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

Diagnosis: Muscle weakness, hereditary spastic paraplegia, and unspecified abnormalities of gait and mobility

Treatment: Continued PT (physical therapy) - codes 97530, 97112, 97140, 97110

The insurer denied coverage for continued PT (physical therapy) - codes 97530, 97112, 97140, 97110.

The denial is overturned.

This case involves a female who has been participating in physical therapy (PT) services due to diagnoses that include muscle weakness, hereditary spastic paraplegia, and unspecified abnormalities of gait and mobility. It is noted she was seen for 31st visit of PT services. The documentation indicated her father reported continued needs for therapy services for his daughter. The documentation indicated she continued with therapy treatment. The documentation indicated she was also seen for therapy services. The documentation indicated the patient can walk 5-8 minutes prior to requiring a break. Since beginning PT, her father does report a decrease in frequency of falling and improved stair regulation. The examination revealed 4/5 strength to the bilateral lower extremities. The documentation indicated she presented with improvements in core strength and the ability to hold a prone plank for 35 seconds at a time. She remained compromised in static and dynamic balance. It was recommended she continue with additional therapy services. The physician indicated an integral part of her disease management is PT services. It is recommended that she continue PT as medically necessary services.

According to the provided documentation, the patient has ongoing leg weakness and spasm and difficulty with ambulation. She has made progress with previous PT sessions. Further PT will further improve strength, function, balance, and activities of daily living (ADLs). Therefore, the requested services were appropriate.

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

The insurer's denial of coverage for continued physical therapy (PT) - codes 97530, 97112, 97140, 97110 is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bell's Palsy. 
Treatment: Inpatient admission. 

The insurer is denied coverage for inpatient admission. 

The denial is upheld. 

This female patient has a history of hypertension, fibromyalgia, Lyme disease, possible recurrent Bell's Palsy, recurrent bronchitis, and anxiety/depression. 

Milliman Care Guidelines (MCG) recommends admission for acute ischemic stroke with neurologic findings when there is National Institutes of Health Stroke Scale (NIHSS) score greater than 2, evidence of hemorrhagic transformation, altered mental status, findings that warrant inpatient physical or occupational therapy treatment or evaluation, dysphagia that warrants evaluation (eg, aspiration risk suspected), significant arm or leg weakness (eg, limiting movement against gravity), aphasia, gait impairment, or finding on brain imaging that requires inpatient care (eg, mass, edema, large acute infarction). The patient was noted to have a NIHSS score of 4; however, 2 points were for facial palsy. This resolved and the patient had a history of Bell's palsy. While the patient did have arm and leg weakness this would not be significant (limiting movement against gravity) as motor strength was noted as 4+/5 right upper extremity weakness and 4/5 right lower extremity. The patient had a history of hypertension and blood pressure was under control prior to admission. Imaging of the brain was normal. The patient could have been monitored, treated, and underwent testing in a lower level of care to include observation. As such, the denial of coverage for the inpatient admission at Richmond University Medical Center is upheld. 

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia

Treatment: Inpatient level of care

The insurer denied coverage for inpatient level of care.

The denial is overturned.

This is an infant female who presented to the emergency room (ER) with a prolonged febrile illness. There had been intermittent fever for 7 days followed by 5 days of persistent fever which was not responding to Tylenol. The child also had a cough, nasal congestion and a runny nose. The mother and other siblings had similar symptoms. As the illness progressed the mother noted that the child was fussy and less active. When she vomited and there was a decrease in both oral intake and urine output the mother brought her to the ER for evaluation.

In the Emergency Room, the child was noted to have fever and signs of dehydration. There were enlarged cervical lymph nodes and sinus tenderness and discharge from the nose. The child had an elevated white blood count 19,800 with a shift to the left and an elevated C-Reactive Protein (CRP) of 3.05. She was treated with an IV (intravenous) fluid bolus and IV ceftriaxone. A respiratory viral panel was positive for adenovirus and rhinovirus. A chest x-ray showed mild right perihilar opacity. Based on the elevated white blood count, abnormal chest x-ray and persistent fever which did not respond to Tylenol and Motrin in the ER, the decision was made to admit the child to the hospital for ongoing antibiotic treatment with a diagnosis of dehydration and pneumonia.

