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

Diagnosis:  Acute appendicitis
 
Treatment:  Inpatient hospital admission 

The insurer denied coverage for inpatient hospital admission.  The denial is upheld. 

This patient is a female who presented to the Emergency Department (ED) complaining of abdominal pain.  The patient was discharged from the hospital where it was noted that she was diagnosed with acute appendicitis via CT scan.  She was previously given antibiotics.  The documentation indicated that she was previously told that if the pain worsened, she was to return to undergo an appendectomy.  On exam, the patient had a temperature of 98.1F with a heart rate of 93 beats per minute (bpm).  Her blood pressure was 116/75 with oxygen saturation at 98%.  The recommendation was made for her to undergo laboratory studies.  The laboratory studies revealed a white blood cell count of 5.71.  The documentation indicated that the patient was recommended to undergo an additional CT scan. 

The documentation detailed that the patient refused a CT scan, as she did not want the additional radiation.  The surgical team was informed of the patient's refusal.  It was noted on examination that the patient had a soft abdomen with significant right lower quadrant tenderness to palpation.  The recommendation per surgery was to admit the patient for further care.  The documentation indicated that the patient did undergo a laparoscopic appendectomy without complication.  She was able to advance her diet and her pain was well controlled postoperatively.  She was able to ambulate and void, as well.  There were no adverse events postoperatively, and she was discharged in stable condition.

According to the referenced literature, the patient may be admitted to inpatient services when there is evidence of active co-morbidities with the inability to arrange adequate outpatient support when the patient is greater than 65 years of age.  Typically, the patient will undergo a laparoscopic appendectomy and will remain at the observation level in the absence of complication with the above-noted indications.  This is a very typical admission for an uncomplicated laparoscopic appendectomy.  The entire stay is 23 hours or less which is considered standard of care for an out-patient or day-surgery.  This reviewer does not see anything in the record provided that qualified for an acute-care full admit.  If the patient was initially admitted from the ED as an acute care, the admission could have been changed immediately after surgery to a day-surgery or observation (23-hours).  There is support for observation, not a full admit.

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. 
 
The carrier's denial of coverage for the inpatient hospital services at the acute level of care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Progressive dementia
Treatment:  Increase in Consumer Directed Personal Assistance Program services to 12 hours/day, 7 days/week, for a total of 84 hours/week 

The Increase in Consumer Directed Personal Assistance Program services to 12 hours/day, 7 days/week, for a total of 84 hours/week is not medically necessary.

The patient's medical needs are met by the current 8 hours a day, 7 days a week.

The patient is a female who lives with her daughter and son-in-law in a private home. The patient has been diagnosed with hypertension, diabetes, progressive dementia, urinary incontinence and vitamin deficiency.  

The patient requires assistance with most adult daily living tasks.  Recently, assessments of the patient have demonstrated a worsening of her cognitive function, from moderately impaired to severely impaired.  The patient's motor skills have worsened, now requiring maximum assist with toilet use.  The patient requires extensive assistance with toilet transfers.  The patient requires extensive assist with eating.  

The patient is currently approved for patient care assistant 8 hours per day 7 days per week. Her family has requested an increase to 12 hours per day 7 days per week, based upon the fact that the patient on more than one occasion has fallen and been found on the floor between the hours that the personal care aide leaves and the family returns home.  No other medical conditions requiring extended hours for the personal care aide have been identified by the patient's physician or by the family.

The patient's medical needs as documented are met by the 8 hours a day, 7 days a week.  While the family's concerns regarding the patient's falls are appreciated and acknowledged, this issue does not fall within the medical scope of Consumer Directed Personal Assistance Program services.  Also, there is no documentation provided that the issues raised in the family's letter (in particular, with respect to the patient's falls after the personal care aide has left the home) have been independently verified.  The standard of care for such scenarios generally falls within the scope of a less-skilled service, such as a sitter. 

