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

Diagnosis: Dental Disorder
Treatment: Crowns teeth #6, #8, and #9
The insurer denied the Crowns teeth #6, #8, and #9.
The determination is overturned.

The patient has root canal treated teeth number (#) 6, #8, and #9. Crowns are being requested at this time. At issue is the medical necessity of the crowns.

According to the provided radiographs, teeth #6, #8, and #9 are root canal treated. Teeth #8 and #9 have moderate fillings on the mesial and distal surfaces in addition to the access hole on the lingual surface. Tooth #6 has a large access hole on the lingual surface and presence of caries on the mesial surface. Root canal treated teeth do not automatically need crowns unless there is visible evidence of large decay, fracture, or minimal tooth structure remaining. In this case, because these teeth have large fillings and caries, the remaining tooth structure is not strong enough to withstand occlusal forces without the protection of a crown. Therefore, the request for crowns on teeth #6, #8, and #9 is medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Yao syndrome.
Treatment: Minocycline Extended-Release (ER).

The insurer denied coverage for Minocycline Extended-Release (ER).  The denial is overturned. 

This is a female patient with a history of Yao Syndrome, Hashimoto thyroiditis, autoimmune disease, allergic rhinitis, chronic idiopathic urticaria and idiopathic angioedema. She has been taking minocycline extended-release (ER) and is followed by a rheumatology specialist. Continuation of therapy is requested. The patient had been on Plaquenil and sulfasalazine but had stopped, and is now on Ilaris as well.

The insurer has denied coverage for Minocycline Extended-Release (ER). They write that plan criteria cover this drug when it is being used for a Food and Drug Administration (FDA)-approved use or a use supported in the compendia of current literature. The patient's use of this drug is either unknown or does not meet the requirement, based on the information that was provided. Formulary alternatives are: doxycycline hydrate, minocycline, tetracycline or Vibramycin Syrup. There must be trial and failure of all the formulary alternatives, but not more than three.

Yao syndrome is a member of the auto inflammatory diseases. It is rare, and there is no defined therapy. Review of PubMed and Up-to-date failed to reveal studies of treatment directed towards this specific syndrome. Based on disease characteristics the use of biologic agents, sulfasalazine and glucocorticoids has been noted. 

The patient has failed sulfasalazine, is on a biologic and glucocorticoids should be avoided if possible due to toxicity.

There is no established antibiotic (or other) treatment for Yao Syndrome. Minocycline ER has helped the patient without apparent toxicity, and there is no reason to suspect that any of the formulary antibiotics will work as well or better. Attempts at tapering the Minocycline ER have failed. The patient has failed non-ER minocycline use.

The patient was on Minocycline-ER when her current Rheumatologist saw her, so there may not be a complete history of past treatments.

There is no literature comparing different antibiotics and forms of minocycline for treating this problem. The patient has been on the ER form, and it has helped. There is a risk of switching, as there is no reason to assume that the alternatives are equivalent or will be free of toxicity. Thus the requested drug is likely to be more effective than the formulary.

Formulary Exception for Minocycline Extended-Release (ER) is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient has a history of stage IV colon cancer and was admitted to the hospital due to syncope, nausea, vomiting, headache and back pain. She was hypotensive in the field and was given 1 liter normal saline. In the emergency room (ER), her blood pressure (BP) was 111/72, heart rate (HR) 83. An electrocardiogram (ECG) was negative. Lab work showed alkaline phosphatase (alk phos) 174, negative troponin, and negative blood cultures. The glucose was 155. A head computed tomography (CT) scan showed a localized peripheral subarachnoid hemorrhage. A chest x-ray (CXR) showed metastatic lung nodules. A magnetic resonance imaging (MRI) scan revealed leptomeningeal disease. An echocardiogram (ECHO) demonstrated a moderate pericardial effusion. A lumbar puncture was completed. Keppra was started in addition to Tylenol, Fentanyl and Zofran. She was subsequently admitted for further workup. The inpatient hospitalization stay is under review for medical necessity.

The requested health service/treatment of inpatient stay was not medically necessary. 
The patient was thought to have orthostatic hypotension in the setting of decreased by mouth (PO) intake and less likely vasovagal. Nothing suggested a cardiac event. Low risk patients are considered to be low risk of mortality or recurrent syncope resulting in injury.  Such patients have no evidence of structural heart disease and have normal baseline ECG.  In most of these cases, the causes of syncope include reflex or orthostatic syncope, both of which are generally considered relatively benign with regard to the risk of early mortality or recurrent syncope.  Most of the time these patients can treated and discharged home for further outpatient evaluation as needed along with plans for prompt outpatient follow up. The patient in this case can be considered to be a low risk patient under these criteria, and, therefore, be treated at a lower level of care.

