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

Diagnosis: Skeletal Class I Malocclusion, Anterior Crowding Bimaxillary Protrusion, Overjet and Lip Incompetence "CI. I Molar, CI. I Canine, Bimaxillary Alveolar Protrusion, OJ: 6mm, OB: 5mm, Lip Entrapment, Convex, Lip Incompetence, and Mentalis Strain."   
Treatment: Orthodontic Treatment

The insurer denied the Orthodontic Treatment. The denial was reversed.   

This is a young female patient who presented to her orthodontist for a consult for orthodontic treatment.  Per Orthodontic the patient had skeletal Class I malocclusion, anterior crowding bimaxillary protrusion, overjet and lip incompetence "CI. I Molar, CI. I Canine, Bimaxillary Alveolar Protrusion, OJ: 6mm, OB: 5mm, Lip entrapment, Convex, Lip incompetence, and Mentalis strain."  A total score of 31 was indicated on the Handicapping Labio-Lingual Deviation (HLD) Index Report.  

The orthodontist has completed the HLD index attaining 31 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements having attained a score of 22 points on the HLD index. To assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

The carrier's denial of coverage for Comprehensive Orthodontic Treatment of the Adolescent Dentition (D8080) is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission 

Summary:
The patient is a female who presented to the ER for further evaluation/management of left upper quadrant abdominal pain. 
The patient's intake vitals were afebrile, hemodynamically stable.

Examination was non focal with no critical abnormalities noted, including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen. Laboratory and ECG (electrocardiogram) testing was also without critical abnormalities noted, including no evidence of acute end organ damage. Abdominal CT revealed evidence of splanchnic portal vein thrombosis. 

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where she received treatment with therapeutic anticoagulation and supportive care with IV fluids, PRN (as needed) analgesics and continued cardiac monitoring. She responded well to the prescribed therapies, and she was subsequently discharged in stable condition. 

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where she received treatment with therapeutic anticoagulation and supportive care with IV fluids, PRN analgesics and continued cardiac monitoring. She responded well to the prescribed therapies and was subsequently discharged in stable condition. 

There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed treatment of Inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

According to the records, the patient who initially began physical therapy for impairments and functional deficits related muscle weakness. There is a letter of appeal from the patient stating that she disagrees that physical therapy is not medically necessary, stating that it is necessary for her ability to walk without falling which involves continued work with balance and strengthening of her lower body. She reports having had two recent falls which led her and her physical therapist to believe that she needed continued work with balance and strengthening, particularly of the left leg on which she has had two surgeries, hip replacement surgery, and a knee replacement surgery. It was noted that 17 visits were authorized over six weeks. The patient is requesting coverage for continued skilled physical therapy visits, which was denied by the insurance carrier and is the subject of this review. The health plan's determination of medical necessity is upheld. The requested health service/treatment of physical therapy is not medically necessary for this patient. Diagnosis is noted to be M62.81 muscle weakness, generalized, that reportedly began a year prior. It is noted that the patient was previously authorized for 17 visits of physical therapy over six weeks. The records provided failed to document any significant ongoing functional progress or objective gains to suggest the patient would require additional physical therapy. It appears the patient had plateaued in treatment. Although the patient reports on appeal that she needed to continue working with balance and strengthening of her lower body, this can be accomplished outside of an office setting, for further progress independently and does not require ongoing skilled therapy sessions. Medical necessity was not established.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a history of hypertension and hyperlipidemia. In 2019 he was evaluated by a cardiologist for a complaint dyspnea with bending over. Coronary computed tomography (CT) angiography performed showed significant two vessel disease. He presented to the hospital for scheduled cardiac catheterization. His cardiovascular exam was unremarkable. There were no acute electrocardiographic changes. Catheterization was performed and an obstruction in the proximal left anterior descending coronary artery was treated with atherectomy and two stents. There was residual disease in the distal right coronary artery. The procedure was uncomplicated. He was discharged home the following day.

The health plan's determination is upheld. 

