Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Family history of Factor V Leiden
Treatment: 81241-F5 coagulation Factor V gene analysis, Leiden variant
The insurer denied the 81241-F5 coagulation Factor V gene analysis, Leiden variant
The denial is upheld

The patient is a female who had 81241-F5 coagulation Factor V gene analysis, Leiden variant performed. No other clinical information is available.

No, the requested health service is not more beneficial than any standard treatment for the insured's condition or disease.
Thrombosis is a rare event in children. The incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) was estimated to be 5.3 per 10 000 hospital admissions or 0.07 per 10 000 children. According to the Dutch registry, the annual incidence of venous thromboembolism (VTE) was estimated to be 0.14 per 10 000 children. Other national registries have reported similar incidences.  Both adult and pediatric patients who have two or more inherited thrombophilia traits have been shown to be at an increased risk of venous thromboembolism (VTE). The prevalence of thrombophilic defects in children with Venous thromboembolism (VTE) varies widely, from 10%-78%.  Differences in patient cohorts, definition of thrombosis, types of investigations, and study size most likely contribute to the wide variations in the prevalence of Venous thromboembolism (VTE). A meta-analysis of observational studies published from 1970-2007 on the impact of thrombophilia traits on Venous thromboembolism (VTE) development or recurrence in children reported that all investigated traits showed a significant association with first-ever Venous thromboembolism (VTE). However, many of the included studies had methodological flaws, so the relative contribution of prothrombotic defects to a child's susceptibility to Venous thromboembolism (VTE) remains to be elucidated. Idiopathic Venous thromboembolism (VTE) in children is rare, and approximately 95% of Venous thromboembolisms (VTEs) in children are usually associated with serious disease. It is debatable whether children presenting with secondary Venous thromboembolism (VTE), such as central venous line (CVL)-related deep vein thrombosis (DVT), should be screened for congenital prothrombotic disorders because the results do not generally affect the management of the child. The use of oral contraceptives increases the risk of Venous thromboembolism (VTE) by five-fold compared with nonusers (odds ratio = 5.0; 95% confidence interval, 4.2-5.8). Routine screening before the initiation of oral contraceptives is not recommended.  Screening for congenital prothrombotic risk factors may be appropriate for children with idiopathic Venous thromboembolism (VTE). 

To date, there is no clinical evidence to support routine screening of asymptomatic children with a positive family history of thrombophilic defect. The provided information does not support the testing that the patient had.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Family history of Factor V Leiden
Treatment: 81241-F5 coagulation Factor V gene analysis, Leiden variant
The insurer denied the 81241-F5 coagulation Factor V gene analysis, Leiden variant
The denial is upheld

The patient is a female teen that was tested for Factor V Leiden because of family history and physician recommendation. The paternal grandmother has the disease, the father and two of his siblings have the disease, and all but the father have history of blood clots. Her father had formal testing revealing one copy of the Factor V Leiden (R506Q) gene mutation.

No, the health plan should not cover the proposed treatment.
Genetic testing for Factor V Leiden was not medically appropriate in absence of an abnormal activated protein C (APC) resistance assay.

No, the requested health service is not more beneficial than any standard treatment for the insured's condition or disease.
Per plan language, Factor V Leiden testing is warranted when a first-degree blood relative is positive for the disease in conjunction with a patient's abnormal activated protein C resistance assay. 

Per the American College of Medical Genetics, testing for Factor V Leiden mutation may be indicated for relatives of individuals known to have the mutation because it may be useful information for pregnancy and oral contraceptive recommendations. The College concludes, "when relatives of individuals known to have factor V Leiden are tested, the DNA method is recommended." However, this guideline is about twenty years old and not reflective of current lab capabilities and practices. 

Based on current studies, "phenotypic testing showed a high level of sensitivity, specificity, and other biostatistical values compared with genotypic testing" (Murphy & Sabath) suggesting that the activated protein C (APC) resistance assay is an appropriate first-line test with confirmatory DNA testing if warranted.

