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

Diagnosis: Atrial Fibrillation
Treatment: Service code 33274 (transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed)
The insurer denied the insertion of the permanent leadless pacemaker.
The denial is upheld.

The patient is a male with a history of paroxysmal atrial fibrillation (AF) and recurrent syncope. An implantable loop recorder documented pauses of up to 4 seconds with AF termination. He underwent implantation of a leadless right ventricular pacemaker. The subject under review is the medical necessity for the insertion of permanent leadless pacemaker.

Based on the documentation provided implantation of the leadless pacemaker is not medically necessary.

Leadless cardiac pacing is a relatively new technology. For patients requiring a single right ventricular lead permanent pacemaker the primary advantage of these devices is the elimination of several complications associated with transvenous pacemakers, including pocket infections and hematoma and lead fracture. At this time, there are no randomized controlled trials directed comparing outcomes with leadless versus transvenous pacemakers. Data obtained from observational studies have shown similar rates of vascular events and lead dislodgement, markedly fewer infectious complications and more cardiac perforations/pericardial effusions, with leadless versus transvenous devices. Unfortunately, despite the lack of a lead traversing the tricuspid valve with leadless devices, the incidence of tricuspid regurgitation does not seem to be significantly less, likely due to mechanical interference of the lead on the valve or subvalvular apparatus. Long-term data are lacking and the patient population that would most benefit from this technology has yet to be fully defined.

While the leadless pacemaker is known to be effective in this situation and is Food and Drug Administration (FDA) approved for this indication it is not yet considered the standard of care and it is considerably more costly than transvenous pacing which, in this situation, would be expected to produce equivalent results. Thus, medical necessity is not met.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who presented to the emergency department (ED) with a complaint of facial/jaw pain and limited mouth opening. An oral and maxillofacial surgery consult was obtained in the early morning and a decision was made that surgical intervention was needed. 

The inpatient hospital admission is not medically necessary for this patient.

Mandible fractures are generally treated at a lower level of care. There does not appear to be any notes that support an inpatient hospital admission other than the patient being placed on intravenous antibiotics. There was no airway compromise noted and the patient was stable throughout the course of the stay and surgical procedure. An inpatient hospital admission was not indicated and a lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: psoriasis.
Treatment: Stelara
The insurer denied Stelara. 
The health plan's determination is upheld. 

The patient is a female with moderate to severe psoriasis (60% body surface area involvement) which worsened after having her recent baby. Phototherapy has been avoided because bright light triggers migraines for this patient. The patient has tried and failed topical clobetasol solution, nystatin cream, clotrimazole cream, 0.1% triamcinolone cream, betamethasone dipropionate cream and ointment, and mupirocin ointment. The patient is currently nursing and plans on getting pregnant in the near future.

Ustekinumab (Stelara) is not medically necessary for this patient. 
For a patient who is both planning to become pregnant and nursing, the only acceptable treatments for moderate to severe psoriasis are light therapy and the biologic agent Cimzia (the latter of which does not cross any placental membrane and therefore does not enter the blood of the fetus/child). Stelara is not acceptable or proven to demonstrate safe and effective use in pregnant or nursing patients, and neither are first-line oral medications methotrexate or cyclosporine. If the patient cannot tolerate phototherapy because it would cause migraines, the standard of care would be Cimzia.
Consistent with current medical literature, Stelara is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned.

The patient is an adult patient with a past history significant for Hepatitis C, endocarditis, polysubstance abuse, and intravenous (IV) drug abuse who presented to the Emergency Department (ED) with a 3-day history of worsening right hand pain and swelling. The patient was admitted for inpatient care for a diagnosis of cellulitis of the right upper extremity while suffering from concurrent opioid withdrawal. 

Based on the submitted documentation, inpatient care was required for this patient. The patient presented with cellulitis of the right upper extremity with subcutaneous edema noted on the ultrasound. The patient was also noted to have opioid withdrawal and developed an allergic reaction to IV vancomycin. At the time of admission, the patient was tachycardic (heart rate 103) with a fever of 100 degrees Fahrenheit. The patient developed a severe reaction to vancomycin (red man syndrome) and exhibited electrocardiogram (EKG) changes (prolonged QTc (interval on an EKG)). Based on the clinical scenario provided, an inpatient stay is deemed medically necessary for this patient. The decision is overturned.  