According to Milliman Care Guidelines (MCG) guidelines for Syncope, admission to inpatient status is indicated by 1 or more of the following: Hemodynamic instability and altered mental status that is severe or persistent. Neither of these were present.
Other indications include the following: There was no central nervous system (CNS) event such as stroke, mass, hydrocephalus, pulmonary embolus, aortic dissection, acute congestive heart failure (CHF) or anemia secondary to blood loss. There was no indication of cardiomyopathy, valvular heart disease, ischemic heart disease, myocarditis, subclavian steal, arrhythmia, tamponade, or severe dehydration.
The patient did not meet the requirements listed above that would dictate inpatient hospitalization.

Therefore, inpatient hospitalization was not medically necessary. The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Radiology Services. 
The insurer denied neurolytic destruction of nerves in knees. The determination is upheld.

The patient is a male with a complaint of bilateral knee pain. The provided records document that this patient had bilateral knee osteoarthritis and underwent bilateral knee cortisone injections. Due to persistent bilateral knee pain, the patient subsequently underwent right knee radiofrequency medial genicular nerve ablation. At issue in this case is the medical necessity of the nerve ablation procedures performed for the right knee.

The requested health service/treatment of neurolytic destruction of nerves was not medically necessary for this patient. 

The rationale for this determination is based upon the provided medical records and the recommendations of the current, peer-reviewed literature with respect to medial genicular nerve ablation. The current, peer-reviewed literature has not clearly defined radiofrequency nerve ablation as an effective treatment modality for advanced knee osteoarthritis.

An article published by Gupta and colleagues in the Pain Physician journal in 2017 concluded that "Overall, the studies showed promising results for the treatment of severe chronic knee pain by radiofrequency ablation at up to one year with minimal complications. Numerous studies, however, yielded concerns about procedural protocols, study quality, and patient follow-up." A second article by Oladeji and associates in the Journal of Knee Surgery in 2018 was a review article that determined "A total of eight reports that use cooled radiofrequency ablation (C-RFA) in the treatment of chronic knee pain were identified and analyzed. There were two prospective trials, one retrospective cohort study, and five case reports or case series. C-RFA is an emerging procedure with encouraging early results; however, additional long-term prospective clinical trials are necessary to further characterize how C-RFA can best be used to treat chronic knee pain." Therefore, there is limited evidence in the current peer-reviewed literature that radiofrequency nerve ablation is an effective long term treatment for knee pain associated with knee osteoarthritis.

This determination is based upon the provided medical records and the conclusions of the current, peer-reviewed literature with regard to medial genicular nerve ablation.
Appeal type: Medical necessity
Decision: Upheld

Respiratory
Inpatient hospital

Diagnosis: COPD
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a man with antiphospholipid syndrome, chronic obstructive pulmonary disease (COPD), cerebrovascular accident (CVA) with left-sided weakness and speech impairment, gout, diabetes, hypertension, chronic kidney disease and aortic valve vegetation who presented to the hospital with a chief complaint of shortness of breath and chest tightness which started several days earlier. Vital signs showed temperature 97.4 Fahrenheit, heart rate 92, and blood pressure 143/83. Oxygen saturation was 96%. On physical exam, heart was regular, breath sounds were normal with no wheezes, and the abdomen was soft and nontender. The patient was admitted with suspected COPD exacerbation. The plan of care included steroids, bronchodilators, renal consult, monitor kidney function, Renal ultrasound, sodium bicarbonate for metabolic acidosis, and continue other home medications. The pulmonary service saw the patient and assisted with management of COPD. 

The inpatient hospital admission was not medically necessary.

The patient was admitted for chest pain and suspected ACS (acute coronary syndrome) along with suspected COPD exacerbation. However, he was hemodynamically stable, was not hypoxic, did not have acute electrocardiogram (EKG) abnormalities or respiratory distress, and had no other complicating factors such as involvement of the aortic valve vegetation. His hospital stay was relatively stable and of low acuity. He did not need an inpatient level care.

The patient was hemodynamically stable and although he was seen by cardiology and pulmonary specialists, he was never acutely ill or in respiratory distress, based on the description of symptoms and the reported physical exam findings in progress notes. In addition, there was no evidence of pneumonia or sepsis. Overall, this was a stable hospital stay and the treatment plan could have been provided safely and effectively at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal
Home Health Services

Diagnosis: Osteoarthritis
Treatment: Personal Care Assistance
The insurer denied Personal Care Assistance: 7 Days per Week, 24 Hours per Day [Split Shift]. The health plan's determination is overturned.