While testing for this patient was reasonable and appropriate given the strong family history of Factor V Leiden and the potential impact on oral contraceptive use and future pregnancy, the health plan's requirement for APC (activated protein C) resistance testing was reasonable, consistent with the current standard of care, and not fulfilled prior to genetic testing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment: Hospital Admission

The insurer denied coverage for hospital admission

The denial is upheld

This man had a history of atypical chest discomfort at an early age and intermittent episodes of palpitations and dizziness for several years.  He developed left sided chest pain while driving to play soccer, but felt it was related to indigestion.  While playing soccer, he developed dizziness, left the field to go to the bathroom where he vomited and then had witnessed syncope, lasting 1 to 2 minutes without head trauma.  He was brought to the emergency department (ED) by ambulance, arriving, with initial vital signs blood pressure (BP) 121/75, heart rate 96, temperature 98.4 Fahrenheit, respiratory rate 20, and oxygen saturation on room air 98 percent (%).  Electrocardiogram (EKG) revealed normal sinus rhythm and ST (intervals on EKG) segment elevations suggestive of early repolarization, although Brugada pattern was considered.  Chest X ray was normal and laboratory test results included white blood cell (WBC) count 14.9, hemoglobin 16.1, creatinine 0.78, and troponin <0.012, with subsequent troponin level of <0.012.  Echocardiogram was normal, with left ventricular ejection fraction 64%.  He was evaluated by electrophysiology who felt that the EKG was not characteristic of type 1 Brugada pattern, noted the normal PR (intervals on EKG) interval, and recommended 30 day event recording and treadmill stress testing.  He was discharged on no medications for outpatient testing.

Denial of coverage for the hospital admission is upheld because there is no evidence that this patient was at increased risk for short term adverse cardiovascular events requiring inpatient monitoring and management, based on his clinical presentation and results of testing in the Emergency Department (ED).  The health plan acted reasonably with sound medical judgment in the best interest of the patient.

There is no evidence that this patient required an acute inpatient level of care to determine that his syncope was not related to malignant cardiac arrhythmias or to rule out acute coronary syndrome.  This should have been completed in the ED or at an observation level of care.

The insurer's denial of coverage for the hospital admission is upheld.  Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary disease and hypercholesterolemia. 

Treatment: Praluent. 

The insurer denied coverage for Praluent. 

The denial is upheld. 

This is a male patient with a history of coronary disease, status post percutaneous coronary intervention (PCI) to the left anterior descending (LAD) and left circumflex (LCX) arteries is also known to have a chronic total occlusion of the right coronary artery (RCA).  Past medical history is significant for hypertension and hypercholesterolemia.  He has a known history of non-compliance.  He has been prescribed atorvastatin 80 milligrams (mg).  Ezetimibe 10mg daily was recommended but does not appear on the patient's medication list in the medical records provided.  The patient's low-density lipoprotein (LDL) cholesterol was 166 milligrams per deciliter (mg/dL).

Current American Heart Association and American College of Cardiology guidelines clearly note that in patients with atherosclerotic cardiovascular disease (ASCVD) or high risk conditions of future ASCVD risk and persistent elevation of LDL despite statin therapy, randomized trial proven non statin therapy should be considered.(1) Evolucumab was demonstrated to reduce major adverse cardiovascular events by 15% in the Fourier randomized clinical trial.(2)  Alirocumab demonstrated a significant reduction is ASCVD events when administered to patients with a history of acute coronary syndrome (ACS) on maximally tolerated statin therapy.(3)  American Heart Association/American College of Cardiology (AHA/ACC) guidelines recommend the use of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in patients with atherosclerotic coronary disease and LDL levels greater than 70mg/dl in patients intolerant to statin therapy.(1) In the Odyssey Alternative double blind randomized trial patients that were intolerant to statin therapy were randomized to treatment with alirocumab, Zetia or rechallenge with atorvastatin.  Alirocumab reduced LDL cholesterol by 45% versus Zetia's 15% reduction.(4) In this case, the patient appears to be noncompliant with statin therapy, which would explain his elevated LDL levels.  Even if he has been taking atorvastatin, it does not appear as if he has been taking ezetimibe.  Given these findings, Alirocumab (Praluent) therapy is not medically necessary. 

