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

Diagnosis: Gum Disease/Pain.
Treatment: Deep gum and root cleaning in all four quadrants.

The health plan denied the dental service of deep gum and root cleaning in all four quadrants as not medically necessary.  The reviewer has upheld the health plan's determination.

The patient presents to the office of her dental provider for evaluation and treatment of her periodontium.  In question is the medical necessity of the treatment of scaling and root planing (4341) for upper right (UR), upper left (UL), left lower (LL), right lower (RL).

The requested health service/treatment of deep gum and root cleaning in all four quadrants is not medically necessary for this patient. The utilization of scaling and root planing as a periodontal therapy requires that the patient have evidence of attachment loss. The mere presence of deep probing depths does not indicate that the patient has any attachment loss as periodontal pocketing also occurs due to anatomical variation and is considered to be a pseudopocket. The therapy of scaling and root planing in a patient without periodontal attachment loss has been shown to damage the periodontal attachment and result in attachment loss. For this patient radiographic presence of an intact lamina dura, radiographic evidence of intimate proximity of the bone to the cementoenamel junction (CEJ), no recorded attachment loss, no diagnosis of periodontal disease, and minimal to no bone loss throughout the mouth all indicate that scaling and root planing is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures

Treatment: inpatient admission

The insurer denied coverage for the inpatient admission

The denial is upheld

This case involves a male patient with a history of a long hospitalization due to severe Guillain Barre syndrome followed by a chlamydia infection. The documentation indicated while initially hospitalized he developed reactive arthritis in addition to seizures and required a gastrostomy tube with tracheostomy and oxygen collar. He was initially transferred to a rehabilitation center however 3 days after transfer he presented to the emergency department (ED) due to increasing seizures. The documentation detailed he had a second seizure that was approximately 7 minutes long which prompted the hospital presentation. He does have a significant history of seizures and was utilizing Keppra. The physical examination revealed no significant findings. There were no focal deficits. The recommendation was made for neurological evaluation for recurrent and hard to control seizures. Additionally, it was recommended he undergo a computed tomography (CT) scan of the head and laboratory studies. The CT scan of the head revealed no intracranial hemorrhage. A chest x-ray did reveal aspiration infiltrate to the right lower lung. He also had laboratory studies revealing anemia. It was recommended he be admitted for further care. During admission it was noted he was placed on one-on-one supervision due to symptoms of depression and anxiety. He continued with treatment and did have additional seizure episodes. The documentation indicated he did have seizure-like activity for approximately 1 minute or so during an evaluation. He was treated with Ativan and did not have any further seizure activity. The documentation indicated later that day he was cleared to return to the nursing center for further treatment with the recommendation to follow-up with psychiatric services.

The patient presented to the ED with a history of a prolonged seizure, lasting approximately 7 minutes. Documentation shows he did not have focal findings and underwent a normal head CT. The patient underwent neurological and psychiatric consultations for probable non-epileptiform events. He was treated with Ativan for one single seizure-like event, lasting for about one minute. The patient's medication was adjusted during hospitalization and follow up was arranged with psychiatry for probable non-epileptiform events. Care provided, including diagnostic imaging, specialty consultation and medical management could have been performed at an observation level of care. Therefore, the inpatient admission was not medically necessary.  

The healthcare 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 admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male with a past medical history remarkable for diabetes, hypertension, and schizophrenia, who was admitted for chest pain and back pain. Review of system was negative for additional symptoms.
The patient was afebrile (Temperature of 97.9), described as well appearing and no acute distress. His blood pressure was 147/87, pulse rate of 82, respiratory rate of 20, and oxygen saturation of 98% on room air. Physical examination was unremarkable for positive clinical findings.
Laboratory evaluation demonstrated a sodium of 135, potassium 4.8, chloride of 102, carbon dioxide (CO2) of 24, blood urea nitrogen (BUN) of 15.2, creatinine of 0.81, white blood count (WBC) of 6.7, Hb (hemoglobin) of 12.2, Hematocrit (HCT) of 34.8, and platelets of 251. Chest x-ray revealed perihilar and bilateral lower lobe atelectasis and or consolidation. A computed tomography (CT) scan showed ground glass alveolar opacities of the lower lobes bilaterally. An electrocardiogram (EKG) revealed normal sinus rhythm. The patient was admitted for pneumonia.

