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

Diagnosis: Tooth Agenesis

Treatment: Dental implant placements on Tooth 2, Tooth 3, Tooth 4, Tooth 5, Tooth 6, Tooth 7, Tooth 8, Tooth 9, Tooth 10, Tooth 11, Tooth 12, Tooth 13, Tooth 14, Tooth 15, Tooth 18, Tooth 19, Tooth 29, Tooth 30, and Tooth 31

The insurer denied coverage for dental implant placements on Tooth 2, Tooth 3, Tooth 4, Tooth 5, Tooth 6, Tooth 7, Tooth 8, Tooth 9, Tooth 10, Tooth 11, Tooth 12, Tooth 13, Tooth 14, Tooth 15, Tooth 18, Tooth 19, Tooth 29, Tooth 30, and Tooth 31.

The denial is upheld.

This is a female with no documented history. She presented to the Dentist's office for an evaluation. X-rays were taken. The treating dentist determined that the patient needed dental implant placements on Tooth 2, Tooth 3, Tooth 4, Tooth 5, Tooth 6, Tooth 7, Tooth 8, Tooth 9, Tooth 10, Tooth 11, Tooth 12, Tooth 13, Tooth 14, Tooth 15, Tooth 18, Tooth 19, Tooth 29, Tooth 30, and Tooth 31.

The insurer states that endosteal implants are not the only appropriate treatment and are only covered when there is a medical condition that will be alleviated by implants. They also noted the patient had within the prior 60 months received a partial denture.

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in both the maxilla (edentulous) and mandible. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, alternative appropriate treatment would include conventional removable dentures. Further the documentation provided does not support, justify, or substantiate the requested treatment. Therefore, as removable denture (complete and partial) remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use or manipulation of partial dentures, the endosteal implants are considered elective and not medically necessary.

Based on the above, the medical necessity for the aforementioned endosteal implants is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal Cancer

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.	

The denial is upheld.

The patient had rectal cancer and had a resection 3 weeks earlier. She had high ostomy outputs and was found to be dehydrated. She had a blood pressure of 79/52 and a pulse of 106. However, after IV (intravenous) hydration the blood pressure improved to 106/69 and the pulse was 90. There was no abdominal rebound or guarding. The blood urea nitrogen (BUN) was 36 and the creatinine 0.78. lmodium was ordered. She was able to tolerate a diet. She was given Bactrim for a urinary tract infection (UTI). The renal function improved.

Clinical indications for admission for Dehydration (MCG (Milliman Care Guidelines) M-123) include hemodynamic instability. This is defined as a vital sign abnormality that persists despite appropriate treatment. In this case, the blood pressure and pulse improved with the IV hydration. Other indications include severe vomiting, altered mental status, severe electrolyte abnormalities, and acute renal failure as manifested by a 3-fold increase in the serum creatinine. The patient did not have these conditions.

This patient developed dehydration from a high ostomy output. She required IV hydration and was also given imodium. She responded well to this treatment and her renal function improved. However, she was stable to have been given the IV hydration with observation status. She did not meet MCG criteria for admission for Dehydration. The health care plan acted reasonably and with sound medical judgement. An inpatient hospitalization was 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 the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: headache

Treatment: Ubrelvy

The insurer is denied coverage for Ubrelvy.

The denial is upheld. 

This female patient has a history of gastroesophageal reflux disease (GERD), hyperthyroidism, migraines, and gastric ulcers.

All the formulary options (class) except for Nurtec have been tried without success. Alternate option of Nurtec ODT (one dose treatment) is a viable option that would not have the concerns listed with tachycardia (Triptans) and/or anti-inflammatory properties. Nurtec and ubrelvy are both calcitonin gene-related peptide (CGRP). This is an appropriate choice. There is no evidence to suggest improved effectiveness of Ubrelvy over Nurtec.

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 Ubrelvy is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical services. 
The insurer denied: joint surgery (total knee replacement). 
The health plans determination is overturned in whole. 

The patient is a male with a complaint of right knee pain. He failed conservative treatment for his knee pain and opted to undergo right total knee replacement surgery. The records document that he attempted oral non-steroidal anti-inflammatory drugs (NSAIDs), Tylenol, activity modification, and an aspiration and cortisone injection prior to surgery without relief of his pain. The patient's health plan denied the surgery with a determination that the operation was not medically necessary. At issue in this case is the medical necessity of the total knee replacement surgery. The health plan's determination of medical necessity is overturned in whole. 

The rationale for this determination is based upon the provided medical records and the recommendations of the current, peer-reviewed orthopedic literature. First, the provided records document that this patient attempted reasonable conservative management of his persistent right knee pain from osteoarthritis with oral medications, activity modification, and injections prior to the total knee replacement surgery. Based on the documentation in his records, the medical necessity for the total knee replacement was established for this patient. The plain radiographs and pre-operative computed tomography (CT) scan of this patient's right knee confirmed advanced arthritic changes in the knee with sub-chondral sclerosis, joint space narrowing and osteophyte formation. This is clearly documented in the progress notes and therefore, the medical necessity of the total knee replacement is established based on the records. In addition, the patient meets the evidence based treatment guidelines for total knee replacement surgery based upon the literature published by Christensen and colleagues in The Journal of the American Academy of Orthopedic Surgeons in 2020.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overjet, overbite, and anterior crowding.