While some period of monitoring immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document from the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. This patient met none of these criteria. Given that atherectomy was performed and two stents were placed in the same vessel, the patient could have been appropriately managed at a lower level of care status.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient has recurrent syncope. An ambulatory monitor documented a 21 second pause. The patient clearly needed a permanent pacemaker in view of the recurrent syncope related to sinus pauses. The provider is requesting a leadless pacemaker as it has shown a reduction in morbidity relative to a pacemaker with intracardiac leads. This is the subject of this review. 

The health plan's determination is overturned. The leadless pacemaker is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient is young and one can anticipate multiple generator changes and potential lead changes in view of the possibility of the long expected usage based on her young age. The leadless pacemaker has been approved by FDA. In this young patient with expected usage of at least 30-40 years, a leadless pacemaker is likely to be more beneficial than standard treatment. The medical literature supports its use in cases such as the present one.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient has history of (h/o) a prolonged symptomatic sinus pause for which a pacemaker was required. Under review is the Transcatheter Insertion or Replacement of Permanent Leadless Pacemaker, Right Ventricular, Including Imaging Guidance and Device Evaluation.

The health plan's determination is upheld. A leadless pacemaker has been developed to potentially decrease pocket and lead complications and malfunctions known to occur with current implanted pacemakers. However, they do not have demonstrated long term effectiveness or demonstrated improved outcomes compared to implantable pacemakers. Therefore, they have not been established as standard of care, compared to an implanted pacemaker, towards improved cardiac outcomes. As such it is not indicated in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient presented for evaluation of syncope. The patient had a history of bipolar disorder and vasovagal syncope, with episodes occurring over about 10 years and reported episodes of syncope increasing in frequency, to about once or twice a month. An electroencephalogram (EEG) was normal. An event monitor recorded a 21 second pause, with syncope correlating with this finding. An echocardiogram (ECHO) showed normal left ventricular function. Placement of a leadless pacemaker was recommended. This is the subject of this review.

The health plan's determination is overturned. The leadless pacemaker is likely to be more beneficial than standard treatment for this patient. The patient has vasovagal syncope, with prolonged sinus pauses on event monitoring. She requires pacing, but does not need atrial pacing for effective therapy. The leadless pacemaker is an Food and Drug Administration (FDA) approved therapy. Per guidelines, it is acceptable to use for patients who have sinus node dysfunction, including sinus pauses, for whom atrial pacing is not considered necessary. In this patient, an additional advantage would be avoidance of long-term lead complications (fractures, infection, etc).
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with a history of diabetes, chronic obstructive pulmonary disease (COPD), depression, and anxiety who presented to the hospital with hematuria. She stated that she was had recently started seeing blood in her urine or vagina that morning. She also reported suprapubic pain. She denied fevers, chills, and increased urinary frequency. She did report multiple prior urinary tract infections. Review of systems was negative for fevers, chills, chest pain and shortness of breath. Vital signs showed temperature 36.5 Celsius, heart rate 71, blood pressure 137/81, and respiratory rate 15. On physical examination, she was alert, heart was regular, breath sounds were normal, abdomen was soft and nontender. Labs showed white blood cell (WBC) count of 17.5, hemoglobin 13.6, platelets 266, sodium 143, potassium 4.8, creatinine 1.47, and glucose 112. The patient was admitted with hematuria and suspected urinary tract infection. The plan of care included urine culture, intravenous (IV) antibiotics, kidney ultrasound, monitor kidney function, IV fluids, and continue other home medications. The patient was later diagnosed with Clostridium (C.) difficile (diff) after developing diarrhea. She requested to be discharged against medical advice.

The health plan's determination is upheld. 

No, the inpatient hospital stay was not medically necessary, based on the available documentation. The patient primarily was admitted for urinary tract infection in the setting of multiple urinary tract infections in the past. The patient was hemodynamically stable. She had an elevated white blood cell count, but no evidence of sepsis or pyelonephritis, she was not encephalopathic, and was only incidentally found to have C. diff infection after developing diarrhea, but this can be treated as an outpatient, especially when symptoms are mild. The patient had no other acute complications. She needed further care, but it could have been safely and effectively provided at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic focal segmental glomerulosclerosis post kidney transplant 
Treatment: Velcade
The treatment with Velcade is medically necessary.

