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

Diagnosis: Malpositioned Teeth. 
Treatment: Braces. 
The health plan denied the braces. 
The determination is overturned. 

The patient is a male. He has a Class I malocclusion with moderate crowding and protrusive maxillary incisors. He has an 8-millimeter (mm) overjet and 5-mm overbite. He is treatment planned for 24-30 months of orthodontics with extraction of four first premolars to correct the crowding and protrusion, but his insurance company rejected the claim on the basis that treatment is not medically necessary. 

At issue is the medical necessity of braces. 

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

The requested health service/treatment of braces is medically necessary for this patient. There is strong medical evidence that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma.[1] Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+mm overjets, which this patient has.[2] For these reasons orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient Hospital Admission. 
The health plan denied the inpatient hospital admission. 
The determination is upheld. 

This male patient presented to the emergency department (ED) complaining of chest pain that was exacerbated by movement of his torso to the left. His medical history was remarkable for hypertension, hyperlipidemia, chronic pancreatitis, and polysubstance abuse. In the ED, his blood pressure was 124/82 millimeters of mercury (mmHg) with a heart rate of 98 beats per minute. His respiratory rate was 18/minute with a room air oxygen saturation of 98 percent (%). His physical exam was remarkable for chest wall tenderness. His electrocardiogram and chest x-ray were normal. His high sensitivity troponin level was mildly elevated at 21.6. The urine toxicology screen was positive for cocaine and marijuana. The patient was treated with aspirin and ketorolac and was admitted to the hospital to rule out acute coronary syndrome. The repeat troponin levels were 21.9 and 25. The patient was discharged. 
At issue is the medical necessity of the inpatient hospital admission. 
The health plan's determination of medical necessity is upheld in whole. The requested health service/treatment of inpatient hospital admission is not medically necessary for this patient. 
This patient presented with atypical chest pain. Due to his mildly elevated serum troponin level, there was concern for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with a normal electrocardiogram. There was no significant delta troponin. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under an alternate status. This approach has been shown to be both safe and cost-effective and is in accordance with current guidelines including the 2021 Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes. 
The Milliman Care Guideline (MCG) for chest pain was provided for review. Per the document, indications for inpatient admission include hemodynamic instability, respiratory distress, chest pain indicative of a serious diagnosis other than coronary artery disease, and severe pain requiring inpatient management. This patient met none of these criteria.
Appeal type: Medical necessity
Decision: Upheld

Endocrine
Pharmacy/prescription drugs

Diagnosis: Obesity
treatment: wegovy
The insurer denied wegovy. The health plan's determination is upheld. 

This is a case review for a male being prescribed Wegovy (semaglutide) for the diagnosis of obesity. Coverage for this medication was denied by the health plan.

Wegovy (semaglutide injection) is not medically necessary for this patient.
The patient has not sustained weight loss with treatment; his weight is increasing. The Endocrine Society Clinical Practice Guidelines were correctly applied which recommend that the medication be discontinued if there is not a 5% weight loss. This is deemed an ineffective trial of the medication. Ongoing therapy is not indicated if the treatment is not effective. The patient can discuss alternative weight loss options with their physician.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is overturned.
 
This adult presented to the hospital complaining of chest pain radiating to his left arm and back. Pain began while at rest but was exacerbated by exertion and accompanied by dyspnea. Past medical history was significant for coronary artery disease and previously placed left anterior descending (LAD) stent, hypertension, diabetes and hypercholesterolemia. On arrival to the hospital the patient was hypertensive with a blood pressure of 166/93. The pulse was 74. A 12-lead electrocardiogram (EKG) revealed normal sinus rhythm, left ventricular hypertrophy and an anteroseptal infarct of undetermined age. Serum blood testing revealed hyperglycemia. Serum troponin was not elevated. The patient was admitted to the hospital for monitoring and treatment.  An echocardiography revealed a preserved left ventricle ejection fraction (LVEF) of 57% (percent). Cardiac catheterization was performed utilizing a radial artery approach. Results revealed a patent LAD stent and an 80% first diagonal artery lesion. The patient was treated medically with ranolazine and discharged with cardiology follow up. 