The inpatient hospital admission was not medically necessary.
The patient was admitted for possible COVID pneumonia. The documentation does not support inpatient level of care. The patient was not in respiratory distress and had no evidence of hypoxemia. Additionally, the patient did not have comorbid conditions or underlying lung disease which increase the risk of complications and treatment failure. The patient was hemodynamically stable, and the care could have been rendered at a lower level of care for monitoring of oxygenation. Inpatient level of care is not justified since there was no clear indication for ventilatory support or partial pressure of oxygen (PO2)< (less than) 60. There was also no clear evidence of systemic manifestation since patient did not have fever, elevated white cell count and normal renal function.
The patient was admitted for viral pneumonia with no clear evidence of sustained hypoxemia, leukocytosis, or signs of sepsis. Based on the risk stratification of community acquired viral or bacterial pneumonia, the CURB-65 (confusion, uremia, respiratory rate, blood pressure, age >= 65 years) and Pneumonia Severity Index predict a low mortality based on the patient's age, comorbid condition, and renal function. Therefore, the care could have been rendered at a lower level of care with subsequent discharge after two midnights.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory Distress. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This is a male toddler with a history asthma. He presented to the emergency room (ER) with complaints of respiratory distress. The physical examination revealed wheezing and subcostal retractions. A chest x-ray (CXR) revealed no significant findings. He was admitted with an asthma exacerbation. The patient was maintained on an oral (PO) diet and vitals were monitored. Intravenous (IV) fluids were given. Albuterol nebulizers were given every 2 hours in the beginning then every 4 hours.  The patient was discharged 3 days later with instructions to continue albuterol treatments and take 4 milliliters (ml) of Prednisolone every 12 hours for two days. 

The patient could have managed at a lower level. There was no need for repeated Magnesium sulfate, no need for continuous nebulizers for prolonged time, no need for terbutaline drip or continuous steroids. The patient's oxygen saturation lowest was 90 to 95 percent. If one were to assess the asthma severity such as pediatric Asthma severity score or Pediatric respiratory assessment Score (PRAM), the score would indicate that patient needed only a lower level of care such as observational status or outpatient. Furthermore, the CXR was normal which is expected. Also, there was no underlying medical conditions such as chronic lung disease or congenital heart disease. There was also no need for high flow nasal cannula oxygen or bilevel positive airway pressure (BiPAP). The hospital course was suggestive of rapidly improving clinical picture. Due to all the above reasons, the patient only required observational status care. 

The health care plan acted 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 the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Celiac Disease. 
Treatment: Common procedural code (CPT) 82523/90 collagen cross links. 

The insurer denied coverage for common procedural code (CPT) 82523/90 collagen cross links. 

The denial is overturned. 

The patient is an adult male diagnosed with celiac disease, nephrolithiasis, osteoporosis, and kidney stones. The treating provider requests plan approval for common procedural code (CPT) 82523/90 collagen cross links. 

The following bone turn over markers are very useful in the long-term planning of bisphosphonate use. 

"Immunoassays for biochemical markers of bone resorption were emerging that appear to be sufficiently specific and convenient for clinical use. The need for them arises because the impact of osteoporosis on the aging population increases and better tools to aid in risk prediction and prevention of osteoporosis was mandatory. Bone resorption markers are important indicators of disease activity in patients with osteoporosis. Normalized results of these indicators are helpful in establishing the disease and its managements. Urinary N-telopeptide has been used for monitoring treatment for osteoporosis for a long time, but now, clinicians are using it to predict the onset of osteoporosis. The new ELISA (enzyme linked immunosorbent assay) immunoassay for the urinary excretion of cross-linked collagen peptides is a reliable and specific biochemical marker of bone resorption. The telopeptides are from Type I collagen which forms 90 percent (%) of organic bone matrix and are cross-linked at N and C terminal ends of the molecules to form the basic fabric and tensile strength of the bone tissue. Urinary N-telopeptide (NTx) is a sensitive and specific marker of bone resorption. NTx is the stable degradation end product, which can be measured both in serum and urine. The NTx sequence is generated by osteoclastic activity and proteolysis. Hence it does not require further breakdown or metabolism by kidney or liver for its production. Urinary N-telopeptide value does not significantly vary between male and female, and its range is pretty much same once the patient attains menopause. The urinary excretion is not affected by diet, and therefore shows less variation than the conventional markers." (Ganesan, et al., 2019). 

The requested, common procedural code (CPT) 82523/90 collagen cross links is considered medically necessary for this patient. 