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

The inpatient level of care is considered medically necessary for this child.

The patient had a prolonged illness with fever, decreased oral intake and an abnormal chest x-ray. Her fever did not respond to treatment in the ER with Tylenol, Motrin and IV fluids. The white blood count was elevated with a shift to the left suggesting a bacterial infection. It was appropriate to admit her to the hospital pediatric floor for ongoing IV fluids and antibiotics. 

It is not clear why the insurer commented on the need for admission to the neonatal intensive care unit (NICU) since this patient was admitted to the pediatric floor. During the course of her hospitalization when her fever persisted, she had repeat blood testing which documented a further increase in her white blood count to 22,400 and her c-reactive protein (CRP) to 7.3. In addition, she was found to have pansinusitis detected on a computed tomography (CT) scan of the sinuses.  The decision to admit this child for ongoing treatment with intravenous (IV) fluids for dehydration and antibiotics for a bacterial infection was appropriate and consistent with the standard of care.  The child was not stable enough to be able to take in adequate fluids by mouth to permit her to be treated at home with oral antibiotics.

The insurer's denial of coverage for inpatient level of care is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: painful contractions

Treatment: inpatient level of care

The insurer is denied coverage for inpatient level of care.

The denial is upheld. 

This female patient has a history of Gravida 3, Para 1011.

According to the submitted information, the patient was noted to have contractions and she was sent to labor and delivery for evaluation. It is unclear why the patient was admitted since an evaluation for active labor does not require admission.

The patient could have been observed for a few hours for cervical changes. If cervical changes were happening, then the patient would be considered in active labor, and she would be transferred to a higher level of care. Ruling out active labor does not require hospital admission. This is routinely done in the triage/observation area.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient level of care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic Short Stature (ISS)

Treatment Nutropin AQ (somatropin) Nuspin

The insurer denied coverage for Nutropin AQ Nuspin.

The denial is upheld.

This is a pre-teen child diagnosed with idiopathic short stature (ISS). This request is for Nutropin. Her GH (growth hormone) stimulation test with clonidine and arginine peaked at 11.7. Her height velocity is reported to be 7.9 centimeters per year (cm/yr). Her bone age slightly increased. Her breasts were at tanner 2-3. The patient's insulin growth like factor 1 (IGF1) was 345 (76-549); Z-score was +1.0 SD (standard deviation); insulin like growth factor binding protein 3 (IGFBP3) was 5360 (2456-6992). 

Her height was 139 cm (-1.51 SDS [standard deviation score]) and later was 142.5 cm (-1.53 SDS) with height velocity over 5 months of 8 cm/yr.

Her mother's height is 165.10 cm and father's height is 175.26 cm and mid parental height is 163.68 cm (+0.05 SDS). 

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient, as the request is not medically necessary as described below.

The peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below:

Idiopathic Short stature

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4, [5, [6, [7, [8, [9]. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS 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."

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. 

The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary.

The insurer's denial of coverage for growth hormone therapy with Nutropin AQ Nuspin
 is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines
Treatment: Ubrelvy, Pre-service
The insurer denied the Ubrelvy, Pre-service
The denial is upheld. 

The patient is a male with migraine headache disorder. There is no documented previous trials of abortive medications. The provider is requesting Ubrelvy.  

The requested medication was denied coverage as the patient has not tried and failed the preferred medications for his condition.