Therefore, given the above, the Increase in Consumer Directed Personal Assistance Program services to 12 hours/day, 7 days/week, for a total of 84 hours/week is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right rotator cuff tear
Treatment: Shoulder surgery
The insurer denied the shoulder surgery.
The denial is overturned. 

This patient is a man with a right rotator cuff tear. He underwent surgery. The patient was reported to have reached and reinjured his shoulder. He was found to have weakness and decreased motion. He received ongoing physical therapy (PT). His physician diagnosed new onset recurrent rotator cuff tear which failed to respond to eight weeks of conservative management. The patient's physician performed additional surgery. 

Yes, the shoulder surgery was medically necessary.

The patient sustained a re-tear of the rotator cuff after surgery. His physical findings were dramatic with positive (+) drop arm test, weakness and decreased motion. The imaging demonstrated the re-tear. His condition could thus be considered an acute re-tear. 

Per reference #1, in the setting of an acute traumatic re-tear in a physiologically young, healthy, active and non-pseudoparalytic patient, arthroscopic revision surgery is generally recommended. 

Based upon a defined pain generator, options of management include conservative treatment versus immediate operative repair. The clinical presentation of subjective complaints and known pathology unlikely would respond to physical therapy. There is distinct disruption to the musculoskeletal unit and common practice would be to consider operative intervention. Delay would likely result in increased atrophy and stiffness. The timing of surgery after re-tear would be based upon clinical presentation versus necessity of non-operative care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: GERD
Treatment: Dexilant 60mg OR CPDR
The insurer denied the Dexilant 60mg OR CPDR. 
The denial is upheld. 

The patient is a male with gastroesophageal reflux disease (GERD). Esophagogastroduodenoscopy (EGD) revealed a hiatal hernia and there was esophagitis. The patient has failed treatment with omeprazole, pantoprazole and Pepcid. The doctor (MD) is requesting treatment with Dexilant.

No, the proposed treatment is not medically necessary.

The patient has GERD and has been documented to have failed treatment with omeprazole, pantoprazole and Pepcid.. Per the provided policy, in order for criteria for Dexilant to be met, the patient must have failed treatment with omeprazole, esomeprazole, lansoprazole, pantoprazole and Zegerid. As the patient has not tried and failed esomeprazole, lansoprazole and Zegerid, criteria for Dexilant are not met. As there is no medical literature to support that Dexilant is more effective than esomeprazole, lansoprazole and Zegerid for the treatment of GERD, Dexilant would not offer a better chance of avoiding surgery that the preferred alternatives, and the proposed Dexilant is not medically necessary, and the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Kidney Injury

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This male patient has a medical history of asthma, diabetes mellitus, hyperlipidemia, hypertension, gastroesophageal reflux disease and depression who presented to the Emergency Department (ED) with complaints of abdominal pain.  The patient's lab workup showed normal lipase and liver enzymes. The patient's computed tomography (CT) scan of the abdomen and pelvis was suggestive of pancreatitis. The patient also had elevated creatinine likely due to pre-renal azotemia and was started on intravenous fluids (IVF).  The patient underwent upper endoscopy, which was negative.  The patient was started on therapy for hypertriglyceridemia and was discharged in stable condition 2 days later.  The patient's condition resolved within 48-hour of admission. The patient's care could have been safely provided at the observation level of care. 

Based on the review of the medical record and literature, inpatient admission was not medically necessary for the treatment of acute pancreatitis for this patient. The patient did not have signs of severe inflammation, and had inability to maintain oral hydration. There was also no documentation of evidence of infection (e.g., fever, peripancreatic abscess) and severe pain that was not responsive to observational level of care. The patient had elevated blood pressure but was otherwise hemodynamically stable with normal oxygenation. The patient did not have severe electrolyte abnormalities that required inpatient level of care. The patient's acute kidney injury was responsive to intravenous fluids, and was reversible without evidence of intrinsic etiology. The patient did not require renal replacement therapy.  Thus, inpatient admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient hospital should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a female with a past medical history significant for hypertension (HTN) and gastroesophageal reflux disease (GERD).  She presented to the Emergency Room for evaluation of chest pain of one day duration, which was non-exertional, mid-sternal, with radiation to both arms, and constant.  The patient was hemodynamically stable.  Electrocardiogram (ECG) revealed sinus rhythm with diffuse ST elevations with PR depression, consistent with acute pericarditis.  The patient underwent a computed tomography angiography (CTA) of the chest, which was negative for pulmonary embolism.  There was no significant pericardial effusion.  Troponin was negative.  The patient was admitted to rule out acute coronary syndrome (ACS).  The patient was treated for pericarditis with colchicine and Motrin.  She was discharged home with a plan for outpatient follow-up.