This patient presented with chest pain and dyspnea. His pretest probability of coronary artery disease is high. Utilizing the HEART score (history, electrocardiogram (ECG), age, risk factors, and troponin) he was considered intermediate risk (6 points). Risk assessment of patients presenting with chest pain and no significant ST (interval on an ECG) changes on an ECG was reviewed by Hedayati. Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation at a higher level of care. Serial troponin measurement, echocardiography and ischemia work up were warranted prior to discharge. In conclusion, admission to the hospital to treat an acute cardiac event was medically necessary. Given the patient's presentation and multiple cardiac risk factors, inpatient hospital admission was appropriate.

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

Diagnosis:  Allergic rhinitis.
Treatment:  Allergy Shots.
The insurer denied Allergy Shots.  
The denial is upheld.

The patient is an adult male with a diagnosis of allergic rhinitis. The health plan denied coverage of the requested allergy shots, citing that the doctor's notes do not show that the patient is receiving injections in the clinic setting. This denial is being appealed.

The requested allergy shots are not medically necessary.

The patient is sensitized to multiple aeroallergens and has been receiving allergen immunotherapy. There is limited clinical documentation from clinic notes supporting that the patient has been receiving allergen immunotherapy in the clinic setting. The submitted clinical records are primarily in the form of handwritten notes, which are difficult to read and interpret and do not provide sufficient support. Allergen immunotherapy given in a non-clinical setting is unproven and not safe.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins
Treatment: Outpatient procedures (right ambulatory phlebectomy): Codes 37765x1, 37766x1, 37785x1, and 37799x1
The insurer denied: Outpatient procedures (right ambulatory 
phlebectomy): Codes 37765x1, 37766x1, 37785x1, and 37799x1
The denial is overturned

This adult female patient presented because of right leg varicose veins. She described symptoms of swelling, itching, and burning. She also had tenderness on palpation. Additionally, the patient reported leg fatigue at the end of the day. The patient's physical exam demonstrated varicose veins of the anterior and lateral aspect of the right thigh. Duplex did not demonstrate great saphenous reflux, but enlarged veins were identified by ultrasound in the right thigh, measuring between 3.7 and 5.3 millimeters. The same study also documented the presence of ropey outer thigh varicosities. An accompanying sketch shows the location of the varicosities. The provider has recommended stab phlebectomy. 
Coverage was denied on the basis that the patient did not have varicosities large enough to warrant phlebectomy. The size threshold under the medical policy is 3.0 millimeters. The denial letter also mentions that there was no evidence of vein stripping or ablation being done at the same time.

The proposed treatment is medically necessary.

This patient has large symptomatic varicose veins in the absence of axial reflux. Stab phlebectomy is an appropriate and medically necessary treatment. The presence of symptoms was well documented in the office notes. The large varicose veins have been well documented by ultrasound. The report includes measurement of the size of the varicosities as well as a sketch showing their location in the leg.
Code listings:
37765 - phlebectomy 10 to 20 incisions
37766 - phlebectomy 20+ incisions
37785 - phlebectomy one cluster
37799 - unlisted vascular procedure, use when doing phlebectomy fewer than 10 incisions
The above are alternative codes for phlebectomy. A single code is selected after the procedure is performed because it is usually not possible to determine in advance exactly how many incisions will be needed. 
The denial decision did not account for the fact that the patient's varicose veins were measured by ultrasound. The ultrasound measurements show that the varicose veins meet the policy threshold of three millimeters or larger.
The denial letter also mentions that the there was no evidence of vein stripping or ablation being done at the same time. However, there is no medical necessity in this case for vein stripping or ablation because the patient does not have axial reflux. The fact that vein stripping or ablation is not being done does not change the medical necessity of phlebectomy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ventilator dependent respiratory failure

Treatment: continued long term acute care (LTACH) services

The insurer denied coverage for continued long term acute care (LTACH) services

The denial is upheld

 
This is a patient with multiple medical issues, hypertension, coronary artery disease, diabetes, and ventilator dependent respiratory failure. The patient was admitted to the long-term acute care hospital (LTACH) after hospitalization for sepsis, and respiratory failure. The patient's initial hospitalization was for chest pain complicated by cardiogenic shock and Klebsiella pneumonia sepsis. The patient had been on vasopressors and antibiotics in addition to other medications. The patient underwent a tracheostomy and was transferred to a LTACH for ventilator weaning and further care. 

