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

Diagnosis: Diverticulitis.

Treatment: Emergent hospital admission.

The insurer denied coverage for emergent hospital admission.

The denial is upheld. 

This female patient has a history of hypertension and diverticulitis.

Milliman Care Guidelines clinical indications for admission for Acute Diverticulitis (M-150) include hemodynamic instability, peritoneal signs, persistent gross bleeding, and a significant abnormality seen on imaging studies. This abnormality can be a fistula, obstruction, perforation, or abscess. The patient did not have these conditions. She also did not have severe vomiting that was unresponsive to antiemetic, severe dehydration or an inability to maintain oral hydration after observation care.

This patient had diverticulitis that was not complicated by an abscess or perforation. It could have been treated with a course of oral antibiotics as an outpatient. There was no need for a surgical intervention. She did not meet MCG criteria for admission for acute diverticulitis.

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 emergent hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastric Ulcer.

Treatment inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

The patient presented with dizziness and melena. In the emergency room she had a blood pressure of 77/54. The hemoglobin was 5.6. The blood urea nitrogen (BUN) was 76. The hemoglobin went up to 8.6 after transfusions. An endoscopy revealed a gastric ulcer that was treated with hemostatic clips. There was no further bleeding.

Milliman Care Guidelines (MCG) clinical indications for admission for upper GI (gastrointestinal) Bleeding (M-180) include hemodynamic instability and the presence of active bleeding. Peptic ulcer disease with high-risk endoscopic features, such as bleeding requiring endoscopic hemostasis therapy is also an indication for admission.
This patient had an endoscopy and a gastric ulcer with oozing hemorrhage was found. It required endoscopic hemostatic therapy. In view of the hypotension, severe anemia, and gastric ulcer that was actively, bleeding and required hemostatic therapy she met MCG criteria for admission for upper GI bleeding. 

The healthcare plan did not act with sound medical judgement. An inpatient admission was medically necessary. 

The insurer's denial of coverage for the inpatient hospital admission is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: inpatient hospital stay

The insurer denied coverage for inpatient hospital stay.

The denial is upheld.

This patient presented to the emergency department complaining of chest pain as well as shortness of breath.  The documentation indicated he also had left leg weakness since the prior morning.  The documentation does detail he has a history of hyperlipidemia, hypertension, and polysubstance abuse.  He does indicate he last utilized cocaine 3 months prior.  The physical examination revealed a temperature of 98.6 with blood pressure 142/81.  Respirations were 18 and oxygen saturation was 98% [percent].  The physical examination also revealed the patient was alert and oriented.  The recommendation was made for laboratory and diagnostic studies.  The patient had a blood urea nitrogen (BUN) of 26 and a negative troponin.  The patient also underwent a computed tomography (CT) scan of the head revealing no acute intracranial hemorrhage or mass-effect.  An electrocardiogram (EKG) revealed a normal sinus rhythm.  The physician detailed the patient passed a dysphagia screen.  He has mild left-sided weakness noted on ambulation.  He was not a tissue plasminogen activator (TPA) candidate due to the prolonged onset of symptoms in ambiguous symptoms.  He was diagnosed with a principal discharge diagnosis of acute coronary syndrome.  He was admitted for cardiac monitoring.  The documentation indicated he underwent a Neurology consultation who recommended he undergo additional imaging.  He continued treatment and the following day requested to be discharged against medical advice.

The patient presented to the hospital with chest pain with shortness of breath with left lower extremity weakness with examination showing mild left leg weakness noted on ambulating. Patient was admitted for cardiac monitoring and a neurology consultation was obtained who recommend additional diagnostic testing/imaging with initial CT of the Head demonstrating no acute changes/hemorrhage. Care provided could have been performed in the ED and at an observation level of care. Therefore, 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 hospital stay is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite.
Treatment: Full Braces, Pre-service.

The insurer denied the Full Braces, Pre-service.  The denial is overturned. 

The patient is a female.  The request is for dental benefits for orthodontic treatment (braces)/pre-service.  Dental clinical consultation was performed, orthodontic records were made; the patient needed restorative and hygiene dental work done prior to orthodontic treatment.