No, the proposed inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain.  The diagnosis of an acute myocardial infarction (MI) was ruled out by cardiac enzymes, which were negative.  ECG findings were consistent with acute pericarditis.  CTA revealed no evidence of acute pulmonary embolism.  There was no evidence of pericardial tamponade.  There was no evidence of acute myocardial infarction, ACS, decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability.  Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic low back pain
Treatment: RFA (radio frequency ablation) (64635x2, 64636x4)
The insurer denied the RFA (radio frequency ablation) (64635x2, 64636x4).
The denial is overturned. 

The patient is a female with chronic low back pain. She previously underwent a bilateral RFA (radiofrequency ablation) at L3-4, L4-5, L5-S1 over 15 months ago with near 100% improvement, with a return in her pain.  The procedure is being denied due to no documentation of failure of conservative treatment or imaging studies. 

Yes, the RFA (64635x2, 64636x4) is medically necessary.

The patient has axial low back pain that is extension based, with no severe stenosis or previous spinal fusion. She has previously undergone an RFA 15 months ago with over 80% relief. The pain has started to return.  Imaging studies are available, as described above. The patient has undergone conservative treatment prior to the RFA and has been on various pain medications since that time, including opiates, gabapentin and vitamins. The literature does not have specific guidelines on additional conservative treatment prior to repeat RFA.  The patient is already on opiates, increasing opiates is not without risk.  She meets the criteria of axial, non-radicular pain with greater than six months relief from previous RFA as defined by Medicare criteria, the American Society of Interventional Pain Physicians, and the Spine Intervention Society.  Given the above, the requested RFA is medically necessary. 

Alternatives include increasing medication, which are not without risk, especially in a young patient, and surgery, which has not shown to be effective in axial low back pain with no symptomatic spondylolisthesis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation

Treatment: Inpatient admission

The insurer denied coverage for acute inpatient admission.

The denial is upheld. 

This female patient has a medical history of diverticulosis, gastroesophageal reflux disease and thyroidectomy. The patient presented to the Emergency Department (ED) with complaint of chest pain. She endorsed an irregular pulse, and reported that her symptoms had been going on for several months, intermittently. The patient had undergone a stress test and Holter monitoring about one year prior to this hospital presentation, which were both normal. The patient's physical exam was unremarkable except for tachycardia. The patient's electrocardiogram (EKG) showed atrial fibrillation with rapid ventricular response (RVR) but her troponin level was unremarkable. The patient's chest x-ray showed no active cardiopulmonary disease. The patient was evaluated following administration of second dose of Diltiazem and reported feeling better with no pressure in her chest. It was noted that monitor showed conversion to normal sinus rhythm. The patient was admitted for further evaluation and management of paroxysmal atrial fibrillation. Repeat troponin was negative. The patient's echocardiogram showed an ejection fraction 56-60% with no definite wall motion abnormalities, mild left ventricular (LV) diastolic dysfunction, mild aortic regurgitation, mildly dilated left atrium and mild aortic valve sclerosis without stenosis. The patient was medically stabilized and discharged home with instructions to follow up with cardiology for ischemic workup in one week. 