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

The insurer's denial of coverage for Praluent is upheld.  Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Fracture Root Canal.

Treatment crowns (D2740) on teeth #4, 5 and buildups (D2950) on teeth #4, 5, and 14

The insurer denied coverage for crowns (D2740) on teeth #4, 5 and buildups (D2950) on teeth #4, 5, and 14

The denial is modified.
D2740 and D2950 for teeth #4,5 is not considered medically necessary for this patient.
D2740 and D2950 for tooth #14(15) is considered medically necessary forth patient.

Upon review of the documentation provided which includes copy of select periapical and bitewing radiographs, narrative letters and insurer correspondence, it appears that this patient presented to the dentist for comprehensive care. The treating dentist recommended full coverage crown for #4,5,14(15) and buildups. (There is a discrepancy as to which tooth 14 or 15 is at issue. The insurer notes tooth 14 the appealer notes tooth 15. Both teeth are in the same state). 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 these services and therefore the services do not meet medical necessity criteria. The patient is appealing.

The objective documentation provided for review is copies of select periapical and bitewing radiographs. It appears that there is no evidence of fracture or other pathology specifically affecting #4 or #5 based on the images provided for review. There does not appear to be any radiographic evidence of caries. The radiographs do not substantiate the requested dental services for these teeth as enumerated above and therefore the crowns/buildups are deemed not medically necessary for teeth #4 and #5.

As regards #14 (15) this tooth is endodontically treated. The dental standard of care in this circumstance is a buildup and full coverage crown. Therefore, the buildup and crown for tooth #14 (15) is considered medically/dentally necessary.

Uphold denial of coverage for D2740 crown teeth #4 and #5 as not medically necessary as the documentation is insufficient to justify or substantiate the treatment. Overturn denial and approve buildup and crown for tooth #14(15) as this would be standard of care treatment in dental practice for endodontically treated teeth.

The healthcare plan did act reasonably and with sound medical judgement and in the best interest of the patient for teeth #4 and #5. 

The healthcare plan did not act reasonably and with sound medical judgement and in the best interest of the patient for tooth #14 (15).

D2740 and D2950 for teeth #4,5 is not considered medically necessary for this patient.
D2740 and D2950 for tooth #14(15) is considered medically necessary forth patient.

The insurer's denial of coverage for crowns (D2740) on teeth #4, 5 and buildups (D2950) on teeth #4, 5, and 14 is modified. Medical necessity is partially substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Sinusitis. 
Treatment: CPT 31298 (50) Nasal/Endoscopy, Surgical w/ Dilation Frontal &
Sphenoid Sinus, CPT 31254 (50) Nasal/Sinus Endoscopy w/ Ethmoidectomy,
CPT 31295 (50) Nasal/Sinus Endoscopy Maxillary Sinus. 

The insurer denied the CPT 31298 (50) Nasal/Endoscopy, Surgical w/ Dilation
Frontal & Sphenoid Sinus, CPT 31254 (50) Nasal/Sinus Endoscopy w/ Ethmoidectomy,
CPT 31295 (50) Nasal/Sinus Endoscopy Maxillary Sinus. 

The denial is overturned. 

