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

Diagnosis: High Blood Sugar and Vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient is a female with a history of type 1 diabetes, diabetic retinopathy, diabetic nephropathy, peripheral neuropathy.  The patient presented to the emergency department complaining of nausea, vomiting, high blood sugar.  She also had right lower quadrant abdominal pain.

The patient's blood pressure was 193/104 with a pulse of 87.  Sodium was 117 with a potassium of 6.3, chloride 94, bicarbonate 20 (21-30), BUN (blood urea nitrogen) 28, creatinine 1.23, anion gap 19.3, beta hydroxybutyrate 4.7.  At presentation her blood sugar was 995.  The venous blood gas did not show acidosis.  Calculated serum osmolality was 299 (285-295).

The patient received 2 L (liters) of normal saline, morphine, Zofran, insulin.  The patient was treated with the diabetic ketoacidosis protocol.  She was started on Lantus insulin after ketones improved.  The patient left against medical advice the next day.

Yes, the Inpatient admission was medically necessary.
Acute inpatient admission for patients with symptomatic diabetes is necessary when the patient has evidence of ketoacidosis or a hyperosmolar state [1-6]. Observation is generally sufficient for patients with ketosis or vomiting that resolves after hydration [7-9].

The patient had symptomatic diabetes with severe ketosis, and increased anion gap, vomiting, hyperosmolar state.  The patient was appropriately treated with an insulin infusion as the patient had hyperosmolar state with ketosis.  The patient could not has been safely managed except in the inpatient setting.  The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

No, the health plan did not plan act reasonably, with sound medical judgment and in the best interest of the patient as the request is medically necessary as described above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart Failure
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male. He was hospitalized at an out of network facility for newly diagnosed HFrEF (heart failure with reduced ejection fraction) of 15-20%. It was suspected that this might be from viral myocarditis. His PMH (past medical history) includes Hypertension, morbid obesity, CKD (chronic kidney disease) and hyperlipidemia.

The patient's exam was remarkable for generalized edema with dyspnea on exertion, RR (respiration rate) of 18, diminished breath sounds and initial blood pressure reading of 129/65. O2 (oxygen) saturation was 94% on RA (room air). Chest x-ray reported stable cardiomegaly, slight increase in hazy opacities involving the mid to lower lung fields and increased blunting of the costophrenic sulci, right greater than left indicating worsening pleural effusions.

Treatment included IV (intravenous) bumetanide and losartan and hydralazine dosages were increased. No tracheal deviation or mediastinal widening. The visual structures are intact. Coronary CTA (Computed Tomographic Angiography) done was negative.

Coverage for the inpatient admission was denied by the health plan as not medically necessary, as the patient was deemed stable to transfer from the ED (emergency department) to an in network facility for further care. The denial is being appealed.

No, the Inpatient admission was not medically necessary.
Based on the peer reviewed medical literature, the documentation submitted for review do not establish the requested Acute Inpatient Hospital Stay was medically necessary for this patient. According to the MCG (Milliman Care Guidelines) Guidelines titled: Heart Failure (ORG: M-190), the inpatient admission was not medically necessary, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay per the guideline. Criteria for inpatient stay are not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by CKD (chronic kidney disease) and CHF (congestive heart failure) , hypertension requiring inpatient hospitalization, CVA (cerebrovascular accident), pulmonary embolism, aortic dissection, pneumonia, severe electrolyte abnormalities or any other medical condition or other medical instability or acute care needs for which emergency and observation care have failed or are not considered appropriate and that would require acute inpatient management. The care he received for an uncomplicated, acutely decompensated chronic LV (left ventricle) systolic HF (heart failure) is routinely provided safely and effectively at a lower level of care. The Inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Masticatory/speech difficulties

Treatment is D8080 braces

The insurer denied coverage for D8080 braces

The denial is overturned.

According to the documentation submitted, this is a male with no documented medical history. He presented to the Orthodontist's office for an evaluation. X-rays and pictures were taken. The treating Orthodontist recommended D8080 braces.  

Utilizing the Handicapping Labio-lingual index this patient does meet criteria for coverage. The patient meets the automatic qualifier of an overjet greater than 9 mm. 

Braces are medically necessary and the standard of care. The Index of Orthodontic Treatment Need (IOTN) was also developed to assess the need for orthodontic treatment according to the highest potential risk to the integrity of the teeth or supporting structures from the malocclusion. The IOTN has two categories, the dental health component (DHC) and the esthetic component (AC). The DHC is determined by considering the potential harm that a particular occlusal trait could have on the longevity of the dentition. The DHC categorizes the detrimental effects of various deviant occlusal traits in order of severity. The severity is categorized into five grades 1-5 based on the relative effect of various deviant occlusal traits on the longevity of the dentition. The AC can be determined once the permanent dentition has erupted. The score reflects the aesthetic impairment and guides the practitioner to treatment need. Grade 5 is a very great need, Grade 4 is great, Grade 3 is moderate, Grade 2 is little, and Grade 1 is no need. An overjet greater than 9mm (millimeters) is Grade 5.