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

The insurer's denial of coverage for common procedural code (CPT) 82523/90 collagen cross links is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical spondylosis 

Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.

The denial is upheld.

This is the case of an adult female with a history of diabetes mellitus, hypertension, hyperlipidemia, axial neck pain, cervical spondylosis with foraminal stenosis and disk degeneration. She presented to the hospital for a planned cervical (C) 4-C7 anterior cervical discectomy and fusion (ACDF). The patient underwent surgery and was discharged 2 days later. 

An analysis of 2,000 ACDF patients in an ambulatory surgery center (ASC) setting with a standardized perioperative protocol demonstrates that surgical complications occur at a low rate, less than 1 percent, and can be appropriately diagnosed and managed in a 4-hour post anesthesia care unit (PACU). Surgeons can safely perform ACDFs in an ASC utilizing patient selection criteria and perioperative management protocols similar to those reported here (1).

Outpatient discharge after ACDF is a viable treatment option with a reasonable safety profile. Appropriate patient selection is key, and the standard of care nationally for the comorbid patient remains inpatient admission (2). 

The patient is an adult female with a medical history of diabetes mellitus, gastrointestinal reflux disease, hypertension, and hyperlipidemia. She presented for elective surgery for neck pain radiating to the head and both arms with paresthesia. She was found to have left upper extremity strength of 3/5 and reduced sensation in the cervical (C) 6-7 distribution. She underwent an anterior cervical discectomy and fusion C5-6 and C6-7 for cervical radiculopathy. She had an American Society of Anesthesiologists (ASA) score II. Preoperative clearance with low risk by Cardiology. She had improvement in symptoms and there were no complications. A Jackson Pratt drain was placed. Postoperatively the patient received intravenous (IV) lactated ringers at 125 milliliters/hour (ml/hr) until the following day at which time she transitioned to oral fluids/food. She was maintained on oxygen at 2 liters per minute via nasal cannula until her day of discharge. Vital signs every four hours were stable.

The patient was low risk prior to surgery. According to the medical records, she did not have any uncontrolled pain and there were exams to show no significant neurological deficit.

The inpatient stay is not medically necessary. The patient's care could have been provided at an observational level for oxygen requirements. Her comorbid conditions were stable, her ASA score was II, she did not require round the clock intravenous pain medications or frequent neurological checks, she did not have any worsening neurological status and her drain output was minimal. The patient was eating, drinking, and voiding. She required oxygen at 2 liters via nasal cannula and she was hemodynamically stable. 

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: Formulary Exception
Decision: Upheld

Diagnosis: Asthma

Treatment: Dulera (formoterol-mometasone).

The insurer denied coverage for Dulera (formoterol-mometasone).

The denial is upheld.

This patient has a history of allergies, gastroesophageal reflux disease (GERD), migraines, asthma, tracheomalacia, and alpha 1-antitrypsin deficiency. She presented to the Pediatric Pulmonologist's for a follow up visit for asthma. The patient reported that her symptoms remained stable despite decreasing her inhaler regimen. The physician recommended continuing Dulera 200-5 micrograms (mcg) 2 puffs a day (QD), try decreasing Combivent use to twice a day (BID) for the next 2 weeks, and continuing albuterol every 4 hours (Q4H) as needed (PRN) for wheezing.  

The patient has moderate persistent asthma. Her spirometry was normal. Her imaging was normal. There was no unanticipated emergency department (ED) visits nor hospitalizations. Her moderate persistent asthma could be downgraded to mild persistent asthma if her asthma control continues to be better. She has alpha 1 atitrypsin deficiency and is stable. She has GERD (gastroesophageal reflux disease) which is stable.

She does not have daily symptoms and no daily nocturnal symptoms. Hence in NAEPP (National Asthma Education and Prevention Program) step, she could be step 2. 
We don't know the definition of "failed" therapy to inhaled corticosteroids (ICS) - whether patient had abnormal Spirometry, whether increased emergency department (ED) /Hospitalization rates etc. Hence, Dulera is not likely to produce a more clinically beneficial outcome than the formulary medications.

The insurer's denial of coverage for Dulera (formoterol-mometasone) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bariatric surgery. 
Treatment: Liver Biopsy (code 47379). 

The insurer denied the Liver Biopsy (code 47379). 
The denial is upheld. 

