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

Diagnosis: Cavity under tooth cap
Treatment: D2751 (White Glass with Metal Crown) Tooth #3
The insurer is denied coverage for D2751 (White Glass with Metal Crown) Tooth #3.
The denial is upheld. 
This is a male patient who presented to the dentist for an dental evaluation. Upon review of the documentation provided which includes periapical radiographs narrative comments from the patient. The dentist recommended full coverage replacement crown for #3.

The objective documentation provided for review is periapical radiographs. Tooth #3 has a preexisting full coverage crown that appears to be stable and intact. It appears that there is no evidence of fracture or other pathology specifically affecting Tooth #3. There does not appear to be any radiographic evidence of caries/ recurrent decay on Tooth #3. The radiographs do not substantiate the requested dental service as enumerated above and therefore, the crown is deemed not medically necessary.

The health plan acted reasonably with sound medical judgement, and in the best interest of the patient. D2751 (white glass with metal crown) tooth #3 is not considered medically necessary for this patient.

Based on the above, the medical necessity for D2751 (White Glass with Metal Crown) Tooth #3 is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Respiratory System. 
Treatment:  Advanced Imaging Services. 

The insurer denied CT scan of the chest.  The denial was overturned in whole. 

The patient is a female with a history of a T1cN0M0 left breast cancer.  The patient has completed surgery, adjuvant chemotherapy, and adjuvant hormonal therapy with tamoxifen; she is currently receiving extended adjuvant therapy with letrozole.  The patient is a smoker (70-pack years) and also has a history of pulmonary nodules.  A computed tomography (CT) of the chest was ordered and is under review for medical necessity. 

The health plan's determination is overturned in whole. 

The CT of the chest is medically necessary for this patient.  This patient has a 70-pack year smoking history and a documented history of pulmonary nodules.  The service under review is not being obtained, due to her breast cancer; the patient is at high risk of developing lung cancer.  The National Comprehensive Cancer Network (NCCN) and United States Preventive Services Task Force (USPSTF) recommend screening lung CTs in this scenario.  The authors of UpToDate similarly support this recommendation.  With regard to her pulmonary nodules, they state "...CT of the chest without contrast is the preferred exam for imaging surveillance of an incidental pulmonary nodule...".  Annual imaging surveillance is recommended by the Fleischner Society guideline.  Given the support in the literature and in national guidelines, medical necessity has been established for this service.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal - Back Pain
Chiropractic Services

The patient is a female, who began chiropractic treatment of neck pain with initial diagnoses of cervical-thoracic radiculopathy. Treatment included spinal manipulation, ultrasound and mechanical traction. Notes indicate Visual Analog Scale (VAS) 6-8/10 for neck and upper back pain, and VAS was 5/10. 

The health plan's determination is upheld. 

The chiropractic services were not medically necessary. The patient was being treated for ten months for the same chief complaints, with the same treating diagnoses and treatment, with no objective evidence of sustained and measurable clinical progress, and this makes such treatment not medically necessary, as non-corrective care. There was no detailed re-examination, no ongoing Oswestry scoring, no attempt to improve treatment outcomes with a different treatment approach, and no non-supervised home rehabilitation program.

Using the American College of Occupational and Environmental Medicine (ACOEM) as a good guideline, the standard of care for chiropractic spinal treatment with spinal manipulation is objective evidence of clinical improvement within two weeks, and four weeks total, using two or more forms of manual therapy, which can include spinal manipulation.  Such objective evidence was lacking, many months after treatment had begun in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal
Treatment: Surgical Services
Diagnosis: Digestive System/Gastrointestinal/Other-Obesity
Treatment: Surgical Services
The HP denied the procedure as E/I. The reviewer has upheld the HP determination.

This case involves a patient with severe obesity who had previously undergone a laparoscopic gastric band placement. Weight loss was poor after this treatment and the patient sought assistance from a bariatric surgeon who felt like conversion to a laparoscopic modified, single anastomosis duodenal switch (SADS) was the best operation. The surgeon believes that since the patient failed a purely restrictive operation, another operation should have an additional malabsorptive component.
There are no good studies to support the proposal that treatment with single anastomosis duodenal switch is better than standard gastric bypass or sleeve. SADS has modest supporting published literature for  a treatment for severe obesity. However, the literature does not substantiate use of this procedure for revisional purposes. In addition, considerable data contradict the assertion that vertical sleeve gastrectomy and gastric bypass are purely restrictive operations.
In their study, Andalib et al found that when RYGB was compared directly to SADS, RYGB led to equivalent or better weight loss after a failed sleeve gastrectomy. [1]
In their study, Frantzides and colleagues found that RYGB provided excellent weight loss (35% weight loss) after failed lap band. These data also support the use of standard bariatric operations as effective for revisions, and suggest that the SADS is not required. [2]
In the conclusion of their article, Kallies and Rogers indicate that the single anastomosis duodenal switch operation is a variant of the class of the classic duodenal switch and as such merits consideration for endorsement by the society as an appropriate primary [not revisional operation] operation for those with severe obesity. [3]
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal
Treatment: Surgical Services