No clinical notes were sent for review, mostly ventilator sheets were provided. The patient was on a Trach (tracheostomy) Collar with adaptive support ventilation (ASV) for most of the time. This patient was ultimately discharged to a skilled nursing facility (SNF) on ASV.

The patient could have been discharged to a lower level of care. A LTACH stay 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 continued long term acute care (LTACH) services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis.

Treatment is an inpatient admission.

The insurer denied coverage for an inpatient admission.

The denial is upheld.

Based on clinical documentation, the patient had acute appendicitis. The patient presented to the emergency department. The patient underwent an uneventful laparoscopic appendectomy and was discharged on the same day. There were no reported complications. Outpatient appendectomy is as safe and effective, with complication rates, readmission rates, and satisfaction equivocal to those patients kept in observation.

Per clinical documentation, the patient presented to the emergency department with a one-day history of right lower quadrant abdominal pain. There was no associated nausea or vomiting. Vital signs were within normal limits. The white blood cell count was elevated to 17.01. The patient was cleared for discharge from a surgical standpoint and discharged on the same day. Admission may be necessary for patients with severe systemic illness (sepsis), poorly controlled comorbidities COPD (chronic obstructive pulmonary disease), chronic heart failure), or complications from the procedure (infection, bleeding) that require more than 24 hours of postoperative care. There were no immediate complications documented after the surgery. 

Peer-reviewed literature also indicates that outpatient laparoscopic appendectomy can successfully be performed in those with uncomplicated appendicitis. Suitable criteria for same-day discharge include hemodynamic stability, tolerating liquids, and pain controlled on oral medications. Surgical documentation notes that the patient was uncomplicated. 

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

Diagnosis: Wound management.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission. 

The denial is upheld.



This patient sustained a dog bite on the right leg, treated with rabies vaccination, immunoglobulin, antibiotics, and suturing. The patient returned to the Emergency Department (ED) for suture removal, was prescribed oral Augmentin for suspected wound infection. The patient then presented to the ED for a wound check and complaints of right lower extremity pain. The patient completed antibiotic course the day of presentation to the ED.

On examination, there was a 7-centimeters (cm) mildly tender and irregular but linear ulcer over right anterior leg, no bleeding and no discharge, with healing granulation tissue present. There was no pitting edema around the wound including the pedal area. There was also an 8x8 cm firm to hard swelling over the right medial thigh, warm and mobile and tender on firm touch. Orthopedics assessment found a wound on lateral aspect right tibia, still not fully approximated, and myositis ossificans; no surgical intervention indicated.

The patient had non-purulent cellulitis in the area of the myositis ossificans. The cellulitis was not progressive or severe. The patient did not have severe swelling and pain. Switching to a different antibiotic to cover possibility of Methicillin- Resistant Staphylococcus Aureus (MRSA) was indicated, but a parenteral route of administration was not necessary as the patient was well appearing, afebrile, and hemodynamically stable. The exam was not indicative of spreading or worsening infection or a complication such as fasciitis, myositis or abscess. Lab work was within normal limits except for a mildly elevated platelet count, and Xray which showed myositis ossificans.

Outpatient therapy with oral antibiotics is indicated for healthy persons with non-purulent cellulitis if they have no evidence of sepsis. Inpatient therapy with parenteral antibiotics is recommended in patients with sepsis, hemodynamic instability, mental status changes, poor compliance, failure to respond to oral antibiotics, facial involvement, or immune suppression. 

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 inpatient admission is not substantiated.
Appeal type: Step Therapy
Decision: Overturned

Diagnosis: Type 2 Diabetes and Proteinuria
Treatment: Farxiga 5 mg (milligrams) tablet
The insurer denied the Farxiga 5 mg tablet.
The determination is overturned.