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 inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission
 
The denial is upheld 

The patient had a history of chronic constipation and presented with abdominal pain. The patient was afebrile, and the vital signs were stable. There were no peritoneal signs. A Computed Tomography scan was read as proctocolitis. There was inflammation between bowel loops, but no clear fistula was demonstrated. Intravenous (IV) antibiotics were given. The patient rapidly improved and was able to tolerate a regular diet. The patient was discharged on oral antibiotics. There was a plan for an outpatient colonoscopy. 

Milliman Care Guidelines (MCG) clinical indications for admission for Gastroenteritis (MCG M-170) include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had abdominal pain and colonic inflammation. The patient was started on antibiotics and rapidly improved. IV hydration and antibiotics could have been given in the Emergency Room with observation status. The patient was able to tolerate a diet. The patient did not meet MCG criteria for admission for Gastroenteritis. An inpatient admission was not medically necessary. 

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: Upheld

Diagnosis: Cholecystitis. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient presented with abdominal pain, nausea. and vomiting. She was afebrile and the vital signs were stable. The abdominal exam was benign. There was no leukocytosis. The liver enzymes were elevated. An abdominal ultrasound revealed a mildly distended gallbladder with stones and trace pericholecystic fluid. The common bile duct (CBD) measured 8 millimeters (mm). The study was equivocal for acute cholecystitis. A Magnetic resonance cholangiopancreatography (MRCP) was negative for CBD obstruction. Intravenous (IV) antibiotics were started and she was then discharged on oral antibiotics. She was able to tolerate a regular diet. 

Medical necessity was determined using Milliman Care Guidelines (MCG) M-555 for Gallbladder or Bile Duct Inflammation or Obstruction. Acute cholecystitis is an indication for admission if certain conditions are met. These include having abdominal pain with systemic signs of inflammation. In this case, the patient did not have systemic signs of inflammation. She also did not have acute cholangitis. She did not have hemodynamic instability, CBD obstruction, severe vomiting, severe dehydration, or bacteremia. 

This patient had gallbladder disease but did not have CBD obstruction. The sonogram was equivocal for acute cholecystitis. IV hydration and antibiotics could have been given with observation status. No surgical interventions were needed. She improved and was able to be discharged on an oral antibiotic. She did not meet MCG criteria for admission for Gallbladder or Bile Duct Inflammation or Obstruction. 

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental problem

Treatment: D2740 and D2950 on tooth # 12

The insurer denied coverage for D2740 and D2950 on tooth # 12

The denial is upheld

 
Upon review of the documentation provided which includes copies of undated periapical and bitewlng radiographs, narrative report from the patient and insurer correspondence, it appears that this patient presented to the dentist for comprehensive care. The treating dentist recommended full coverage replacement crown for #12. The Insurer has denied these services stating the there is no clinical/ radiographic evidence, such as traumatic injury or decay, provided to support the necessity of this services and therefore the services do not meet medical necessity criteria. The patient is appealing.

The objective documentation provided for review is periapical and bitewing radiographs. It appears that there is no evidence of fracture or other pathology specifically affecting #12, based on the images provided for review. There does not appear to be any radiographic evidence of caries. There does not appear to be any structural or pathologic issue associated with the existing crown on #12. The radiographs do not substantiate the requested dental services as enumerated above and therefore they are deemed not medically necessary.

Uphold denial of coverage for D2740 and D2950 on tooth #12 as not medically necessary as the documentation is insufficient to justify or substantiate the treatment.

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 D2740 and D2950 on tooth # 12 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II malocclusion
treatment: Braces and Monthly visits (x12)
The insurer denied Braces and Monthly visits (x12). The health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on tooth 6. She presents with a skeletal Class II malocclusion with minor crowding in the maxilla and the mandible. She is treatment planned for Braces and Monthly visits (x12) to address the crowding and crossbite. 