Treatment comprehensive orthodontic treatment of adolescent dentition and periodic orthodontic treatment visit.

The insurer denied coverage for comprehensive orthodontic treatment of adolescent dentition and periodic orthodontic treatment visit.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite, and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-lingual Deviation (HLD) index attaining 26 total points 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 having attained a score of 15 points on the HLD index. 

It is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist does not claim an automatic qualifying condition
and completes the second portion of the index arriving at 26 points to justify orthodontic care.  

This reviewer concurs with the index completed by the insurer attaining a total of
15 points on the HLD index (5 overjet, 3 overbite, 5 anterior crowding, 2 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

Regarding the validity of the HLD, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies.

The clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval. The health plan acted reasonably.

Based on the above, the medical necessity for the comprehensive orthodontic treatment of adolescent dentition and periodic orthodontic treatment visit is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Partial Dentures

Treatment dental implants for teeth 3, 13, 14, 15, 18, 19, 20, 21, 22, 23, 26, 27, 28, 29, 30 and 31 (codes D6010 and D7140)

The insurer denied coverage for dental implants for teeth 3, 13, 14, 15, 18, 19, 20, 21, 22, 23, 26, 27, 28, 29, 30 and 31 (codes D6010 and D7140).

The denial is upheld.

Based on review of the submitted documentation which includes copies of panoramic radiograph in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants and associated services for teeth areas in multiple areas of the maxilla and mandible as enumerated above. The dentist is requesting implants over removable partial dentures. The insurer has denied the aforementioned services stating that in their estimation endosteal implants are not the only appropriate treatment, and implant services are only covered when there is a documented medical condition that will be alleviated by the implants. The insurer states that the medical records received do not demonstrate such a condition and therefore the endosteal implants and related services are considered not medically necessary, considered elective and therefore no benefit is available.  

Upon review of the objective documentation which primarily consists of panoramic radiograph, the patient exhibits oligodontia in both the maxilla and mandible, with numerous restored endosseous implants already in place in the maxilla. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, as in this patient who already has several maxillary implants, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include conventional removable dentures. Further the documentation provided does not support, justify or substantiate the requested treatment. 

Therefore, as removable dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use or manipulation of partial dentures, the endosteal implants are considered elective and not medically necessary.

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

The insurers denial of coverage for the dental implants for teeth 3, 13, 14, 15, 18, 19, 20, 21, 22, 23, 26, 27, 28, 29, 30 and 31(codes D6010 and D7140) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Asthma Exacerbation and Breakthrough Seizure.

Treatment: inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is modified.

The patient has a history of chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP), diabetes mellitus (DM), hypertension (HTN), Seizure Disorder who presented to the emergency department (ED) with complaint of shortness of breath (SOB) and some chest tightness. The patient was noted to be wheezing so was administered breathing treatments on the way to the hospital.  Labs revealed white blood count (WBC) was 9.8. The patient was hypomagnesemic to less than 1. Electrocardiogram (EKG) revealed prolonged QTc (interval on EKG). The patient had a seizure while in the ED. No tongue bite or injury. No loss of consciousness (LOC). The patient had a head computed tomography (CT) which was unremarkable. Neurology was consulted. The patient was loaded with Keppra and started back on oral Keppra bid [twice daily].

The patient was admitted to the hospital for asthma exacerbation and breakthrough seizure.

Chest x-ray did not reveal any pneumonia. The patient was given IV (intravenous) magnesium. Treatment for asthma continued with steroids, bronchodilators (BD) and PO [oral] antibiotics. Pulmonary recommended to taper steroids.

Vital signs in the emergency department were temperature 98.2, heart rate 108, respiratory rate 28, blood pressure BP (blood pressure) 128/86 and oxygen saturation 95% (percent). The patient was using accessory muscles. The lung exam revealed bilateral wheezes. Peak expiratory flow (PEF) was 150. The patient was started on intravenous (IV) steroids, bronchodilator.

Given the patient multiple comorbid diagnoses admission for evaluation and treatment was medically necessary. However, two days later from admission date, the patient was feeling much improved, was afebrile and hemodynamically stable with no further seizures. The patient was alert and oriented with non-focal neurological exam. Peak Expiratory Flow (PEF) up to 300. Lungs were clear. Arterial blood gases were unremarkable and there was no CO2 (carbon dioxide) retention.  The patient was on oral seizure meds. She has been evaluated by Pulmonary and Neurology; at that point she did not need further inpatient stay.

The health plan acted reasonably in part with regard to the length of stay but not the admission. 

Based on the above, the medical necessity for the inpatient hospital admission partially substantiated. The insurer's denial is modified.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Obstructive Pulmonary Disease Exacerbation.