The patient is a female with history of nasal airway obstruction and nasal
congestion for several years. It is present at all times and severe in nature. In
addition, she has episodes of nasal pain, post-nasal drip, and cough. She has
failed course of antibiotics, antihistamines, decongestants, intranasal steroids, and saline nasal rinses as well as mechanical techniques to open the airway (strips). Examination shows bilateral middle meatus narrowing, bilateral inferior turbinate hypertrophy, and nasal septal deviation to the left. CT (computed tomography) scan shows pansinusitis. The patient underwent bilateral endoscopic nasofrontal duct dilation, bilateral endoscopic sphenoid dilation, bilateral anterior ethmoidectomies, bilateral submucus resection of the inferior turbinates, and cryosurgery for removal of inflamed tissue. 

The appeal in this case is regarding 31298 Nasal sinus endoscoy with dilation of
frontal and sphenoid sinus, 31254 Nasal/sinus endoscopy with etmoidectomy, and 31295 Nasal/sinus endocapy of maxillary sinus. 

Yes, the health plan should cover the proposed treatment. 

Endoscopic sinus surgery is the treatment of choice for sinusitis that have failed
conservative therapy (1-4). This patient has the following: 

1) Documented pansinusitis by CT (computed tomography) scan 
2) Documented nasal pathology by endoscopy 
3) Documented failure of all conservative therapy. 

Therefore, according the literature (1-4), Otolaryngology's Academy's guidelines
(1), and Standard of Care, endoscopic sinus surgery is indicated, and the requested services are appropriate to address all the involved sinus and associated pathology. 

Yes, the requested therapy is likely to be more beneficial. 
The patient has already failed all other alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Sinusitis. 
Treatment: CPT 31298 (50) Nasal/Endoscopy, Surgical w/ Dilation Frontal &
Sphenoid Sinus, CPT 31254 (50) Nasal/Sinus Endoscopy w/ Ethmoidectomy,
CPT 31295 (50) Nasal/Sinus Endoscopy Maxillary Sinus. 

The insurer denied the CPT 31298 (50) Nasal/Endoscopy, Surgical w/ Dilation
Frontal & Sphenoid Sinus, CPT 31254 (50) Nasal/Sinus Endoscopy w/ Ethmoidectomy,
CPT 31295 (50) Nasal/Sinus Endoscopy Maxillary Sinus. 

The denial is partially overturned. 

The patient is a female with a history of recurrent acute sinusitis/chronic sinusitis.
She has a history of six episodes of sinusitis per year. There had been treatment
with Ceftin and Augmentin and courses of oral and nasal steroids. Sinus CT
(computed tomography) reported pansinusitis with the frontal sinuses aplastic. The
patient underwent multiple procedures, including 31298 (50) Nasal/Endoscopy,
Surgical w/ Dilation Frontal & Sphenoid Sinus, 31254 (50) Nasal/Sinus Endoscopy
w/ Ethmoidectomy, and 31295 (50) Nasal/Sinus Endoscopy Maxillary Sinus. 

Yes, in part. The health plan should cover the proposed treatment, in part. 

Specifically, the health plan should cover 31254-50 and 31295-50. However, the
health plan should not cover 31298-50. 

The patient has failed maximal medical therapy with multiple medications, including
antibiotics, nasal and oral steroids. A sinus CT (computed tomography) reports
multiple sinus disease with the exception of the frontal sinuses which are aplastic. 

Based on the above, and consistent with scientific literature and AAO HNS 
(American Academy of Otolaryngology-Head and Neck Surgery) guidelines, the
medical appropriateness of the sinus procedures 31254-50, 31295-50 would be
confirmed. However, there are no frontal sinuses present and 31298-50 is a
combination code (frontal and sphenoid sinus surgery). Therefore, based on the
information provided, the medical appropriateness of 31298-50 cannot be
confirmed. 

Specifically, 31254-50 and 31295-50 are likely to be more beneficial for the enrollee
than any available standard therapy. 31298-50, however, is not. Please see the
response to question 1, above.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Comminuted Fracture, Left Clavicle

Treatment full hospital admission

The insurer denied coverage for full hospital admission.

The denial is overturned.

The patient presented to the emergency department (ED) with complaints of left shoulder pain and left-sided back pain after a fall.