The patient is a female with multiple issues, including age-related debility with cognitive and physical functional disabilities. Under review is the medical necessity of the requested increase in personal care assistance: 7 days per week, 24 hours per day [split shift].

Personal Care Assistance: 7 Days per Week, 24 Hours per Day [Split Shift] is medically necessary for this patient.
The patient is an elderly female with a past medical history significant for osteoarthritis, impaired functional mobility, lumbar spinal stenosis, venous insufficiency, lumbar spondylosis, cognitive impairment, constipation, nocturia and symptomatic tachycardia. Due to the above-listed conditions she requires total assistance with all her ADLs (activities of daily living) which include bathing, dressing, hair foot and skin care, ambulation within her home with a walker or wheelchair, toileting that includes transferring on and off the toilet, changing incontinence products, dressing, clean up assistance with transferring from walker to chair to bed throughout the day. She also requires help to prepare her meals and take her medications according to the required dosing schedule. She currently is in a skilled nursing facility and wishes to return home. She does live alone and has no one that can provide personal care services to her once her aide leaves for the day. 
According to the patient's provider and advocate, the patient requires nighttime assistance with toileting, walking and transferring with such frequency that a live-in aide would be unable to obtain five uninterrupted hours of sleep. As documented by her treating physician she wakes up at unscheduled times 2-3 times throughout the night needing to use the bathroom. As a result of her impaired functional mobility, balance issues and dizziness, she has suffered multiple falls and is often left sitting in a soiled diaper until her aide arrives the next morning. This has caused the patient to have frequent urinary tract infections. Per the patient's provider, her condition has declined recently, and her incontinence is causing uncontrollable voiding at night. Therefore, the Personal Care Assistance: 7 Days per Week, 24 Hours per Day [Split Shift] is medically necessary for this patient to ensure that she has adequate assistance with all her ADL's including toileting, including post elimination cleanup, especially at night.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis.
Treatment: Inpatient Hospital Stay.

The insurer denied the inpatient hospital stay.  The determination is upheld.

The patient has a history of breast cancer and was admitted to the hospital due to watery, non-bloody diarrhea, a fever, abdominal cramping, and nausea. She received neoadjuvant chemotherapy for breast cancer about 2 weeks prior to admission. Her blood pressure (BP) was 111/69, heart rate (HR) 86, respiratory rate (RR) 18, temperature 36.9 degrees Celsius, and oxygen (O2 sat) 96%. Her hemoglobin was 9, white blood cell count (WBC) 17.2, and platelets 185,000. The creatinine was normal, as were the calcium and liver function tests. The sodium (Na) was 130 and potassium (K) 3.4. The discharge summary listed her diagnosis as gastroenteritis. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. She was given intravenous fluids (IVF), antiemetics, Cipro, Rocephin, and a clear liquid diet. A computed tomography (CT) scan showed enterocolitis. Clostridium difficile (C. diff) was negative. 

The patient had no alarming symptoms that warranted inpatient hospitalization. She could have been managed at a lower level of care with transition to inpatient stay if there was deterioration. There were no alarming symptoms or signs such as dry mucous membranes, decreased skin turgor, increased thirst, altered mental status, dizziness/lightheadedness, headache, tachycardia or palpitations, hypotension, orthostasis, syncope or presyncope, weakness/fatigue, or decreased urine output. There were no bloody stools, weight loss, severe abdominal pain, prolonged symptoms, recent hospitalization or antibiotics, age greater than (>) 65 years, multiple comorbidities, or pregnancy. There was no mention of dehydration, intractable vomiting, or severe electrolyte abnormalities. Most patients with gastroenteritis can be managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient Hospital stay.

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

The patient is a male with a history of alcohol abuse, decompensated alcoholic cirrhosis, ascites, depression, hypertension, and post-traumatic stress disorder (PTSD). He had a paracentesis for ascites. He presented to the emergency department (ED) with right lower quadrant abdominal pain, nausea, emesis (two episodes), melena, diarrhea, and chills. He had tremors, and his abdominal examination revealed distension, tenderness, and guarding with a positive Rovsing's sign. His stool was occult blood positive, alcohol level was 243.3. A computed tomography (CT) scan of the abdomen revealed non-specific procto-colitis, mild ascites, hepatomegaly, and periportal edema. He was admitted to the hospital, given intravenous (IV) fluids, IV Pantoprazole, Thiamine/ Multivitamins/ Folic Acid. He was placed in a Clinical Institute Withdrawal Assessment (CIWA) protocol, started on Ceftriaxone, and gastroenterology was consulted

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

The patient had presented to the ED with evidence of an upper gastrointestinal bleed with melena, occult blood positive stool, anemia, nausea, emesis, abdominal pain, underlying alcoholic cirrhosis, and tachycardia. He may have been safely, appropriately, and effectively been placed under an observational level of care. He may have been treated with IV Pantoprazole/ Antibiotics/ fluids. He may have had a CT scan, and gastroenterology may have been consulted. He may have been observed clinically overnight and had an EGD the next morning. If he remained clinically and hemodynamically stable, he may have been discharged home with close outpatient follow up. Acute inpatient medical admission level of care was not clinically indicated, nor medically necessary, and therefore, cannot be approved.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure (braces). 
The insurer denied the Dental/Orthodontic Procedure (braces).  The denial is overturned.

