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

Diagnosis: Dental issues
Treatment: Apicoectomy on tooth #21, retrograde filling on teeth #s 21 and 22, and anesthesia 

The proposed apicoectomy on tooth #21 and retrograde filling on teeth #s 21 and 22 are medically necessary; however, the anesthesia services are not.

The case is an appeal request for surgical endodontic therapy (apicoectomy) and retrograde filling of the apex, in two teeth - #'s21 and 22, for an adult dental patient. The teeth have had previous conventional endodontic therapy, and are restored with crowns. There is radiographic evidence of peri-apical pathology / peri-apical periodontal bone resorption indicative of chronic inflammation, leakage or tissue necrosis requiring treatment. The requested surgical treatment is reasonable and indicated.  In this case, the two teeth have shown prior therapy, are not amenable to conventional retreatment endodontic therapy, and are restored with crowns. The requested treatment meets and substantiates standard of care, and approval is recommended. 

However, there is no material submitted to substantiate any medical necessity for requested IV anesthesia services (ie, anxiety, medical management issues, complex surgery), and so these services are denied.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opiate dependence

Treatment: Inpatient substance detoxification treatment

The insurer has denied inpatient substance detoxification treatment. The denial was reversed.

This is a male patient who was admitted for inpatient substance detoxification treatment for opioid detoxification. He had withdrawal symptoms including tremors, sweats, nausea, teary eyes, yawning, anxiety, restlessness, joint pain, and lethargy, and had a blood pressure of 130/88 and COWS of 16. He reportedly had a history of seizures, hypertension, asthma, and a head injury. He was homeless and unemployed. He had a history of bipolar disorder. He took Trazodone for sleeping problems. He reported a past inpatient substance detoxification treatment in early 2019. The patient was put on a five day Methadone taper and given Methadone for detoxification treatment. He was discharged with a referral to rehabilitation treatment.

The insurer denied coverage for continued inpatient substance detoxification treatment as not medically necessary treatment then. They stated that there were no seizures, vital signs were such that he could be managed a lower level of care, and there were no medical or mental health conditions requiring 24 hour detoxification treatment. They recommended a less restrictive level of care then.

The medical record supports the necessity for continued inpatient substance detoxification treatment. The American Psychiatric Associated (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders indicate that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. In this case, this patient had been using large amounts of heroin including up to 20 bags per day and was at risk for severe withdrawal as he had a COWS of 16 on admission. According to the LOCADTR, he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use large amounts of heroin, and he required and needed detoxification medication including Methadone from to modify withdrawal and prevent severe withdrawal symptoms, and continued to use heroin despite a recent past inpatient substance detoxification treatment in early 2019. He also was homeless and unemployed.  He had limited supports to safely and effectively be treated for detoxification in an outpatient setting.  It was unlikely that he would remain abstinent so he required the time in this treatment setting.

As a result, continued inpatient substance detoxification was medically necessary. The health care plan did not act reasonably or in the best interests of the patient.

Based on the above, the medical necessity for the continuation of inpatient detoxification services is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heroin abuse
 
Treatment: Inpatient detoxification, medication, monitoring

The insurer denied continued inpatient detoxification stay. The denial was reversed.

This male was admitted to inpatient substance detoxification treatment for heroin detoxification.  The patient had withdrawal symptoms including sweats, teary eyes, irritable mood, anxiety, and a blood pressure of 140/80. The patient had an initial Clinical Institute Withdrawal Assessment (CIWA) score of 11 and a Clinical Opiate Withdrawal Scale (COWS) score of 9.  The patient had multiple prior inpatient substance treatments. The patient was put on a 5-day methadone protocol and also was taking Clonidine for withdrawal.  