In treating children with this complex rejection presentation, commitment to prolong and rescue this first kidney allograft using the therapies available to control the process and resolve if it is possible must be made.  Most of the immunosuppressive medications do not have absolute FDA indication for immunosuppression in organ transplantation.  The use of these medications is based on clinical retrospective trials, small series, and most importantly, the need to solve complex immunological phenomena by learning from other disciplines such as Pediatric Oncology and others. 

Previous review labeled the use of Bortezomib as unproven, with no RCT (randomized controlled trials) for the evaluation of the efficacy of Bortezomib for the treatment of antibody mediated rejection.  This child has undergone the standard therapy for antibody mediated rejection and has had no evidence of improvement.  The use of Bortezomib for the treatment of antibody mediated rejection in children has been done and published in small series demonstrating that Bortezomib stabilizes the immunological process and may preserve renal function in the majority of children treated.  

This child has a very high possibility of losing her graft with the levels of antibodies and specially after failing to respond to standard therapy.  Bortezomib is the last option to attempt to preserve renal function, by eliminating plasma cells that are the producers of antibodies.  This kidney graft does not have significant chronic injury.  

In this reviewer's opinion, and supported by literature in pediatric kidney transplant patients, Bortezomib is justified for the treatment of non-responding acute antibody mediated rejection on this child's care. This child needs adequate renal function in the next years to accomplish adequate growth and development.  Graft failure and dialysis will be a devastating complication. This is a very difficult disorder in pediatric organ transplantation, lacking good agents to treat patients with high levels of antibodies injuring the graft effectively.  In patients like this, it takes a full combination of all agents available to attempt to provide control and possible resolution of this disorder.
Appeal type: Medical necessity
Decision: Upheld

The patient  has multiple medical problems but most notably dementia of Alzheimer's type. The patient requests 24 hour a day split shift personal care aide. The patient previously has been approved for a live-in aide.The health plans determination of medical necessity is upheld in whole. The requested health service/treatment of 24 Hour/7 Days Split Shift per Week Personal Care Aide is not medically necessary for this patient. There was not a significant change in the medical necessity for additional services from the first assessment to the second assessment.
These services can be performed within the 84 hours allotted for the week.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia vs. Bronchitis.

Treatment: inpatient admission

The insurer denied coverage inpatient admission. The denial was upheld.

This patient is a female with past medical history (PMH) of: hypertension (HTN), chronic obstructive pulmonary disease (COPD) on home oxygen, obstructive sleep apnea (OSA) - non compliant with bilevel positive airway pressure (BIPAP). The patient presented to the Emergency Department (ED) with complaints of shortness of breath (SOB) over the past several days. The patient's nebulizer machine at home was broken. The patient has history of multiple intubations in the past for COPD exacerbations. The patient still smokes 3-5 cigarettes/day. The patient had been also suffering from some upper respiratory tract infection (URTI) symptoms. The patient also complained of some palpitations.

The vital signs at presentation in ER were: blood pressure (BP) 156/89, respiratory rate (RR) 22, heart rate (HR) 102 and oxygen saturations were 86 %. The vital signs per Emergency Department Medical Doctor (MD) were temperature 98.7, respiratory rate (RR) 20, blood pressure (BP) 120/72 mm Hg and oxygen saturation at 100%. The patient was in no acute distress (NAD).  Lungs had mild respiratory distress and bilateral basal rales. The cardiovascular system (CVS) S1 S2 was normal (N). There was no jugular venous distention (JVD).  The abdomen was soft and nontender (NT).

As per the History & Physical the patient was afebrile and vital signs (VSS) stable. The patient was saturating 100% on nasal cannula. There was no use of accessory muscles. There was mild wheeze. The cardiovascular system (CVS) S1 S2 was normal. The admitting diagnosis was COPD exacerbation likely from Acute Bronchitis. The patient's peak expiratory flow (PEF) was 170 (Baseline 200). The chest x-ray was unremarkable. The computer tomogram (CT) indicates - chest right lower lobe (RLL) infiltrates or Pneumonia. The arterial blood gas (ABG on 2L) was 7.37/68/52/38/ 86 %. This is close to her baseline. The plan was to continue on steroids, bronchodilator, Azithromycin and BIPAP at night with 10/5 setting.