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

The insurer's denial of coverage for D8080 braces is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient Stay. 
The denial is upheld. 

This patient is a male with no significant past medical history who presented with clinical history, examination, and imaging consistent with acute appendicitis. He was admitted as an acute inpatient and underwent an uncomplicated laparoscopic appendectomy on that day and was discharged to home on the following day. 
At issue is the medical necessity of Inpatient Stay. 

The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of Inpatient Stay is not medically necessary for this patient. 
The patient was never unstable, his surgery was uncomplicated, and he stayed 1 night as an inpatient. He required no services to necessitate an inpatient stay. Uncomplicated appendicitis with a laparoscopic appendectomy can be safely performed without an inpatient admission. The patient had an uncomplicated acute appendicitis that was treated with a laparoscopic appendectomy, generally an outpatient procedure. It is well established in the medical literature and in surgical practice that a laparoscopic appendectomy for uncomplicated appendicitis can safely be performed as a same day surgery or outpatient procedure. The American College of Surgeons endorses this perspective. 

Therefore, the requested health service/treatment of Inpatient Stay is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe crowding and an anterior crossbite. 
Treatment: D8080 (braces) Comprehensive orthodontic treatment of the adolescent dentition. 

The insurer denied coverage for D8080 (braces) comprehensive orthodontic treatment of the adolescent dentition. 

The denial is upheld. 

According to the documentation submitted, this is the case of a female with no submitted medical history. 

Upon review of the submitted documentation including only a letter from the orthodontist and insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings such as crowding and anterior crossbite. He has recommended orthodontics. The orthodontist has not completed the Handicapping Labiolingual Deviation (HLD) index, nor has he submitted any other clinical or radiographic information to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements. 

In this case, the treating orthodontist did not submit any clinical or radiographic documentation to support orthodontic necessity therefore orthodontic necessity cannot be determined. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. 

Each of the peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

In this case the orthodontist did not submit any information to justify orthodontic care. 

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

The insurer's denial of coverage for D8080 (braces) comprehensive orthodontic treatment of the adolescent dentition is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Generalized Musculoskeletal Pain. 

Treatment: Osteopathic Manipulative Treatment and injection, codes 98925 Osteopathic manipulative treatment (OMT); 1-2 body regions involved, 98926 OMT; 3-4 body regions involved, 98927 OMT; 5-6 body regions involved, 98928 OMT; 7-8 body regions involved, 98929 OMT; 9-10 body regions involved and 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s). 

The insurer denied coverage for Osteopathic Manipulative Treatment and injection, codes 98925 Osteopathic manipulative treatment (OMT); 1-2 body regions involved, 98926 OMT; 3-4 body regions involved, 98927 OMT; 5-6 body regions involved, 98928 OMT; 7-8 body regions involved, 98929 OMT; 9-10 body regions involved and 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s). 

The denial is upheld. 

This is a female patient with complaints of generalized musculoskeletal pain.  She was evaluated for complaints of neck, arm, back and leg pain. Osteopathic manipulative therapy was recommended and subsequently provided. 

The treatment notes submitted for review provide insufficient objective clinical information to support the medical necessity for OMT. The treatment notes from various medical practitioners document the provision of OMT without reported sustained pain relief. Prior OMT resulted in variable pain locations and ratings, without evidence of consistent improvement. The previously provided OMT for reported generalized pain, with the lack of significant quantitative functional improvement or sustained pain relief is consistent with maintenance treatment and therefore not supportive of resumption. 

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, coverage for OMT is not medically necessary. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary tract infection.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a female with past medical history remarkable for diabetes, hypertension, asthma, right hemicolectomy, who presented for worsening of altered mental status. The patient was recently hospitalized with diabetic ketoacidosis (DKA) and had alteration in her mental status at that time. Review of system was positive for right upper abdominal pain. The patient was admitted for worsening of mentation and urinary tract infection. The patient was found to have acute encephalopathy due to urinary tract infection and post-operative psychosis. 

The inpatient admission was medically necessary. The care could not have been safely rendered at a lower level of care.
The patient was admitted for infectious encephalopathy and urinary tract infection. The documentation supports inpatient level of care for complicated urinary tract infection with associated altered mental status, and delirium.
The patient had a complicated Urinary Tract Infection (UTI) in the setting of worsening mental status and delirium. Complicated UTIs are associated with patient-level factors that compromise urodynamics or host defenses, such as indwelling or intermittent urinary catheterization. Overall, UTI's in the elderly with multiple comorbid conditions has the potential for serious complications and mortality in the elderly patients and therefore must be treated with antibiotics tailored to the organism to avoid treatment failure and complications.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain.
Treatment: Intracept procedure.
The insurer denied the Intracept procedure.
The determination is upheld.