Based on the review of the medical record, the patient presented with atrial fibrillation and converted back to sinus rhythm in the ED. The remainder of the patient's cardiac workup was unremarkable, including negative cardiac troponins. The patient remained clinically and hemodynamically stable throughout the hospitalization. Inpatient admission was not medically necessary for this patient. In the absence of evidence of myocardial ischemia, hypoxemia, hemodynamic instability, or other end-organ dysfunction, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing. Inpatient admission criteria were not met. Medical policy criteria were not met for any other additional extenuating circumstances. Thus, inpatient admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient hospital admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cyclic vomiting

Treatment: Inpatient admission

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

This patient is a female child with a past medical history notable for autistic spectrum disorder, psychomotor retardation and recurrent vomiting episode who presented to the Emergency Department (ED) for assessment and management of non-bloody, non-bilious vomiting since the morning (10 episodes). The patient's mother noted decreased oral appetite. The patient reported no associated upper respiratory infection (URI) symptoms, sick contacts, travel, distention, dehydration or weight loss. Of note, the patient had then been recently discharged with a similar episode that resolved with acid suppression that the family did not continue after discharge. The patient's vital signs on ED arrival were: blood pressure 120/80, heart rate 100, temperature 98 F, respiratory rate 20 and oxygen saturation of 100% on room air. The patient's admitting weight was 70.8 kilograms. The patient's physical exam showed a well-developed, well-nourished female in no apparent distress. The decision to admit the patient occurred with a diagnosis of cyclic vomiting.

In regard to this patient's risk for aspiration, based on the review of aspiration in infants and children from UpToDate, this patient had a minimal risk of aspiration. The patient did not have a history of recurrent pneumonias, impaired oxygenation from baseline or requirement for frequent deep suctioning despite repeated vomiting episodes in the past. The patient was noted to maintain her nutrition and hydration exclusively by oral intake. The inability of the patient to easily change position with vomiting had not led to aspiration by history and could be prevented by the family with appropriate precautions and monitoring. The appealer's suggestion that this patient was at significant risk for aspiration to justify the acute inpatient setting is not supported or substantiated by this patient's history or hospital course.

The carrier's denial of coverage for inpatient admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender Dysphoria.
Treatment: Facial feminization surgery.
The insurer denied Facial feminization surgery.
The health plan's determination is overturned.

Summary.
This is a male to female transgender. She desires facial feminization surgery. Plan is for mandibular reduction, chin augmentation, masseter reduction and cheek contouring. 

Facial feminization surgery is medically necessary.
This patient has depression that her mental health providers attribute directly to her facial appearance. She has severe anxiety and depression that her physician believes is secondary to the incongruence of her facial appearance with her assigned sex. A study by Ainsworth et al found improved mental health functioning for transgender women following facial feminization surgery. Her condition represents a unique clinical situation in which, facial feminization is indicated. A systematic literature review on facial feminization by Morrison et al concluded: "based on these studies, it appears that facial feminization surgery is highly efficacious and beneficial to patients." These procedures are necessary to treat the patient's unique clinical situation of disabling dysphoria and anxiety related to the incongruence of her facial appearance.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Oral and maxillofacial deformity
Treatment: Braces and 12 monthly visits 
The insurer denied coverage for D8080 braces and D8670 monthly visit X12.
The denial is reversed.

The patient is a female child who presented for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class II, retruded mandible, maxillary and mandibular crowding, deep impinging overbite and severe overjet. The orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of overjet greater than 9 mm with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements attaining a score of 14 points on the HLD index where 26 points is required. Dr. Kuncio is appealing on behalf of the patient.

Upon review of the submitted documentation, it is evident that this 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 overjet greater than 9 mm with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. This automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. Thus, the requested coverage for D8080 braces and D8670 monthly visit x12 is considered medically necessary for this patient. 
 
The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for D8080 braces and D8670 monthly visit X12 should be reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: Braces
The Braces are medically necessary.

The patient has a deep overbite with soft tissue trauma to the palatal tissues. This is an "automatic qualifying" condition according the handicapping index. The patient needs orthodontic treatment to correct this problem.