Treatment: inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient has a history of asthma and presented to the emergency department with complaints of shortness of breath as for the patient she took her albuterol but it did not get her much relief so she presented to the emergency department.  Vital signs on presentation were temperature 98.4, respiratory rate 20, blood pressure 132 / 86, heart rate 100, and oxygen saturation was 93% (percent). The patient had bilateral wheezes noted on lung exam peak expiratory flow (PEF) was 200, white blood count was 10.2, hemoglobin was 12.8, electrolytes were within normal limits, and influenza screen was negative. The patient was treated with intravenous steroids, bronchodilators, and intravenous Ivy fluids and azithromycin were given. The patient was placed briefly on BIPAP (Bilevel positive airway pressure).  The patient did not tolerate BIPAP so it was switched to oxygen via nasal cannula 4 liters with oxygen saturation's at 98%.  The patient had a chest X ray which did not reveal any acute changes. A computed tomography of the chest was done which revealed some faint ground glass opacities and questionable atypical pneumonia versus viral pneumonia.  The patient was admitted for Asthma / chronic obstructive pulmonary disease exacerbation. The patient was treated with Steroids, Xoponex, oral Singulair and Doxy and Intravenous Ceftriaxone. The patient was improving on above treatment.

The patient was found to be smoking in her room and was advised not to do so. She however refused to comply with instructions and decided to sign out against medical advice.  The patient was saturating to 96% on room air.

This patient did not need acute inpatient hospitalization. She could have been placed in observation status while diagnostic testing and treatment were initiated. The patient was responding to treatment in emergency department and remained afebrile and hemodynamically (HD) stable. PEF at admission was 200. Best 270. The patient was tolerating oral. The patient was on BIPAP for a very short time and did not tolerate it so was switched to nasal cannula. The patient remained afebrile and HD stable after admission.

The patient could have been placed in Observation status which could be for up to 48 hrs. She could have been discharged on oral meds once improved.

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: difficulty with the partials.

Treatment: D6010 surgical placement of implant body: endosteal implant.

The insurer is denied coverage for D6010 surgical placement of implant body: endosteal implant.

The denial is upheld. 

This male patient has a history of difficulty with the partials, to speak (dysphagia), and nausea (gag reflex).

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in both the maxilla and mandible. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, as in this patient who already has 2 maxillary implants placed in the maxilla, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include conventional removable dentures, which the patient already has. Further the documentation provided does not support, justify or substantiate the requested treatment.  Therefore, as removable dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use or manipulation of partial dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary.
Uphold denial of coverage for dental implants as not medically necessary, as an appropriate alternative standard of care treatment would be conventional removable dentures and the medical documentation provided does not substantiate a limitation that would  preclude his using removable partial dentures. Therefore, as other acceptable alternative treatments are appropriate, and the documentation provided does not support the recommended treatment this renders the endosteal implants and associated services not medically necessary.

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 D6010 surgical placement of implant body: endosteal implant is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rhabodomyolysis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He was admitted for altered mental status and was found to have rhabodomyolysis.

The patient was started on intravenous fluid. He underwent abdominal ultrasound for elevated liver enzymes, and it showed fatty liver. He was started on Suboxone for history of drug abuse. He was able to tolerate an oral diet well, and he was discharged in stable condition.

No, the Inpatient admission was not medically necessary.
The patient was hemodynamically stable, with normal oxygenation and negative cultures. He did not have significant electrolytes disturbance or change in kidney function. He did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration, no documentation of refractory pain. He was able to tolerate oral diet and did not require total parenteral nutrition. His condition responded to intravenous fluid within 48 hours.

There is no evidence-based literature supporting that inpatient level of care was medically necessary in this patient's case. His condition could have been treated safely under a lower level of care.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
A lower level of care was appropriate for this patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal Bleeding.

Treatment: inpatient admission.

The insurer denied coverage for inpatient admission.
The denial is upheld.

The patient had a history of rectal bleeding and presented with leg pain. He was afebrile but had hypertension. He was scheduled to have a colonoscopy as an outpatient but did not go for the appointment. The abdominal exam was benign. The hemoglobin was 14.1. He was diagnosed with leg claudication and neuropathic pain from diabetes and treated with gabapentin. The hemoglobin remained stable, and he was referred back for an outpatient colonoscopy. His glucose was also poorly controlled, and his diabetes regimen was adjusted. 

Clinical indications for admission for Lower Gastrointestinal Bleeding, Milliman Care Guideline (MCG) M-182 include hemodynamic instability, ongoing active bleeding, failure to control bleeding after a colonoscopy, severe coagulopathy, severe anemia, and severe pain. The patient did not have these conditions.

This patient had rectal bleeding but was not actively bleeding and was not anemic. The hemoglobin remained stable, and he was stable for an outpatient colonoscopy. The vascular surgeon advised that the leg pains could be managed as an outpatient. The gabapentin could also have been given as an outpatient. The diabetes was also poorly controlled but was amenable to outpatient management. The patient did not meet MCG criteria for admission for Lower Gastrointestinal Bleeding. 

The health care plan acted reasonably and with sound medical judgement. An inpatient admission was not medically necessary.

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