The patient is a male with a Class II Division 2 subdivision left malocclusion. He has crowded occlusion and has 100% deep bite causing wear on his mandibular incisors. He is treatment planned for orthodontics to correct his malocclusion. The subject under review is the medical necessity for braces in this case.

The health plan's determination is overturned.

The requested treatment of braces is medically necessary for this patient. The patient has wear on his lower anterior teeth, particularly visible on teeth 24-27 in the mandibular occlusal photograph. If left untreated, this will worsen and cause restorative problems. [1] A deep bite on its own is not a reason to treat with orthodontics. However, at 20 years old, he is already causing wear to the incisal edges of his mandibular anterior teeth. This will worsen with time if left untreated and can lead to periodontal problems in the future that will be more invasive and difficult to correct than the orthodontic problem he currently has. [2]
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health. 
Treatment: Mental Health Inpatient. 

The insurer denied inpatient mental health services. 
The denial is overturned. 

The patient is a male admitted for acute inpatient level mental health care. The patient was brought in by emergency services to the emergency department with worsening symptoms of depression and suicidal ideation together with prominent neuro-vegetative symptoms of depression. He had a history of pulmonary embolus and other general medical conditions that included gastroesophageal reflux disease (GERD), hypertension, dyslipidemia and diabetes mellitus, and somatic symptoms of anxiety including reports of fainting spells. 

He was admitted with subsequent safety monitoring and treatment with milieu therapy that included group, educational and activity therapies. He received medication with continued treatment with sertraline and olanzapine, and as needed (prn) medications to address anxiety and insomnia. The subject under review is the medical necessity for inpatient mental health services. 

The health plan's determination is overturned. 

The inpatient mental health services could not have been safely or effectively provided with lower level care in this case scenario. During the time interval under review, the patient continued to display acute symptoms related to persistent anxiety and the depressive disorder that warranted continued inpatient level structure and monitoring, as well as efforts to develop a safe and clinically appropriate discharge plan and disposition, and a safety plan. The inpatient level care thru discharge was reasonable in this case and in the best interest of the patient reflecting sound medical judgment with regard to the condition under treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal Pain.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient presented to the hospital with a history of progressively worsening abdominal pain in the right lower quadrant, nausea, vomiting and constipation of 2-days duration. His evaluation included a physical exam, labs, and a computed tomography (CT) scan. He was without a fever at the time of presentation. Vital signs were normal. He was tender in the suprapubic area, and right lower quadrant with a positive Rovsing's sign (right lower quadrant (RLQ) pain with palpation of the left lower quadrant (LLQ)). Lab data identified a normal white blood cell count (WBC) count of 6.29 thousand (K). The CT scan identified a prominent appendix consistent with appendicitis. There was also noted mild thickening of the sigmoid colon noted on the CT scan. Treatment was initiated with intravenous (IV) fluid and serial abdominal exams. Surgical consultation was obtained.

The patient was noted to have improvement with regard to the abdominal pain. Vital signs remained normal throughout the hospitalization without a fever. The diet was advanced and tolerated. He was discharged home.

At issue is the medical necessity of an inpatient stay.

This patient presented with abdominal pain. The evaluation with examination, lab data, and CT scan suggested the diagnosis of appendicitis. The initial treatment included nothing by mouth (NPO) status, IV fluid, and serial abdominal exams. The patient was noted to be improved and was clinically stable for discharge from the hospital with instructions for outpatient follow up.

The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient presented with abdominal pain and monitored with serial abdominal exams overnight. A lower level of care would have satisfactorily provided for the treatment provided and would have been consistent with the accepted standard of medical care. Surgical assessment, serial examination and overnight monitoring could have been provided at a lower level.

Generally accepted guidelines for patient admission indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications, monitoring of a patient with abdominal pain can be appropriately accomplished with an observational level of care. In this case the patient tolerated oral hydration, diet, and was considered to be stable for discharge from the hospital within one day. Inpatient care was not required or medically necessary in this case per Milliman Care Guidelines (MCG) or generally accepted medical standards.