The patient is a man who underwent bariatric surgery (laparoscopic roux en Y gastric bypass and concomitant liver biopsy) performed. The records support that he had a BMI (body mass index) of 42.48. The operative dictation states that the surgeon noted a fatty liver with a blunted edge and obtained a wedge liver biopsy from the left lobe of the liver. The submitted records do not include any pre-surgical lab, imaging or clinical data to indicate liver pathology. The pathology report provides the diagnosis of mild fatty change. 

The surgeon submitted code 47379 (liver biopsy, wedge). The health plan rationale for denial of coverage for liver biopsy per the letter is that there is no documentation of objective signs or symptoms of liver disease to warrant liver biopsy. Per this letter guidelines on the use of liver biopsy in clinical practice do not mention routine biopsy of the liver with bariatric surgery. The health insurance denial letter indicates that the surgeon submitted code 47379 (laparoscopic procedure liver). Appeal material is provided by the surgeon. 

No, the Liver Biopsy (code 47379) was not medically necessary. 

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

The health plan acted reasonably with the determination of medical necessity regarding liver biopsy in this case. Accepted indications for liver biopsy include documentation of signs or symptoms of liver disease (abnormal liver function tests of unknown etiology, knowledge of a specific diagnosis that will likely alter the treatment plan, known liver disease where prognostic information about fibrosis may guide subsequent treatment, the presence of a mass or lesions or focal or diffuse abnormalities seen on imaging studies of unknown etiology). In this case there is no such documentation to warrant wedge liver biopsy (47379 liver biopsy, wedge or 47100). Routine liver biopsy is not an accepted or standard aspect of bariatric surgery. [1] 

In this case, the patient is morbidly obese with a body mass index of 42.48. Lab data and pre-operative imaging are not included with the review material. There is no description of clinical symptomatology to indicate liver pathology. [1, 2, 3]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: Braces.
The insurer denied the Braces.
The determination is upheld.

The patient has a Class I occlusion with a 2 millimeter (mm) overbite and 2 mm overjet. There were not pictures provided but there appears to be minor crowding present in the provided radiographs. He has maxillary and mandibular crowing. He is treatment planned for orthodontics to correct his malocclusion. At issue is the medical necessity of braces.

This is not medically necessary. There is no medical reason to correct his malocclusion with braces. While the patient has crowding, there is no evidence of anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) However, this patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. (2) If his teeth were aligned it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary. The patient and his mother have supplied a narrative that the patient has jaw pain and requires orthodontic treatment. The records provided offer no indication of an orthodontic reason that the patient would be having this pain. It should be explored if dental decay or some other reason is the cause of his jaw pain.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Acne
Treatment: Adapalene-Benzoyl Peroxide Gel
The insurer denied Adapalene-Benzoyl Peroxide Gel.
The health plan's determination is upheld. 

The patient is a female with acne vulgaris. She has failed Tazorac 0.05% (percent) cream, Benzaclin 1%-5% gel, Atralin 0.05% gel, and clindamycin 1% lotion. She has also failed Aldactone 50 milligrams (mg) tablet and doxycycline 100 mg tablet.

A formulary exception is not indicated in this case. 

The formulary drugs (adapalene [except adapalene pads or adapalene solution], benzoyl peroxide, clindamycin gel, clindamycin solution, clindamycin-benzoyl peroxide [generic Acanya, Benzaclin], erythromycin solution, erythromycin-benzoyl peroxide, tazarotene [generic Tazorac], tretinoin, tretinoin gel microsphere) would not be ineffective. The formulary drugs would be as effective as the non-formulary drug (Adapalene-Benzoyl Peroxide Gel). The formulary drugs would not have adverse effects.

Clinical guidelines for the management of acne vulgaris recommends topical therapies such as over the counter and prescription strength adapalene. Zaenglein, et al writes in the "Guidelines of care for the management of acne vulgaris," published in the Journal of the American Academy of Dermatology, that "Topical retinoids are vitamin A derivatives that are prescription agents with randomized, double-blind, placebo-controlled trials supporting their use for acne treatment... Three active agents are available: ...adapalene (0.1%, 0.3% cream, or 0.1% lotion (73,74)." Topical therapies such as adapalene are listed as a first line treatments within the acne guidelines, and throughout the dermatology literature as an effective treatment for acne. There is no documentation provided that the patient has tried and failed over the counter or prescription strength adapalene. Therefore, Adapalene-Benzoyl Peroxide Gel is not medically necessary and no exception is granted.