This is a patient who has a medical history of back pain. She had several episodes of severe pain in the right lower back with radiation down the lateral leg. She had lumbar epidural injections with improvement of her pain. The physical exam (PE) revealed tenderness in the lumbar region. Magnetic resonance imaging (MRI) showed grade 1 anterolisthesis of lumbar (L) 4 on L5 with moderate right neural foraminal stenosis, facet joint arthrosis and ligamentum flavum redundancy; a new tiny disc bulge and tiny central focal disc protrusion with annular fissure at L2-3 level; minimal anterior inferior L2 endplate inflammatory degenerative changes. There is resolution of inflammatory anterior endplate changes at L4, and a right renal lesion that has increased in size compared to a prior MRI. This patient was recommended to have an L2-L3 Intracept procedure for her back pain.
At issue is whether the Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed Intracept procedure is unlikely to be beneficial for the insured's medical condition.
The Intracept system was designed to treat low back pain from a vertebral body by ablating intraosseous nerves. The available medical records did not reveal adequate evidence that this patient's pain is from vertebral bodies. This patient has episodic right side low back pain with radiating pain to the lateral leg. She responded well to epidural injections. MRI revealed grade 1 anterolisthesis of L4 on L5 with moderate right neural foraminal stenosis and impression upon right L4 nerve root. This clinical picture is not consistent with vertebrogenic pain. Current clinical studies supported the efficacy of Intracept procedure for vertebrogenic back pain. However, patients with clinical evidence of other pain etiologies including severe spinal stenosis, disc bulge, nerve impingement and facet arthrosis were excluded from these studies. Ref 1. (Table 1 exclusion criteria in this study).
From reviewing the medical records and current clinical studies, this patient is not an appropriate candidate for the Intracept procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain.
Treatment: Intracept procedure.
The insurer denied the Intracept procedure.
The determination is upheld.

The patient has complaints of chronic low back pain. She has had episodes of severe pain in the right lower back radiating into the right leg. Prior treatments have included epidural injections. Magnetic resonance imaging (MRI) of the lumbar spine without contrast reported multilevel degenerative changes. The physical exam demonstrated tenderness in the lumbar region. There is a request for the Intracept Procedure. At issue is whether the Intracept Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment Intracept Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient has complaints of low back pain and there is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is a lack of data to recommend this procedure as a treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed health service or treatment Intracept Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Pain.
Treatment: Breast magnetic resonance imaging (MRI).

The insurer denied coverage for breast magnetic resonance imaging (MRI).
The denial is upheld.

The patient had a breast magnetic resonance imaging (MRI) that did not show any evidence of implant rupture.  Bilateral breast ultrasound did not show any sonographic evidence of malignancy but did show a stable focus of enhancement of the left breast. Mammogram was not performed due to pain.  Interval surveillance MRIs are recommended to evaluate a focus of enhancement of the left breast.  The MRI report recommends ultrasound or MRI guided biopsy. The area of enhancement is visible on ultrasound.  Ultrasound guided biopsy is the most appropriate treatment (as noted in the documentation from the MRI report) if there is a reasonable concern regarding malignancy, which appears to be the case given the patient and providers continued concerns regarding this area of the breast. If there is a reasonable concern regarding cancer, then biopsy rather than continued surveillance is the most appropriate treatment. If there is no concern regarding cancer, then surveillance mammograms would not be indicated. According to the American College of Radiology regarding indications for breast MRI:

"Lesion characterization - In rare cases, breast MRI may be indicated when other diagnostic imaging examinations, such as ultrasound and mammography (with or without tomosynthesis), and physical examination are inconclusive for the presence of breast cancer and biopsy cannot be performed (eg, possible architectural distortion on only one mammographic view without a sonographic correlate) [43-49]. MRI may also be considered when the clinical suspicion is very high and mammography and ultrasound are normal, such as bloody nipple discharge [50]. MRI should not precede or replace diagnostic mammography and ultrasound to evaluate clinical signs or symptoms in the breast or to evaluate lesions identified on screening mammography. 

...High-risk patients may be referred for annual screening breast MRI in addition to mammography, preferably after risk assessment and counseling either by personnel trained in the assessment of hereditary breast cancer or by a referring physician who has used a breast cancer risk assessment model. Although there is no direct evidence that MRI reduces mortality, supplementing annual screening with MRI facilitates early disease detection in high-risk patients "

In this case, the patient is not documented to be high risk for cancer. The MRI is ordered for surveillance of the left breast lesion rather than to evaluate the breast implants. Finally, there is no contraindication to biopsy.  The patient does not meet the American College of Radiology (ACR) guidelines for breast MRI.

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

The insurer's denial of coverage for breast magnetic resonance imaging (MRI) is upheld. Medical Necessity is not substantiated.