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. This patient had past substance detoxification treatments and still was using large amounts of intravenous (IV) heroin, including multiple bags per day. This placed the patient at risk for overdose and severe withdrawal.  The patient lacked coping skills and required 24-hour detoxification treatment as the patient could not safely and effectively be treated in an outpatient setting.  According to the LOCADTR, the patient did require 24-hour treatment as the patient needed detoxification medication to modify withdrawal and had a history of heavy IV heroin use, putting himself at high risk for overdose and severe withdrawal.  It was not likely the patient would have remained abstinent. The patient required 24-hour medical substance detoxification until his discharge to inpatient substance rehabilitation treatment. The patient was too high a risk for relapse, and it was not likely that the patient would be able to complete detoxification without inpatient treatment. 

The carrier's denial of coverage for continued inpatient detoxification services  is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient presented to the hospital with a complaint of left neck pain and swelling, which had been going on for one month, as well as a 1-day history of fever and diffuse rash.  Apparently, the patient had already been evaluated for cervical lymphadenopathy and underwent a lymph node biopsy, which reportedly came back normal.  In addition to cervical lymphadenopathy, the patient developed painful left supraclavicular lymphadenopathy, as well as lymphadenopathy in the left shoulder.  The patient was prescribed antibiotics as an outpatient, which the patient took, and apparently one day before the day of admission she developed a fever up to 102F, as well as diffuse erythematosus nonpruritic painful rash.  The patient was admitted to the hospital. 

The health plan's determination is overturned.  The inpatient stay was medically necessary.  The patient had painful cervical lymphadenopathy for 1 month.  Apparently, the patient underwent an outpatient evaluation, which even included FNA of the lymph node.  Unfortunately, the workup did not result in any definitive diagnosis, and the patient continued to be symptomatic.  In addition to the symptoms that were reported initially, the patient developed a high fever and skin rash.

Taking into consideration these facts, it was not practical to continue the workup as an outpatient, especially considering the fact that the patient's condition worsened.  It was reported that the patient had a relatively high fever while in the emergency department with some elevation of the lactic acid level.

In general, certain "red flags" should be taken into consideration while evaluating lymphadenopathy.  They include node > 2 cm, a node that is draining, hard, or fixed to underlying tissue, supraclavicular node, risk factors for HIV or TB, fever and/or weight loss, splenomegaly.

In this clinical case, the patient had multiple red flags including supraventricular node, risk of tuberculosis, reported fever.  The differential diagnosis was broad and required a very thorough evaluation.  It was not clear if the patient had an infection, which possibly included tuberculosis, or a malignancy.  In this clinical case, the patient's management included multiple diagnostic and laboratory tests, which required fast interpretation and decision-making.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Numerous Carious Lesions
Treatment: Crowns with a Post and Root Canal Treatment on Teeth #'s 4, 18, 19, 28 and 29

The insurer denied the Crowns with a Post and Root Canal Treatment on Teeth #'s 4, 18, 19, 28 and 29. The denial was upheld. 

This is a young female patient that consulted her dentist for an evaluation due to pain. Radiographic examination was performed revealing significant and numerous carious lesions on the patient's teeth upon removal of orthodontic appliances. She reports that she had regular routine dental care.  Endodontic therapy with post and core and subsequent full coverage crown restorations for teeth #'s 4, 18, 19, 28 and 29 was recommended.  

Based on the submitted information for review, particularly the radiographic examination, each of the affected teeth, #'s 4, 18, 19, 28 and 29 exhibit significant decays/caries, which markedly undermine and compromise tooth integrity, tooth structure, and involve the root structure.  This decay radiographically extends below the alveolar bone height.  Effectively, these teeth will remain retained root tips after caries excavation.  The extent of coronal destruction and caries renders all of these teeth poor supports for full coverage restorations despite the recommended endodontic therapy.  Additional definitive treatment after caries removal in the attempt to maintain these teeth in the arch would require periodontal crown lengthening surgery, further compromising crown and root ratios, leaving less tooth structure than currently exists as support of a fixed crown.  As these teeth would be prosthetically poor supports for crown restorations with a poor long term prognosis, it is determined that the services as recommended are not medically necessary and contraindicated.  