Braces and Monthly visits (x12) are medically necessary for this patient.
This patient presents with an anterior crossbite on tooth 6, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular teeth that can lead to periodontal defects.
If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity.
Treatment: Wegovy.
The health plan denied Wegovy. 
The denial is upheld.

The patient is a female child diagnosed with obesity. This request is for Wegovy. As per letter; she has hyperinuslinism, dyslipidemia, and abdominal pain due to constipation and Obesity. She has been dieting and exercising. She is on metformin ER (extended release) 500 mg (milligrams); phentermine and Topiramate. Topiramate was discontinued due to cognitive problems in school. Her BMI (body mass index) now is 96th percentile. There has been a decrease of the BMI (body mass index) by 17 % since her treatment last year.

Earlier this year, the patient's BMI (body mass index) was 24.15; a year prior her BMI (body mass index) was 25.75; a year before that her BMI (body mass index) was 24.6; a year before that her BMI (body mass index) was 23.46; before that her BMI (body mass index) was 21.05; and before that her BMI (body mass index) was 19.28.

Semaglutide is a GLP1R (glucagon-like peptide 1 receptor) agonist [1] that is FDA (Unites States Food and Drug Administration) approved in the treatment of type II diabetes and obesity [2, 3, 4]. Recent studies published in major peer reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity [5, 6, 7]. This medication is now available for the treatment of obesity in the form of Wegovy.

The standard-of-care for treatment with Wegovy requires that the patient be at certain age and participating in lifestyle modification. It also requires that the patient has a BMI (body mass index) of greater than the 95th percentile. The patient has a BMI (body mass index) greater than the 95th percentile, but the patient is not at this certain age. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory distress
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is overturned. 

The patient in this case is a female with a past medical history (PMHx) of tobacco abuse who presented to the hospital with an elevated respiratory rate (RR) of 31 breaths per minute, Tachycardia up to 117, and Hypoxemia with oxygen saturation of 64% (percent) on room air. She was placed on a non-invasive ventilator on admission. She also was found to have a hypertensive emergency and started on a nitroglycerine drip due to flash pulmonary edema on admission imaging. She was started on abx (antibiotics) for pneumonia concerns and placed on an Intensive Care Unit (ICU) stepdown unit.

The inpatient hospital stay was medically necessary. This patient presented with acute onset dyspnea secondary to flash pulmonary edema. She required non-invasive mechanical ventilation and had significant findings of respiratory distress and with severe hypoxemia. She was noted to have hypoxemia down to 64% on room air and was placed on a non-invasive ventilator (high flow nasal cannula), as well as being placed on a high consequence drip (nitroglycerine) secondary to acute pulmonary edema. The need for non-invasive ventilation and the abnormal vital signs on admission (RR 31, Tachycardia) are indicators of the severity of her disease process.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Heartburn. 
Treatment: LINX Procedure (code 43284). 

The insurer denied: LINX Procedure (code 43284). 
The denial is overturned. 

The patient is an adult male with small hiatal hernia, severe reflux, and esophagitis seen on endoscopy 4 years ago. Esophagram showed non-obstructive cervical esophageal web with normal motility, no reflux was observed. Manometry also showed normal esophageal motility. pH (potential of hydrogen) testing revealed DeMeester score of 31.6. Medications of lansoprazole has not improved his coughing and choking episodes. His symptoms and findings are consistent with a diagnosis of reflux disease. The LINX procedure was recommended by the physician to treat his symptoms. 

The health plan should cover the requested LINX procedure. 

There is significant literature to support benefits of this procedure. Long term effects of the device are also documented, as well. The requested LINX procedure is more beneficial. 
Based on the literature, the LINX device is evidenced to have similar efficacy compared to laparoscopic Nissen fundoplication with less dissection and manipulation and is less invasive. It is also possible to reverse the LINX procedure, unlike a Nissen fundoplication procedure.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Heartburn. 
Treatment: LINX Procedure (code 43284). 

