of thromboembolism (e.g., status post orthopedic surgery) 
- Atrial fibrillation with rheumatic valvular heart disease (e.g., mitral stenosis) 
- New-onset postoperative atrial fibrillation in patient with history of stroke, transient ischemic attack, or other thromboembolism ". 

Chapman, J., Helm, T. A., & Kahwaji, C. I. (2022), "Splenic infarction occurs when the blood supply to the spleen is compromised resulting in tissue ischemia and eventual necrosis. It may be the result of arterial or venous occlusion. The infarction may be global or involve a small segmental area of the spleen depending on which vessel is occluded. Typical presentation includes left sided abdominal pain in a person with an underlying hematologic disorder, hypercoagulable state, blood-borne malignancy, blunt abdominal trauma, or embolic illness."             

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Syncope.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

This is an adult patient that presented to the hospital after a syncopal episode. The patient was seated and noted lightheadedness prior to losing consciousness. Relevant past medical history includes syncope several weeks earlier that resulted in fracture of the jaw. On arrival to the Emergency Department (ED) vital signs were stable (BP 117/80, Pulse 94). No other positive findings were noted on physical examination. A 12-lead electrocardiogram revealed normal sinus rhythm. Serum blood testing revealed hyponatremia with sodium (Na) 134, Blood Urea Nitrogen/Creatinine (BUN/CR) ratio that was within normal limits (14/1.0) and no elevation of troponin. The patient was admitted to the hospital for additional testing and treatment. An Echocardiogram demonstrated a normal left ventricular ejection fraction 60-65% (percent). A Computed Tomography (CT) of the head demonstrated no acute abnormalities and the neurology work up included an Magnetic Resonance Imaging (MRI) and an Electroencephalogram (EEG). After no clear etiology for syncope was determined, an implantable cardiac loop recorder was implanted, and the patient was discharged home. 

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with syncope that occurred while seated. The patient had a previous episode of syncope several weeks earlier that resulted in head trauma. According to the European Society of Cardiology, patients presenting with syncope must be risk stratified for future morbidity and mortality in order to determine the need for hospital admission. In a study of individuals presenting to the Emergency Room, patients that were high risk for cardiac events had a poor prognosis and required admission to the hospital for additional testing and treatment. In this case, the patient had recent head trauma due to syncope several weeks earlier and required a detailed work up that included cardiac and neurologic evaluation. Admission to the hospital for treatment and risk stratification was medically necessary in this case.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I malocclusion.
Treatment: Braces (comprehensive orthodontic treatment) and adjustments for braces (periodic orthodontic treatment).
The insurer denied: Braces (comprehensive orthodontic treatment) and adjustments for braces (periodic orthodontic treatment).
The denial is upheld.

The patient is an adolescent male requesting orthodontic benefits. He has a Class I malocclusion. The patient also has upper second premolars that are palatally positioned. The prior denial was due to a handicapping index score of 12.

The proposed treatment is not medically necessary.

The patient only has a handicapping index score of 12, which is not high enough for orthodontic benefits. The patient does not have a severely handicapping malocclusion; therefore, no benefits can be approved.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post left mastectomy.
Treatment: code 11954-LT (left side), subcutaneous injection of filling material; over 10.0 cc (cubic centimeter).
The insurer denied coverage for code 11954-LT (left side), subcutaneous injection of filling material; over 10.0 cc.
The denial is upheld.

This is an adult female with a history of failed left breast reconstruction. The patient currently has a left chest wall deformity and no breast reconstruction. The submitted code does not accurately describe the procedure performed. Fat grafting is a stage of the patient's reconstruction following mastectomy and the women's health and cancer rights act (WHCRA) mandates coverage for all stages of breast reconstruction. Therefore, fat grafting was an appropriate reconstructive procedure for this patient's post-mastectomy deformity. Longo et. al. describe total post-mastectomy breast reconstruction with fat grafting alone. The procedure performed for this patient is an accepted standard of care for breast reconstruction. However, fat grafting is coded as follows:

Current Procedural Terminology (CPT) codes 15771 (Grafting of autologous fat harvested by liposuction technique) and 15772 (add-on code for autologous fat grafting to the trunk, breasts, extremities, or scalp for each additional 50cc of injectate) can be used to report fat grafting to the breast.

Procedure 11954-LT was not performed. Code 11954 is used for the injection of a filler such as collage or Juvaderm. The CPT code for fat grafting is 15771.  Fat grafting was medically necessary, but the submitted CPT code was not performed and therefore is 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 the code 11954-LT, subcutaneous injection of filling material; over 10.0 cc is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain,
Treatment: Inpatient surgery (lumbar fusion [CPT 20939, 22612, 22633, 22840, 22853, 63047, 63052 x1]).
The insurer denied: Inpatient surgery (lumbar fusion [CPT 20939, 22612, 22633, 22840, 22853, 63047, 63052 x1]).
The denial is upheld.