This is a male patient with type 2 diabetes with proteinuria on Farxiga. The patient's hemoglobin A1C was 9.7 percent (%). There is a request for continuation of Farxiga. This is under review for medical necessity.

This request is for Farxiga for the treatment of type 2 diabetes. The prior request was denied as the patient does not have a documented trial and failure or intolerance or contraindication to metformin. This patient has uncontrolled type 2 diabetes with proteinuria. In a randomized controlled trial, Farxiga reduced the risk of a composite of sustained decline in the estimated glomerular filtration rate (GFR) of at least 50 percent (%), end-stage kidney disease, or death from renal or cardiovascular causes as compared to placebo [1]. This has not been demonstrated with metformin, which is therefore not an appropriate alternative in this patient with uncontrolled type 2 diabetes and proteinuria.

The requested Farxiga 5 milligrams (mg) tablet is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Braces and Monthly Visits
The insurer denied: Braces and Monthly Visits
The denial is overturned.

The patient is a teenaged female. The request is for orthodontic benefits. She has a skeletal class I and canine class II malocclusion. She has severe upper and moderate lower crowding with a deep bite. The health plan's prior denial of coverage was due to a score of 14 points on the handicapping index scale. The denial is being appealed.

The requested braces and monthly visits are medically necessary.

Although the denial was due to a handicapping index score of 14, the patient has an anterior tooth (#26, lower right lateral incisor) that is in crossbite (reverse bite). Also, there is attachment (gum) loss with recession. This is an "automatic qualifier" according to the handicapping index. This case has medical necessity, and orthodontic treatment is needed to correct the problem. Monthly visits are needed to follow up treatment progress.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Short Stature. 
Treatment: Nutropin AQ. 
The insurer denied coverage for Nutropin AQ. 
The denial is upheld. 

This is a child, born female, diagnosed with short stature. This request is for Nutropin. He is on Supprelin. 

Classic growth hormone (GH) deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society[1], the Lawson Wilkins Pediatric Endocrinology Society[2, 3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists[4]. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 standard deviation (SD) below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 year (yr) more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 yr in children over 2 yr of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 yr or more than 1.5 SD sustained over 2 yr. The biochemical criteria include low insulin like growth factor 1 (IGF1) or insulin like growth factor binding protein 3 (IGFBP3) or GH stimulation testing with a peak GH less than 10 nanograms per milliliter (ng/ml). 

The patient did not meet biochemical criteria. Growth hormone stimulation testing is not reported, and growth factors are normal. 

The patient did not meet height and height velocity criteria as pretreatment height and height velocity are normal. 

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4-9]. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SD less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."[10-13] 

The patient does not have a pretreatment height less than or equal to -2.25 SD. The patient therefore does not meet idiopathic short stature criteria. 

Thus, at this time, there is inadequate data to support the use of growth hormone in this setting. 

The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore 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 Nutropin AQ is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ovarian cyst.
Treatment: CPT 76376 - 3 Dimensional (3D) Pictures (Pelvic Imaging).
The insurer denied CPT 76376 - 3 Dimensional (3D) Pictures (Pelvic Imaging). 
The health plan's determination is upheld. 

CPT 76376 - 3 Dimensional (3D) Pictures (Pelvic Imaging) provided at the beginning of the year is not medically necessary for this patient.
The three-dimensional ultrasound imaging of the pelvis is not medically necessary in this case. The purpose of sonography of an ovarian cyst is to assess whether a lesion is growing or resolving, and whether the abnormality raises concern for malignancy. These results would then be used to assess the need for surgery. There are numerous guides and calculators to help a clinician decide where surgery is needed for an ovarian cyst. None of these involve 3D imaging. Simple 2D measurements are the basis for assessment of ovarian cysts, and therefore 3D imaging is not necessary. One can obtain the necessary information to make a decision about surgery from a standard 2D ultrasound. Therefore, the 3D rendered ultrasound (CPT 76376) is not medically necessary.