Orthodontic treatment was approved previously but approval had expired. Due to the COVID pandemic, the patient was unable to complete the necessary dental work and start orthodontic treatment before the approval expiration date.

The health plan denied the treatment on the current request because it was considered "not medically necessary" as the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) index as needed for treatment approval.  The provider's appeal is based on the presence of an anterior crossbite; this is an automatic qualifier per the Handicapping Labio-Lingual Deviation index guidelines.  Furthermore, the treatment was previously approved by the health plan and was never received.

Yes, the proposed treatment of orthodontic therapy is medically necessary.
As evident in the photos and as noted on the Handicapping Labio-Lingual Deviation (HLD) Index , the patient has an anterior crossbite (lower left mandibular incisor).  This crossbite can lead to serious problems with speech, chewing and the ability to maintain proper oral hygiene.  In the absence of corrective measures, the long term effects on the patient's overall dentition would be significantly impacted.

The long term prognosis of teeth that are in crossbite tends to worsen over time if corrective measures are not implemented.  As evident in the photos and as noted on the Handicapping Labio-Lingual Deviation (HLD) Index , the patient has an anterior crossbite (lower left mandibular incisor).  This crossbite can lead to serious problems with speech, chewing and the ability to maintain proper oral hygiene.

In addition, this orthodontic treatment was previously approved by the health plan, but it had expired before treatment could be started.  As noted in the initial clinical report, there were prerequisite dental treatments needed prior to the commencement of orthodontic treatment; these were not completed on time due to the COVID pandemic.  The COVID pandemic had closed all non-essential businesses and non-emergency medical care.  It is reasonable to make adjustments in deadlines for services that were affected.  There is no information stating that the health plan criteria had material changes or that the patient's condition had a spontaneous dramatic correction that would deem the proposed orthodontic treatment to be unnecessary.  Therefore, the initial treatment approved by the health plan should still be the corrective measure of care employed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lumbar Radiculopathy
Treatment: Pain Management (injection 62323 x 1)
The insurer denied the pain management (injection 62323 x 1).
The denial is overturned.

The patient is a female with lumbar radiculopathy. She has previously had ESIs (epidural steroid injections) with greater than 85% relief for 4.5 months with each injection. Her last injection was over six months ago. She has had six weeks of return of pain. She has failed conservative treatment. She had PE (physical examination) findings consistent with radiculopathy. This correlates to her MRI (magnetic resonance imaging) findings.

Yes, the requested injection (62323 times [x] 1) is medically necessary.

This approach is consistent with the guidelines set forth by the American Society of Interventional Pain Physicians (ASIPP). [1] They recommend in the therapeutic phase (after the diagnostic phase is completed, which is the case here), the suggested frequency of interventional techniques should be two months or longer between each injection, provided that greater than (>) 50% relief is obtained for two months. Again this is demonstrated in the attached notes. Given that the options, such as surgery or spinal cord stimulation, are more invasive, and do not offer any guarantees, and given that the patient has failed conservative treatment, and has had 85% relief for over 4.5 months each time, the requested ESI (epidural steroid injection) is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and nausea. 
Treatment: Hospital admission. 

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

This female patient has a history of anemia, morbid obesity, migraines, and lumbar disc disease.

Milliman Care Guidelines (MCG) M-570 lists clinical indications for admission for Liver Disease Complications. These include hepatic encephalopathy, hemodynamic instability, peritonitis, a severe coagulopathy, hepatorenal syndrome, severe dehydration, and acute liver necrosis. The patient did not have these conditions. 

This patient required a workup for a hepatic mass that was causing bile duct dilatation. There was no evidence of sepsis or acute liver failure. There was a concern about a malignancy, but the workup could have been done on an outpatient basis. She did not meet MCG criteria for admission for liver disease complications. 

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 hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulosis.
Treatment: Inpatient hospital admission.

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

This male patient has a history of diverticulitis and diabetes.

Milliman Care Guidelines (MCG) clinical indications for admission for Lower Gastrointestinal Bleeding (M-182) include hemodynamic instability, ongoing active bleeding, failure to control bleeding after a colonoscopy, severe coagulopathy severe anemia, peritoneal signs, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had Lower Gastrointestinal (GI) bleeding. The hemoglobin remained stable, and the colonoscopy did not show active bleeding. He could have had the colonoscopy performed with observation status. He did not meet MCG criteria for admission for lower gastrointestinal bleeding.