The patient is an adult male with back pain and a history of L (lumbar) 4-L5 multiple epidural steroid injections last year and this year. The patient takes multiple medications for pain. According to an appeal letter from the attending physician, the patient "has tried oral medications, at home therapy exercises, activity modification including rest, and steroid injections..."  The patient's exam reveals no focal deficit.  His magnetic resonance image (MRI) shows L4-L5 facet arthropathy but no noted stenosis with normal alignment.  The patient was recommended for L4-L5 transforaminal lumbar interbody fusion (TLIF).

The proposed inpatient surgery (lumbar fusion) is not medically necessary.

Although the patient is stated to have tried medications, home therapy, activity modification and injections, the patient's imaging does not demonstrate a significant pathology that would warrant the fusion that was recommended. The patient's magnetic resonance image (MRI) shows L4-L5 facet arthropathy but there is no noted stenosis at any level. Therefore, the lumbar fusion is not considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crossbite
Treatment: D8080 Braces, D8670 Monthly Visit
The insurer denied: D8080 Braces, D8670 Monthly Visit
The denial is overturned

The patient is an adolescent female. The request is for dental benefits for orthodontic treatment (Braces) and monthly visits. Per the provider's clinical dental summary, the patient evidences Class I skeletal growth pattern, left sided posterior crossbite, maxillary midline discrepancy relative to facial midline, deep overbite, maxillary and mandibular anterior crowding.

The health plan denied coverage of the request because the patient did not score a 26, the score necessary for approval for orthodontic treatment on the Handicapping Labio-Lingual Deviation (HLD) Index Report.

The appeal was requested based on the clinical diagnosis and the provider's score of 28 on the same HLD (Handicapping Labio-Lingual Deviation) Index Report.

The requested braces and monthly visits are medically necessary.

Based on the materials submitted, the patient exhibits a posterior crossbite involving teeth numbers 13 and 14.

The health plan denied coverage of the request because the patient did not score a 26 on the HLD (Handicapping Labio-Lingual Deviation) Index Report. The discrepancy comes from the score in regard to the posterior crossbite; meaning they scored "0" as opposed to "4."

Because the photos support that the posterior crossbite involves teeth numbers 13 and 14, with that scoring the HLD (Handicapping Labio-Lingual Deviation) Index would be a 28; a score that would indicate approval of orthodontic treatment.

Therefore, given the above, the braces and monthly visits are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Left Knee Pain.
Treatment:  Inpatient Stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld.

The patient is a male with a history of gout, hypertension, and atrial fibrillation (on Eliquis), chronic systolic heart failure, and borderline diabetes. He presented with a sudden onset of left knee pain for three days. The pain was rated as a 10 out of 10 and was not associated with any systemic findings such as fever or chills. The review of his systems was negative.

The patient had a hemoglobin A1C (HgbA1C) of 6.5. It was noted that the patient will start on Metformin, and diabetes management supplies were ordered. The patient was discharged from the hospital subsequently.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient.

The inpatient stay was not medically necessary for the patient. The patient had failure with outpatient therapy; therefore, he needed an alternate level of care. The patient could have had a discharge from the alternate level of care at 48 hours after safely ruling out septic arthritis. He has chronic bilateral lower extremity weakness and numbness attributed to degenerative changes in his spine. The review of his systems was negative. The patient had an arthrocentesis (which ruled out septic arthritis), and he received intravenous (IV) Solumedrol. After this, the patient felt better and was started on a tapering dose of Prednisone.

The patient takes his heart medications consistently but takes his other medications as needed (PRN). The patient's chronic issues including atrial fibrillation and congestive heart failure were stable.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Alcohol abuse.
Treatment:  Inpatient Hospital Admission.

The insurer denied the Inpatient Hospital Admission.  The denial is upheld.

This adult male patient with a history of alcohol abuse presented with alcohol withdrawal. He complained of anxiety, tremors, and poor appetite. The patient's vital signs were stable; heart rate was 81 and blood pressure was 135/89. The patient's exam was remarkable for tremors. There were no clinical signs of delirium tremens (DTs). His complete blood count and comprehensive metabolic panel were within normal limits. His chest x-ray showed no acute disease. The patient's electrocardiogram (EKG) showed normal sinus rhythm and no ST changes. His Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score was three. The patient was admitted. The plan of care included Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol. On the next day, the patient's vital signs were stable. No benzodiazepines were required. The patient was cleared for discharge.

The proposed treatment was not medically necessary.