The carrier's denial of coverage for crowns with a post and root canal treatment on teeth #'s 4, 18, 19, 28 and 29 is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who self-referred and presented to the emergency department with complaints related to alcohol withdrawal including tremor, nausea, dizziness and sweats. Despite a blood alcohol level of 0.138, the patient registered a score of 17 on the Clinical Institute Withdrawal Assessment (CIWA) scale for alcohol withdrawal. 
The patient has a history of co-occurring anxiety. He denied psychiatric hospitalization, or suicidal or self-harming behavior. The patient was single, unemployed and homeless. He did not have legal issues or history of trauma or abuse.
He was placed on a detoxification regimen with a Librium taper, vitamin replacement therapy, fluid replacement, and medical monitoring. The health plan's determination is overturned. He did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder, and the presentation with moderately severe withdrawal symptoms. Withdrawal symptoms were managed with tapering dosages of benzodiazepine requiring monitoring, as well as comfort medications and vitamin replacement therapy, and treatment of the co-occurring psychiatric disorder and general medical complaints. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient was admitted following medical screening to inpatient level services for monitoring and detoxification and withdrawal management of severe alcohol, stimulant (cocaine) and opioid (heroin and methadone) use disorders. The patient was using one bag of heroin with intravenous (IV) administration in the context of methadone maintenance at 70 milligrams (mg) per day, alcohol with a binge pattern of use of one pint of liquor and two beers daily, and $30 worth of crack cocaine. The patient had experienced moderately severe alcohol and opioid withdrawal in the past and was beginning to withdrawal from alcohol at the time of admission despite a blood alcohol level of 0.097. The patient has a diagnosis of co-occurring depressive disorder and a history of unspecified bipolar disorder and anxiety disorder. He denied psychiatric hospitalization, or suicidal or self-harming behaviors.

The health plan's determination is overturned. Inpatient Hospital Admission for Detoxification Services is medically necessary for this patient.

The proposed inpatient services and detoxification treatment and withdrawal management for severe alcohol use disorder and other substance use disorders, and the other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care. The adult inpatient treatment of this patient's substance use disorders and associated general medical complications did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder, and the continued presence of craving and withdrawal symptoms including a history of serious complications of opioid use disorder with hepatitis C positivity associated with high risk use of heroin. Withdrawal symptoms were managed with tapering dosages of benzodiazepine requiring monitoring and prn medications, as well as comfort medications. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
 
Treatment: Inpatient substance detoxification treatment, medication, monitoring

The insurer denied the continued inpatient detoxification treatment. The denial was reversed.

This female was admitted to inpatient substance detoxification treatment for detoxification.  She was experiencing multiple withdrawal symptoms and she had a Clinical Opiate Withdrawal Scale (COWS) of 16.  She had a history of drug overdose last year and had a previous inpatient detoxification treatment.  She reportedly was using multiple bags of intravenous heroin per day, smoking crack daily, intravenous cocaine daily, and using Methadone per daily.  She was placed on a Methadone protocol. Upon discharge, she was referred to inpatient substance rehabilitation treatment.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that patients with failure to achieve abstinence or who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. This patient was using multiple serious substances. It was not likely that she could attend an outpatient substance detoxification treatment due to her continued use as she relapsed after the past inpatient detoxification treatment. She was at risk for overdose again due to her previous overdose and large amount of use. She was at risk for severe withdrawal symptoms due to her large amount of substance use. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) she required 24-hour treatment as she needed and received detoxification medication to modify and prevent severe withdrawal. She likely would have withdrawal symptoms again and been at risk for severe withdrawal if she did not have the full detoxification. 

The carrier's denial of continuation of coverage for the inpatient detoxification is reversed. The denial of medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foreign body aspiration
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

All records were reviewed.  The patient is a young child with a history of nut aspiration.  The child was seen in the ED and was admitted as an inpatient.  The next day, the patient was taken to the OR where a direct laryngoscopy and bronchoscopy with FB removal was performed.  The patient was discharged on the following day.  

The nut fragments were removed from the left bronchial system. The patient's vital signs were stable.  The patient was afebrile.  There was no significant respiratory compromise.  There were no intraoperative or postoperative complications.  The patient was given three doses of intravenous (IV) steroids postop and pain was controlled.  The patient was tolerating orals (POs). 