No, the health plan should not cover the proposed treatment with Ubrelvy.
There is no reason the patient cannot be treated with the preferred formulary triptan agents. All of the preferred agents are Food and Drug Administration (FDA) approved for acute treatment of migraine headaches and are considered first line, standard of care, abortive agents (Thorlund et al.). There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Ubrelvy relative to the preferred agents.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cerebellar stroke with impending herniation and hydrocephalus

Treatment Healthcare Common Procedure Coding System (HCPCS) code A0428 [Ambulance service, basic life support, nonemergency transport (BLS)] modifier HH [Ambulance transportation from hospital to hospital] and HCPCS code A0425 [Ground mileage, per statute mile] modifier HH

The insurer denied coverage for Healthcare Common Procedure Coding System (HCPCS) code A0428 [Ambulance service, basic life support, nonemergency transport (BLS)] modifier HH [Ambulance transportation from hospital to hospital] and HCPCS code A0425 [Ground mileage, per statute mile] modifier HH	

The denial is overturned

This is the case of a female patient with multiple vascular risk factors who presented to the Emergency Department (ED) with new onset of nausea and vertigo. She was found to have a large left cerebellar stroke with impending herniation and hydrocephalus. She underwent a shunt placement. She was treated and transported to an inpatient rehabilitation facility via ambulance. 

The patient's insurer has denied coverage of the ambulance transport. Per appeal letter, the Neurology nurse practitioner stated that the patient needed medical transport to the rehab facility as she could not sit upright due to a stroke.

Given the patient's stroke which affected her cerebellum and her balance as well as likely ability to be able to sit upright, she required transport via a stretcher using an ambulance. Therefore, the requested service is medically necessary. 

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

The insurer's denial of coverage for Healthcare Common Procedure Coding System (HCPCS) code A0428 [Ambulance service, basic life support, nonemergency transport (BLS)] modifier HH [Ambulance transportation from hospital to hospital] and HCPCS code A0425 [Ground mileage, per statute mile] modifier HH provided is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is an adult male patient that presented to the hospital complaining of left sided chest pain that has been present for years and related to remote trauma. Past medical history was significant for diabetes mellitus (DM), hypertension (HTN) and active cigarette smoking. Upon arrival to the hospital vital signs were stable with blood pressure (BP) of 170/72 and pulse of 99 beats per minute (bpm). Physical exam revealed no significant abnormality. Electrocardiogram (EKG) demonstrated sinus tachycardia without ischemic ST or T (intervals on electrocardiogram) wave abnormalities. Serum troponin was <0.012 nanograms/milliliter (ng/ml). Echocardiography revealed hyperdynamic left ventricular (LV) function without wall motion abnormality and no significant valvular abnormality. The patient was treated for chest pain. Ultimately the patient signed out against medical advice (AMA).

This patient presented with atypical chest pain and no significant past medical history. His pretest probability of coronary artery disease is low. (1) Utilizing the HEART (History, EKG (electrocardiogram, Age, Risk factors, and troponin) score he was considered low risk. (2) Utilizing the TIMI (thrombolysis in myocardial infarction) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1). (3) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (3). Using the HEART score risk stratification schema, this patient would have a low 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. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care.

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

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

Diagnosis: Back Pain

Treatment: MRI (magnetic resonance imaging) Lumbar Spine without contrast

The insurer denied coverage for MRI Lumbar Spine without contrast.

The denial is overturned.

This is an adult female who has a past medical history of asthma and low back pain for years. According to the visit notes, there are no relieving factors, and the patient had previously attempted physical therapy. The patient has tried Robaxin, Gabapentin, and Naprosyn. A plain lumbar spine X-ray shows mild levoscoliosis but otherwise unremarkable. The physical exam shows positive straight leg raising test and decreased lumbar spine range of motion. The patient is seeing a neurologist for headaches, but that physician has not addressed her back pain.

The American College of Radiology (ACR) appropriateness criteria (1, 2) low back pain (variant 3 chronic low back pain with radiculopathy, an intervention candidate with persistent symptoms following 6 weeks of optimal medical management) states: "usually appropriate".

The patient has unexplained low back pain for the past 2 years and has failed conservative therapy. A magnetic resonance imaging (MRI) of the lumbar spine is medically reasonable and necessary. 

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

The insurer's denial of coverage for Magnetic Resonance Imaging (MRI) Lumbar Spine without contrast is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overjet

Treatment D8080 braces and D8670 monthly visit

The insurer denied coverage for D8080 braces and D8670 monthly visit.

The denial is upheld.