This patient with a history of alcohol abuse was admitted after presenting with alcohol withdrawal. He was not acutely intoxicated. The patient was hemodynamically stable and afebrile. He did not have tachycardia or arrhythmia. He had a mild tremor but did not have delirium tremens (DTs). The patient did not have vomiting. His labs were unremarkable. His Clinical Institute Withdrawal Assessment for Alcohol score was three. The patient was admitted with a plan for Clinical Institute Withdrawal Assessment for Alcohol protocol. He remained medically stable without signs of severe alcohol withdrawal. He did not require benzodiazepines. He had not failed a lesser level of care. The patient did not have symptoms that required an acute inpatient level of care and had not failed a lesser level of care. The acute inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Insomnia. 
Treatment: Sleep study and MSLT test. 

The insurer denied sleep study and MSLT test. 
The determination is upheld. 

The patient has a history of insomnia. She has been followed by a neurology practice for this condition. 
She underwent a home sleep test which showed an apnea hypopnea index (AHI) of 1.0. The patient underwent an attended polysomnography. This study showed an AHI of 0.6. The polysomnogram (PSG) was followed by a Multiple Sleep Latency Test (MSLT). The MSLT was said to have shown daytime sleepiness (multiple sleep latency (MSL) of 6 minutes) but was negative for narcolepsy. 
The patient continued to be followed for her insomnia. She was noted to have trialed mirtazapine and gabapentin as pharmacotherapy. 
She was seen primarily for a complaint of a dysesthesia down her right upper and lower extremity. The note from that visit indicated that she had self-discontinued amitriptyline due to a lack of a perceived clinical benefit. The patient stated that her insomnia had been problematic. She also reported persistent hypersomnolence. The note from the visit indicated that at the time of a prior visit she had been referred for PSG/MSLT, but that the said testing had not been completed. Notes  indicated that the patient reported problems with sleep, gasping for air during the night. 
She endorsed fatigue and daytime sleepiness. She was again recommended to undergo PSG/MSLT. At issue is the medical necessity of a sleep study and MSLT. 

They are not medically necessary. In this case, the patient has a history of insomnia. She has previously undergone diagnostic sleep testing  which was negative for obstructive sleep apnea (OSA) and narcolepsy. 
She is otherwise noted to have a history of insomnia. In general, polysomnography is not routinely recommended for use in the evaluation of insomnia, particularly in the absence of any other signs/symptoms of a comorbid sleep disorder. More specifically, MSLT testing is not recommended in the evaluation of insomnia as it is not specific and non-diagnostic. Often, hypersomnolence can readily be attributed to a patient's underlying insomnia. There were no other factors present in the records that would recommend otherwise proceeding directly to polysomnography. 
The patient otherwise does not have a presentation suggestive of a central disorder of hypersomnolence (which would benefit from MSLT). In as much, that study cannot otherwise be determined to be appropriate either.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders/Psoriasis.
Treatment: Pharmacy/Prescription Drugs.
The health plan denied the requested medication, Otezla, as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with psoriasis. Her right upper arm is affected with psoriasis. She has been on Otezla for greater than a year with improvement. The medication under review for medical necessity is Otezla.

The health plan's determination of medical necessity is upheld, in whole.

The requested health service/treatment of Otezla is not medically necessary for this patient. There is no documentation provided that the patient has tried and failed, has a contraindication to, or intolerance to the preferred therapies such as phototherapy or Methotrexate. There are no comparative, controlled studies showing that Otezla has a superior efficacy to all the formulary alternatives such as phototherapy and Methotrexate.
According to the "national physician specialty society recommendations" for psoriasis, the American Academy of Dermatology Psoriasis Guidelines, and dermatology literature, phototherapy and Methotrexate are effective treatments for the management of psoriasis. [1,2]
Within the peer-reviewed literature, Racz et al writes "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks." [3] Mehta et al writes "Ultraviolet (UV) B phototherapy is most appropriate for patients with >10 % affected body surface area who have not responded to topical treatments...narrow band ultraviolet B phototherapy (NB-UVB) ...is effective treatment options for psoriasis...Long-term data on NB-UVB indicate that it has a good safety profile." [4]
Additionally, West et al 2016 conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that Methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2% [95% confidence interval 34.160.0] of patients achieve psoriasis area and severity index (PASI75) at primary endpoint, Thus, Methotrexate is an effective first-line treatment for the management of psoriasis [5].
Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the information provided by the patient, the request for Otezla is not necessary. There is no documentation provided that the patient has tried and/or failed phototherapy or Methotrexate. The patient also has no true contraindications listed to a preferred treatment modality that would make the use of Otezla medically more appropriate than the other options.
Therefore, the administration of Otezla is not strongly supported for this patient, and Otezla is not medically necessary for this patient, based on the current evidence-based medical literature.