The patient fell from a height of 8-10 feet. This by itself indicated a high level of trauma. He was found to have multiple rib fractures and a clavicle fracture. His injuries would likely result in difficulty breathing and he would be at high risk for pulmonary complications. Multiple rib fractures are extremely painful. He was originally nothing by mouth (NPO) and could not receive oral analgesia. The records show multiple dosages of Toradol were provided. The patient also required additional imaging studies and subspecialty consultations. These services could not have been provided at a lower level of care. 

There was sufficient evidence to support that a full hospital admission was considered medically necessary treatment for the patient's condition.

The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient.

The insurer's denial of coverage for full hospital admission overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Pancreatitis. 
Treatment: Acute inpatient services. 

The insurer denied coverage for acute inpatient services. 
The denial is overturned. 

The patient is an adult male with a history of anxiety, depression, pancreatitis, alcohol use disorder and opioid use disorder on Suboxone. The patient presented to the Emergency Department (ED) with a 1-day history of left flank abdominal pain associated with back pain. He stated that he was sleeping prior to the onset of abdominal pain. The abdominal pain was diffuse but worse on the left flank and epigastric area. The pain was 7-8/10, varying in quality, sharp, and dull, as well as burning. The patient went to the urgent care who recommended that he go to the ED. In the interim, he was able to go and eat sushi at a restaurant and tolerated it well, outside of mild nausea. The patient previously had alcoholic pancreatitis years ago and spent 1 week in the intensive care unit (ICU). He continues to drink and currently drank approximately 20 ounces of beer per night. The patient had no nausea, headache, anxiety, or auditory hallucination or visual hallucination. Blood pressure was 142/94. The physical examination revealed tenderness to palpation of the left flank area with no rebound or guarding and no masses. The patient had an elevated lipase of 700 in the ED. He was given 2 liters of fluid and was admitted to Internal Medicine. The admitting diagnosis was alcohol induced acute pancreatitis unspecified complication status. An abdominal ultrasound revealed multiple gallbladder polyps, mild hepatic steatosis, and mild hepatosplenomegaly. The patient was to follow up with surgery for an elective cholecystectomy. The patient was discharged home in stable condition with a diagnosis of acute pancreatitis. 

The patient presented with clinical symptomatology suggestive of acute pancreatitis. Even though his lab parameters did not show systemic inflammatory response syndrome (SIRS) or other concerning features, he had severe acute pancreatitis requiring ICU management in the past. Acute pancreatitis needs close observation for 48 hours with hydration and pain relief. These can effectively be delivered in an inpatient setting. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The inpatient acute inpatient services rendered is considered medically necessary for this patient. 

The insurer's denial of coverage for the acute inpatient services is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fractured m (mesial) wall. 
Treatment: Dental crown on tooth #25 (code D2740). 

The insurer denied coverage for dental crown on tooth #25 (code D2740). 
The denial is upheld. 

According to the documentation submitted, this is the case of an adult male patient with a fracture of tooth #29. He is being treated by his dentist. The request is for a crown (code D2740 - porcelain/ceramic substrate) on tooth #25. The radiograph shows incisal wear and the notes state that there is a fractured m (mesial) wall. They do not state why a restoration cannot restore the tooth. 

Crowns are needed for: 
- Large, previously placed restorations. 
- Cracked-tooth syndrome 
- Asymptomatic cracks in teeth If the tooth has deep horizontal cracks and an intracoronal restoration, there is a significant possibility that a piece of the tooth will break off during service. 
- Endodontically treated, heavily restored teeth 
- Broken cusps 
- Hemisected teeth 
- Mobile teeth requiring splinting 
- Need for esthetic upgrading.  

There is no documentation of any of the above. The clinical documentation does not support a crown for #25. 

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

The insurer's denial of coverage for dental crown on tooth #25 (code D2740 - porcelain/ceramic substrate) is upheld. Medical necessity is not substantiated.