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 hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee injury.
Treatment: Knee surgery.
The insurer denied Knee surgery. 
The health plan's determination is upheld. 

This case describes a male who sustained a right knee injury as a result of a motorcycle accident. A magnetic resonance imaging (MRI) scan was obtained which confirmed a posterior cruciate ligament tear and a possible tear of the lateral meniscus. Due to persistent pain and instability, the patient opted to undergo arthroscopically assisted posterior cruciate ligament (PCL) reconstruction. The treating physician also noted hypertrophic synovium at the time of the operation and performed synovectomy on medial side of the patellofemoral joint.

The Right Knee Surgery [Procedure to Repair a Structure that Connects Bone-to-Bone Outside of Knee (Collateral Ligament)] performed for this patient was not medically necessary. This determination is based upon the documentation in the provided medical records and the recommendations of the peer-reviewed literature. 
First, the provided records include a magnetic resonance imaging (MRI) scan obtained for this patient's right knee injury. There is no evidence of synovitis documented on the right knee MRI scan. In addition, there is no documentation of any clinical exam findings consistent with right knee synovitis. There is also no history of rheumatoid arthritis of pigmented villinodular synovitis in this patient's medical history for which an arthroscopic synovectomy would be indicated. Thus, the provided records do not justify the medical necessity of the requested procedure.
Second, the peer-reviewed literature, including articles by Triolo and colleagues and by Keyhani and associates document the efficacy of arthroscopic knee synovectomy for both rheumatoid arthritis and diffuse pigmented villinodular synovitis respectively. The records, however, do not document that either of these two diagnoses were present in this patient's right knee.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low muscle tone.
Treatment: Occupational Therapy.
The insurer denied the Occupational Therapy.
The denial is overturned.

The patient is a male child with history of feeding difficulties and diagnosis of low muscle tone of unknown etiology. He was referred for Occupational Therapy evaluation three years prior, at which time his mother had concerns about independence in self-help skills and ability to progress academically, socially, emotionally, and behaviorally. Historically, he had difficulty navigating his environment, with challenges in coordination. The Miller Function and Participation Scales (M-Fun) was administered to evaluate his abilities and level of functioning. He was willing to attempt all tasks but had difficulty when presented with a challenge. He required multiple verbal, visual, and tactile prompts to understand and follow through with instructions. He became progressively more fatigued during seated activities. Both test observations and home observations placed him far below average with participation. His visual motor and fine motor skills were noted to be borderline to mildly deficient and his gross motor skills were noted to be moderately deficient. He had some difficulty with bilateral motor integration as well as ocular motor skills. Based on his assessment, occupational therapy services twice weekly were recommended to address postural strengthening, endurance, body control, ocular motor skills, eye-hand coordination, and self-care tasks.

Yes, based on the occupational therapy evaluation performed, therapeutic services were medically necessary and appropriate for the period of time in question.

This school-aged boy underwent occupational therapy evaluation as a younger child because of concerns with poor strength and coordination. He had been evaluated for low muscle tone and no underlying cause was identified. However, comprehensive occupational therapy evaluation revealed deficits in strength, endurance, eye-hand coordination, self-care, and overall body control. With its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills, processing information, and regulating the response to incoming information, occupational therapy is well suited to address this child's issues and facilitate development of age-appropriate functional skills. The requested services were medically necessary and appropriate, consistent with the standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Otitis media, conductive hearing loss, speech apraxia, ankyloglossia.
Treatment: Intensive Feeding / Speech Therapy.
The insurer denied the Intensive Feeding / Speech Therapy.
The denial is overturned. 

The patient is a male child with medical history significant for serous otitis media, conductive hearing loss, and resultant speech and language difficulties, necessitating placement of tympanostomy tubes. He participated in speech and language therapy and was eventually given a diagnosis of speech apraxia. He concurrently was noted to have difficulties with feeding including frequent gagging and resistance to taking a first bit. He was noted upon evaluation to have weak oral musculature, as well as low facial tone, saliva loss, and difficulties with mastication, bolus management, and tongue movements. He was also eventually diagnosed with ankyloglossia. He has been referred for feeding therapy by multiple professionals to address his feeding difficulties.