Based on the information provided, the medical necessity of the inpatient admission cannot be confirmed, as the patient's care could have been achieved at a lower level of care, observation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rosacea

Treatment: Mirvaso Gel

The insurer denied Mirvaso Gel. The denial was reversed. 

This patient is a male who presented for a dermatology consult for complaints of flaring symptoms associated rosacea. The symptoms are noted to be moderate in severity and a usually occurred in the context of stress. The patient had a history of rosacea, hypertension, hypercholesterolemia, basal skin cancer. The office visit notes on stated that the patient has a longstanding history of rosacea, usually occurring in the context of stress. It was noted that the patient was currently being treated with Mirvaso and Elidel. The patient had tried and failed Doxycycline. Finacea gel and continued Mirvaso topical gel were recommended.  

Mirvaso has been found to be safe and effective in erythro-telangiectatic rosacea. In this case, the patient has erythro-telangiectatic rosacea which makes him self-conscious when he is in public. The patient's symptoms have been flaring and are currently documented as moderate in severity. The patient is currently being treated with Mirvaso and Elidel. The patient has tried and failed Doxycycline and topical Metronidazole treatments. The patient has tried Mirvaso in the past with benefit. Therefore, the request for Mirvaso is medically necessary.

Per Anderson, M. S. et al. (2017), "Brimonidine topical gel 0.33% is a safe, effective, and patient-accepted treatment for facial erythema of rosacea."

Per Jackson, J. M. et al. (2015), "Rosacea is a chronic cutaneous condition with a prevalence rate ranging from 9.6% to 22% in recent studies. Facial erythema (transient and permanent) is considered a common denominator that is frequently observed in all subtypes of rosacea and is estimated to affect more than 40 million people worldwide. Brimonidine tartrate is a selective 2-adrenergic receptor agonist and is the first topical treatment approved for facial erythema of rosacea. Clinical trials have demonstrated that brimonidine tartrate provided significantly greater efficacy, compared to vehicle, for the treatment of moderate to severe erythema of rosacea. In addition, brimonidine tartrate has demonstrated a rapid onset of effect, duration of action throughout the day, and good safety profile in studies of up to 1 year."

Per Del Rosso, J. Q. et al. (2019), "These include the initial use of topical metronidazole or topical azelaic acid concurrently with oral doxycycline for treatment of severe papulopustular rosacea [PPR] with transition to topical therapy alone after adequate response is achieved; topical brimonidine and topical ivermectin for treatment of PPR with diffuse persistent facial erythema of at least moderate severity; and combination treatment with potassium titanyl phosphate laser and topical brimonidine for diffuse persistent facial erythema of rosacea."   
                                                                                                      
The health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient. The request for Mirvaso is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This patient has a body mass index (BMI) 25.13 kg/m2 and history of gastroesophageal reflux disease (GERD) despite medication use. The patient is status/post (s/p) laparoscopic Nissen fundoplication in 2011. An esophagogastroduodenoscopy (EGD) revealed intact wrap. A 24-hour pH study documented an elevated DeMeester score consistent with GERD.

The LINX Procedure with Associated Inpatient Hospital Admission is under review.

The health plan's determination is upheld. The LINX Procedure with Associated Inpatient Hospital Admission is not medically necessary for this patient. Although the requested procedure is a standard surgical treatment for GERD, there are several exclusions to the procedure, which include any history of prior gastric or bariatric surgery. This patient already had an anti-reflux procedure in 2016- (laparoscopic Nissen fundoplication) and would not be eligible to receive the LINX treatment which is not Food and Drug Administration (FDA) approved for use int patients who are less than 18 years of age, have a diagnosis of Barrett's esophagus, BMI > 35 kg/m2 or prior bariatric or gastric surgery.
The requested treatment for GERD is excluded by the FDA for use in patients who have already had prior gastric or bariatric surgery, such as this patient, who has history of a laparoscopic Nissen fundoplication in 2016.