Diagnosis: Digestive System/Gastrointestinal/Other-Obesity
Treatment: Surgical Services
The HP denied the procedure as E/I. The reviewer has overturned the HP determination.

The patient underwent laparoscopic adjustable gastric band surgery. This was performed as treatment for morbid obesity. The  notes indicate that the patient was able to lose 125 lbs. following the gastric band procedure, but subsequently gained weight, now has a choking sensation with meals which has resulted in avoidance of causative foods.
The patient followed with the provider for the condition of refractory morbid obesity. At the time of the request the patient had a body mass BMI 40.3 kg/m2. A psychological evaluation provides mental health clearance for the proposed surgery. The records include an esophagogastroduodenoscopy (EGD) that describes an esophageal ulcer in the area of the gastroesophageal (GE) junction and a 4-cm hiatal hernia. An upper gastrointestinal showed the band to be in stable position. The report states that there is no gastric pouch created by the existing gastric band. Medical clearance is granted. The patient participated with a supervised diet program. The patient's thyroid stimulating hormone (TSH) is normal.
Based on the published literature, the proposed revisional bariatric operation (removal of the existing gastric band with conversion to single anastomosis duodenal switch [SADI-S]) is known to be likely more beneficial than any standard treatment for the insured's condition/disease.
This patient has a gastric band. The UGI supports the conclusion that the band is malpositioned at the gastroesophageal junction as there is no gastric pouch cephalad to the gastric band. The patient has ongoing symptoms of choking attributable to the malpositioned gastric band. Finally, the patient has also realized weight gain and has a current BMI > 40 kg/m2. The proposed treatment in this case is the loop duodenal switch procedure also known as the single anastomosis duodenal switch or single anastomosis duodenoileal bypass with sleeve gastrectomy. This procedure is proposed as a bariatric operation to achieve weight loss in the setting of a prior gastric restrictive operation (adjustable gastric band).
The most recent guideline or statement regarding this proposed procedure from The American Society for Metabolic and Bariatric Surgery was published in 2020.[1] The conclusion of this updated guideline is that there is an adequate volume of peer reviewed publications that report data on approximately 1500 patients and that the single anastomosis duodenoileostomy with sleeve gastrectomy procedure provides similar outcomes to those reported after the classic biliopancreatic diversion with duodenal switch which is an endorsed procedure per the American Society for Metabolic and Bariatric Surgery (ASMBS).
Based on the published data, this procedure [SADI-S] has garnered the support of The American Society for Metabolic and Bariatric Surgery as a proven safe and effective bariatric operation.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal
Treatment: Surgical Services

Diagnosis: Digestive System/Gastrointestinal/Other-Obesity
Treatment: Surgical Services
The HP denied the procedure as E/I. The reviewer has overturned the HP determination.

This patient  is 5 feet 7 inches tall, and weighs 257 pounds giving him a body mass index(BMI) of 40.33 kg/m2. Weight related co-morbid conditions include: Morbid Obesity. Dietary and psychological clearance was obtained. The patient underwent the lap band procedure with 125 pound weight loss and with weight regain. The patient completed 4 months of supervised dietary effort.
The SADS is an approved standard treatment for morbid obesity endorsed by the American Society for Metabolic and Bariatric Surgery (ASMBS) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in published guidelines. The patient meets all standard requirements for bariatric surgery with a BMI that is 40.33 kg/m2, failed dietary and other weight loss efforts including the lap band. The patient has undergone an updated multidisciplinary evaluation that did not reveal any obvious dietary or behavioral barriers to reoperative surgery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dilated cardiomyopathy.

Treatment: LifeVest.

The insurer denied coverage for LifeVest.

The denial is upheld.