The insurer denied: LINX Procedure (code 43284). 
The denial is overturned. 

The patient is an adult male with chronic GERD (gastroesophageal reflux disease) symptoms, along with chronic cough. EGD (esophagogastroduodenoscopy) demonstrated esophagitis and small hiatal hernia. Manometry is normal. Barium swallow demonstrated small cervical web. The request 
is for LINX procedure. 

The health plan should cover the requested LINX procedure. 

This device has received FDA (United State Food and Drug Administration) clearance and approval for the treatment of GERD (gastroesophageal reflux disease). There are multiple studies that have demonstrated safety and efficacy of this device for GERD (gastroesophageal reflux disease). MSA (magnetic sphincter augmentation) has demonstrated better changes of producing less gas bloat syndrome and is safe in small hiatal hernias. The health plan should cover the LINX procedure, 
given the multiple studies that have demonstrated safety and efficacy of this device.
The requested LINX procedure is more beneficial. LINX system has been shown to be more effective in producing less gas bloat syndrome compared to Nissen fundoplication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End stage renal disease, malfunctioning arteriovenous fistula
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a history of end stage renal disease (ESRD) on hemodialysis, diabetes mellitus (DM), hypertension (HTN), gastoparesis, who is legally blind, with anemia, acid reflux, left arm fistula placement and mental delay who presented to the hospital with a chief complaint of needing dialysis after not having a dialysis in the past week. The dialysis facility reported a history of non-compliance with treatments. He reportedly has a court order for dialysis.
An electrocardiogram (EKG) showed sinus rhythm with non-specific T wave changes. His potassium was 5.6. A chest x-ray did not show acute findings. He was transferred to dialysis on arrival but his left upper extremity fistula was unable to be accessed due to patient refusal though the outpatient unit did report it is not functioning well. Interventional radiology (IR) was contacted for placement of a temporary dialysis catheter and vascular surgery was consulted. The patient refused a fistulogram. The patient was admitted to medicine for further management as IR was unable to provide a timeline for catheter placement. An ultrasound (US) of his arteriovenous (AV) fistula did not show an occlusion or thrombosis. He had a permanent hemodialysis (HD) catheter placed and then he underwent dialysis through this catheter during his hospital stay. He was deemed stable for discharge back to his skilled nursing facility. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary based on the documentation provided.
The patient presented after missing dialysis treatment likely due to non-compliance. He had an AV fistula which the patient was refusing to allow the nurses to access. The patient therefore needed a permanent HD line to be placed which was done after which he was able to be resumed on his dialysis schedule. He was hemodynamically stable. He did not require urgent or emergent dialysis. He did not have cardiac arrhythmias or respiratory distress. He did not have uremic encephalopathy or pericarditis. He did not have severe electrolyte or metabolic disorders. He did not have a worsening of clinical condition or new clinical findings that required inpatient management. The patient could have been managed at a lower level of care, with subsequent transition to outpatient follow-up.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: scoliosis

Treatment: continued hospital admission

The insurer denied coverage for continued hospital admission

The denial is overturned

 
The spinal fusion in a medically complicated patient is a risky procedure. The patient has already reduced pulmonary reserve by virtue of Prader Willi Syndrome, sleep apnea, and scoliosis. Patient may be having severe restrictive lung disease. Also, the post operative course was complicated by hypoxia requiring oxygen supplementation. Also, at this time patient was noted to have newly developed diabetes. Patient was at risk for severe complications of diabetes such as diabetic ketoacidosis (DKA) and electrolyte  abnormalities. Spine fusion surgery has inherent complications of severe delayed bleeding/delayed complications from anesthesia , particularly in patients with Prader Willi. Since patient was also having asthma, these patients are at heightened risk for developing near fatal asthma.  Also given the behavior abnormalities patient needed to be monitored in acute settings. Prader Willi Syndrome patients are prone for respiratory depression and the risk is multiplied in the immediate post op period and hence patient needed to be in inpatient status . 

Based on the above, the insurer's denial must be reversed. 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 continued hospital admission is substantiated.