This is a teenage female with no documented history who presented to the Orthodontist's office for an evaluation.

Based on the submitted documentation there does not appear to be any crowding or spacing in the upper and lower anterior. The overjet appears to be normal.

Per An Introduction to Orthodontics, one or more of these dental traits that would have an adverse effect on the longevity of dentition, indicating high need for correction:
1)	Increased Overjet
2)	Increased traumatic Overbites
3)	Anterior crossbites causing decreased periodontal support
4)	Unerupted impacted teeth (where there is danger of pathology)
5)	Crossbites associated with mandibular displacements

Per the clinical records, the patient does not have any of the above problems. There is no increased overjet or overbite noted or crossbites. There is not a high need for orthodontic treatment. The health plan acted reasonably with sound medical judgment.

The insurer's denial of coverage for D8080 braces and D8670 monthly visit is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia as well as congestive heart failure, obesity, diabetes, hypertension, anxiety, depression, and abnormality of gait and mobility

Treatment personal care worker (PCW) level 1 services of 7 days per week, 24 hours per day, continuous care by more than 1 person, for a total of 168 hours per week

The insurer denied coverage for personal care worker (PCW) level 1 services of 7 days per week, 24 hours per day, continuous care by more than 1 person, for a total of 168 hours per week

The denial is overturned

This case involves a female who has been recommended to be seen services 24 hours a day totaling 168 hours a week.  The documentation indicated she has multiple diagnoses that include dementia as well as congestive heart failure, obesity, diabetes, hypertension, anxiety, depression, and abnormality of gait and mobility.  The documentation indicated she was recently admitted due to acute on chronic respiratory failure with hypoxia.  She was initially brought in by ambulance for worsening shortness of breath for two days.  She was unable to provide much history due to respiratory distress.  In the emergency department she had a fever of 102.1 with a respiration rate of 32.  She had a chest x-ray revealing prominent pulmonary vascular markings.  She had pitting edema and was treated with IV (intravenous) vancomycin as well as IV Lasix.  The patient's daughter did confirm that her baseline mental status was typically sleeping all day however she was easily arousable and said hi.  She also indicated she was receiving antibiotics at home.  The submitted documentation indicated she was discharged and she remained clinically stable.  She was medically cleared for discharge.  The documentation indicated she required 24-hour supervision upon discharge given her condition.  It was recommended to be split into 2 12-hour shifts.  The submitted assessment form indicated the patient did live alone and was totally dependent for housework.  The documentation indicated she was frequently bladder incontinent and occasionally bowel incontinent.  She utilizes a wheelchair or scooter from locomotion.  The recommendation was made for home services as noted above.

This elderly female meets the criteria for increased services due to increased frailty, debility and progressive dementia. She will require 7 days a week split shift 24 hour care based on the clinical information provided. She is unsafe to be left alone for any length of time due to a high risk of adverse events including falls.

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

Based on the above, the medical necessity for the requested Personal Care Worker (PCW) Level 1 Services of 7 days per week, 24 hours per day, continuous care by more than 1 person, for a total of 168 hours per week is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hemoglobin Sickle Cell (SS) Disease

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld.

The patient is an adult female with hemoglobin sickle cell (SS) disease, history of transient ischemic attack (TIA), and asthma who presented to the Emergency Room (ER) with an uncomplicated sickle cell pain crisis. Her hemoglobin (Hgb) was 7.6. Her Hgb was 7.3. Her Hgb was stable, and her vital signs were within normal range. A chest x-ray (CXR) and urinalysis (UA) were negative. She was given Dilaudid and admitted to the hospital. The patient was transitioned back to her home pain medications and discharged.

This patient could have been managed in a lower level of care such as observational status on the date of service in question. Uncomplicated sickle cell pain crisis does not warrant acute level hospitalization. This patient presented to the ER with an uncomplicated sickle cell pain crisis. Her hemoglobin (Hgb) was stable, and her vital signs were within normal range. A CXR and UA were negative. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

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

The insurer's denial of coverage for inpatient hospital admission is upheld. Medical necessity is not substantiated.