This is a female patient with a history of diabetes, hypertension, and obesity. The patient presented to the hospital with acute and worsening shortness of breath requiring intubation for suspected flash pulmonary edema due to severe hypertension. The patient's transthoracic echocardiogram revealed a left ventricular ejection fraction (LVEF) of 30% with moderate/severe left ventricular systolic dysfunction, moderate to severe global left ventricular hypokinesis, and moderate diastolic dysfunction. An electrophysiology consultation was done, and LifeVest was recommended upon discharge. The patient had a cardiac catheterization performed, which revealed proximal to mid-left anterior descending (LAD) artery 30% stenosis, 50% stenosis of the proximal first oblique marginal (OM1), and 70% stenosis of the proximal second oblique marginal (OM2). Cardiology and electrophysiology are requesting LifeVest for the prevention of sudden cardiac death due to the patient's diagnosis of dilated cardiomyopathy (including non-ischemic cardiomyopathy [NICM]) with an ejection fraction of less than/equal to 35%.

LifeVest is Food and Drug Administration (FDA) approved for the prevention of sudden cardiac death. However, based on the review of the medical record and literature, the use of LifeVest for the dates under review is not medically necessary for this patient. The patient was diagnosed with non-ischemic cardiomyopathy, with an ejection fraction of 30%. LifeVest technology has not been shown to render clinical benefit when compared to standard-of-care medical therapy for the prevention of sudden cardiac death in patients with newly diagnosed cardiomyopathy. For the dates under review, LifeVest technology is not medically necessary. There is no clinical research evidence that demonstrates the incremental benefit of this technology over conventional medical therapy, which the patient was receiving. LifeVest technology would therefore be considered experimental and/or investigational in this clinical setting and does not represent the standard of care for such patients. The patient's clinical presentation and the absence of extenuating circumstances do not support medical necessity for the use of LifeVest for the dates under review. 

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

Based on the above, the medical necessity for LifeVest is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis

Treatment: full hospital admission

The insurer denied coverage for a full hospital admission.

The denial is upheld.

This is a female patient with a history of osteoarthritis to her right knee. The patient also had chronic obstructive pulmonary disease (COPD) and hypertension. The patient was admitted to the hospital for an elective right total knee arthroplasty. The patient's post-surgical course was uncomplicated. The patient was admitted for post-operative pain control and received patient-controlled analgesia (PCA).  This was stopped, and the patient was transitioned to oral analgesics. The patient was evaluated by physical therapy (PT) and occupational therapy (OT). The patient and the family refused discharge to home. Case management notes demonstrated that subacute rehabilitation (SAR) referrals were sent. The patient was ultimately discharged home with home health care. 

Based on the review of the medical record, the patient had a non-complicated post-surgical course. There were no problems with her wound. The patient did not require a drain. The patient's vital signs were stable with no laboratory abnormalities. The patient's level of pain was tolerable with ability to take oral pain medications. There were no problems with rehabilitation as the patient was able to use a rolling walker in an independent manner. The patient did not require treatment for any underlying medical conditions. There were no reasons to support this patient could not have been transferred to a lower level of care, such as a Skilled Nursing Facility (SNF) or home. There were no extenuating circumstances to substantiate the medical necessity of this patient's inpatient admission and length of stay. Thus, based on the review of the Milliman Care Guidelines (MCG) for knee arthroplasty (ORG: W0081), 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 full hospital admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath, fever, cough, influenza B during pregnancy
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female G3P2002 who was seen at 17 weeks five days in the emergency room for shortness of breath, cough, and fever of 101 for one day.  She had a positive influenza B test as an outpatient and stated she was febrile at home with increasing shortness of breath with no benefit from albuterol nebulizer treatments.  She was admitted to the hospital and given oxygen, Tamiflu, flu vaccine, Z pack, heparin, albuterol and ipratropium nebulizer.  Her condition improved and she was discharged home the next day.  

The facility contends that the admission was medically necessary but does not cite any specific guidelines.  The health plan contends that the admission was not medically necessary due to normal vital signs, no infection with the flu, normal white blood cell count, normal fetal ultrasound, absence of hypoxia, no documentation of lack of improvement after observation, lack of severe infection or high fever, lack of immunodeficiency, lack of abnormal labs and cites MCG 23rd edition Sepsis and other febrile illness without focal infection ORG:M-160 (ISC).

Yes, the proposed inpatient admission was medically necessary.  

Pregnant women are at much higher risk of serious complications of flu including preterm delivery, pneumonia, intensive care unit (ICU) admission, and fetal or maternal death.  The American College of Obstetricians and Gynecologists has issued a practice bulletin outlining guidelines for screening and treatment of pregnant patients with proven or suspected flu.  Per this guideline, patients with dyspnea are considered "elevated risk" and should be admitted to the hospital and even considered for admission to critical care units due to the high risk of complications.  Therefore the admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cystic Fibrosis related diabetes
Treatment: Continuous blood glucose monitor
The insurer denied the continuous blood glucose monitor.
The denial is upheld. 