This patient did not need acute hospitalization. She could have been placed in Observation status while diagnostic testing and treatment initiated. The patient was close to her baseline after initial treatment. Pneumonia if present was mild. The white blood cell count (WBC) was normal. There was no fever. The partial oxygen (PaO2) was close to baseline. The CURB 65 score 0. The patient could have been switched to oral steroids and bronchodilators and oral antibiotics after a period in Observation and then subsequently discharged home with close follow-up in an outpatient setting. The prior denial was appropriate.

The health plan acted reasonably and with sound medical judgment and in the best interest of the patient. The insurer's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history significant for hypertension, bronchitis, gastroesophageal reflux disease (GERD), tobacco abuse, and cocaine abuse who presented to the emergency department with complaints of abdominal pain, nausea, vomiting, and anorexia for 4 days. At the time of admission, the patient  was unable to tolerate any liquids or solid food. The patient reported an intermittent lower abdominal cramping pain, which he described as 2-3/10 in intensity. The pain resolved spontaneously, and each bout lasted for 10-15 minutes. At the time of initial evaluation, the patient denied diarrhea and stated that the last bowel movement was 2 days before the day of admission.
At the time of admission the patient denied any fever, chills, dysphagia, odynophagia, dyspepsia, bloating, hematemesis, melena, or fresh blood in the stool. The patient was afebrile, blood pressure was 129/78, pulse rate 72 beats per minute (bpm), respiratory rate 18, oxygen saturation 98% on room air. The patient had mild tenderness around the umbilicus without rebound tenderness. He also had an itchy scaly rash on the hands. The rest of the physical exam was unremarkable. Abdominal x-ray showed nonspecific bowel gas pattern. Subsequent computed tomography (CT) scan of the abdomen and pelvis did not reveal any significant abnormalities in the abdomen. The patient was admitted to the hospital with a diagnosis of abdominal pain and vomiting, which was attributed to acute gastroenteritis. It was indicated that the patient's electrolytes were within normal limits. The requested health service/treatment of inpatient stay was not medically necessary for this patient, since neither the severity of the patient's condition nor the complexity of services provided justified acute inpatient level of care. Most likely, according to the records submitted for review, the patient had acute gastroenteritis, which is usually a self-limited condition and mostly requires supportive care only. This patient's hospital stay was very short. The patient responded to the supportive care provided and was discharged from the hospital. In the records submitted the Milliman Care Guidelines criteria for gastroenteritis is referenced.  The patient had none of the circumstances listed above qualifying for an inpatient hospital stay. There was no need for any invasive procedures or diagnostic studies necessitating admission at the acute inpatient level of care. The patient could have received treatment at a lower level of care.
The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pancreatitis versus gastritis
 
Treatment: Inpatient admission, medication, monitoring

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

The patient presented with vomiting and abdominal pain. She was afebrile and vital signs were stable. The patient had abdominal guarding but no peritoneal signs. There was no leukocytosis. The pancreatic enzymes were mildly elevated. A sonogram did not show evidence of acute pancreatitis. The abdominal pain improved and the patient was able to tolerate a diet. Proton Pump Inhibitor (PPI) therapy was given for alcoholic gastritis. The patient was discharged and advised to avoid alcohol.

Clinical Indications for admission for pancreatitis (M-250) include having acute pancreatitis as manifested by 2 factors including abdominal pain, pancreatic enzymes greater than 3 times the upper limit of normal or characteristic imaging. This patient did not have pancreatic enzymes greater than 3 times the upper limit of normal or characteristic imaging. She also did not have hemodynamic instability, hypoxemia, acute renal failure, or a severe electrolyte abnormality.

Clinical indications for admission for gastritis (M-560) include gastric outlet obstruction, perforation, peritoneal signs, and vomiting that is persistent. The patient did not have these conditions. The vomiting resolved after treatment in the emergency room. 

This patient had alcoholic gastritis and mildly elevated pancreatic enzymes. Intravenous (IV) hydration, PPI therapy, and antiemetics could have been given in the ER. She did not meet MCG criteria for admission for either pancreatitis or gastritis. She could have been managed with observation status. 

Based on the above, the patient did not meet medical necessity for the inpatient hospital admission. The insurer's denial is upheld.