The patient is a female diagnosed with cystic fibrosis related diabetes. This request is for CGM (continuous glucose monitor) Dexcom. 

As reported, the patient has been using Dexcom G 6 CGM to manage her diabetes. She has an insulin deficient form of diabetes. She is prescribed insulin to manage hyperglycemia. The CGM she uses provides alerts to notify her of potential hypoglycemia before it occurs, allowing her to prevent sequelae of hypoglycemia, including confusion, weakness, seizure and death. She is on Humalog up to 50 units; Basaglar up to 50 units. 

The patient wore a libre device for two weeks as part of a clinical study. Her A1C (glycated hemoglobin) was 6.3 %. 

No, the blood glucose monitor is not medically necessary.

Continuous glucose monitoring systems, including real-time systems, have FDA approval (1, 2). They are not the subject of Phase I-III clinical trials. The peer-reviewed literature supports the long-term use of CGMS (continuous glucose monitoring system) in adult (>= [greater than or equal to] 25 year old) patients. The ADA position statement on standards of medical care in diabetes published in 01/2011(3), states, "Continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens can be a useful tool to lower A1C in selected adults (age >=25 years) with type 1 diabetes." The ADA considers this to have a level of evidence of "A" which is "Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered."

In addition, the peer-reviewed literature supports the use of long-term CGMS in patients with type I diabetes with hypoglycemia unawareness and episodes of hypoglycemia(6). The ADA position statement on standards of medical care in diabetes published in 01/2009 (7) states, "CGM may be a supplemental tool to SMBG in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes." There is evidence that real-time CGMS with an alarm function detects hypoglycemia (8) leads to an improvement in glycemic excursion, leads to a reduction in duration of hypoglycemia, and prevents hypoglycemic reactions in adult patients with type I diabetes (9-12). Although not all episodes were detected (13), the majority were detected. This represents a 60% reduction in patients with complete hypoglycemia unawareness. 

Although there are studies showing utility of using CGM in patients with cystic fibrosis related diabetes, it is only approved for use in type I diabetes. In addition, the patient has no evidence of using a basal/bolus intensive insulin regimen. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Trauma/Injuries. 
Treatment:  Inpatient Hospital. 

The insurer denied inpatient stay.  The denial was upheld in whole. 

The patient is a male that presented to the emergency department (ED) via Emergency Medical Services (EMS) because of possible gas exposure in the home.  The parents and other family members noted a gas-like smell, causing dizziness, lethargy, and nausea.  The Fire Department was contacted but did not detect a carbon monoxide gas level in the home.  The infant appeared tired, slightly hypotonic, but had no vomiting.  Vital signs included temperature 36.9, hart rate 170, and respiratory rate 41 with 99% oxygen saturation in room air.  Examination was significant for no acute distress, clear lungs, regular heart rhythm, benign abdomen, and normal muscle tone.  Laboratory work-up revealed normal venous blood pH, mild hyponatremia, metabolic acidosis, mild hyperglycemia, and leukocytosis.  He did well with an oral challenge, taking two bottles each of formula and Pedialyte.  He was admitted for monitoring, while the rest of the family was admitted for evaluation of altered mental status after unknown toxic exposure.  Ultimately it was determined that the family had eaten gummies that were later noted to contain cannabinoids.  Social Services was consulted, and after interviewing the family, had no concerns regarding the patient's disposition home.

The health plan's determination is upheld in whole. 

The inpatient stay was not medically necessary.  This patient was at home with his family when the majority of the family members developed dizziness, nausea, and altered mental status.  The mother was concerned about a gas leak, so the Fire Department was contacted.  There was no evidence of carbon monoxide in the home, but because multiple persons were affected, they were all taken to the ED along with the infant.  The baby had some laboratory abnormalities but was overall stable with good appetite and no altered mental status.  With further investigation, it was discovered that the family had been given tainted gummies, and all but the eldest daughter and the patient had eaten them.  All the family members were hospitalized for monitoring.  The patient was initially hospitalized for monitoring, and when the details were discovered, he had to remain in the hospital pending guardian discharge.

The initial plan was to monitor the patient overnight, but it became clear that the patient was not exposed.  However, there were no family members able to care for him.  He remained in the hospital overnight for monitoring, Social Services consultation, and availability of an appropriate guardian for discharge.  While he did not require acute inpatient admission, it was (at first) medically necessary and reasonable to monitor his status overnight, which could have been completed at a lower level of care status.