Yes, the requested feeding/speech therapy was medically necessary and appropriate.
A feeding disorder is an inability to consume adequate and appropriate nutrition by mouth. While feeding disorders may ultimately lead to eating disorders, they are not the same. Feeding disorder symptoms include inadequate fluid intake, food refusal, difficulty swallowing, inability to feed oneself, prolonged feeding time, choking or gagging and emesis, inappropriate mealtime behaviors and selecting food by its type or texture. About 25 percent of all children, and up to 80 percent of developmentally disabled children, exhibit feeding disorders. Severe and persistent feeding disorders occur in three to ten percent of children, particularly those with chronic conditions. The etiology of feeding disorders is multifactorial, and includes medical, nutritional, behavioral, psychological and environmental factors. If not dealt with appropriately, feeding disorders can lead to cognitive decline, malnutrition, growth retardation, increased susceptibility to illness and even death. 

This child presented at a young age with chronic otitis media with effusion and hearing loss requiring tympanostomy tube placement and extensive speech and language therapy. He was also noted to have difficulties with feeding, particularly with gagging and inability to initiate feeding. This is consistent with a feeding disorder, likely with both organic (chronic otitis media with effusion), anatomic (ankylosglossia), neurologic (poor muscle tone and difficulty with mastication), and behavioral components. The requested intensive feeding therapy concurrent with speech therapy provided was medically necessary and appropriate to address his complex deficits and prevent further patient morbidity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological-laparoscopic Hysterectomy
Treatment: Inpatient hospital stay
The insurer denied inpatient stay as not medically necessary. 
The health plan's denial is upheld in whole.

The patient is a female presenting with pelvic pain. She underwent a laparoscopic hysterectomy and was discharged to home the next day.

The requested health service is not medically necessary. The patient had an uncomplicated surgery, did not require conversion to laparotomy and was able to ambulate, void and take oral intake and an oral diet after surgery. She had a non-focal exam and did not have any conditions that would have rendered inpatient level of care medically necessary. She would have been appropriate for a lower level of care. Inpatient level of care is not supported by peer reviewed literature, it is not standard of care, and it is not supported by professional organizations.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: prostate cancer
Treatment: SBRT (Stereotactic Body Radiation Therapy) 
The insurer denied SBRT. The health plan's determination is upheld.

This is the case of a male who presented with prostate cancer with pelvic and retroperitoneal metastasis to the level below renal vein and iliac bone metastasis. He was enrolled in protocol. He was treated with SBRT (Stereotactic Body Radiation Therapy) to inferior pubic rami as part of the protocol. The SBRT is the subject of review.

Stereotactic Body Radiation Therapy (SBRT) is not medically necessary for this patient. Medically necessary treatment is defined as those treatments which are in accordance with generally accepted standards of medical practice in the United States.
SBRT for this patient is not generally accepted as a standard of medical practice in the United States. There is no published literature for SBRT for this patient. The standard treatment for this patient would be with hormone therapy and/or systemic chemotherapy followed by palliative RT (radiation therapy).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative Rectosigmoiditis
Treatment: Mesalamine DR 1.2 GM DR TAB (two times a day), Pre-service
The insurer denied the Mesalamine DR 1.2 GM DR TAB (two times a day), Pre-service.
The denial is upheld. 

The patient is a female patient who has a history of ulcerative colitis. The patient also has a history of anxiety and alcoholism. The patient was initially started on Lialda and responded well.  She was then later treated with mesalamine enemas and responded well.  She was later treated with Humira and eventually received weekly dosing. The patient was noted to be doing well with the Humira as well as mesalamine 1.2 grams, two doses, twice daily. The provider has requested continuation of her current therapy.  The plan denied this request as the patient had not tried and failed Apriso, Balsalazide, or sulfasalazine prior to consideration of mesalamine oral.

No, the proposed treatment with mesalamine is not medically necessary.
While the treatment is medically appropriate, the use of mesalamine 1.2 grams DR is not medically necessary. There is no cogent medical information as to why the patient cannot use Apriso, which is also mesalamine, or the other plan formulary accepted medications.

The plan acted appropriately with sound medical judgement and in the patient's best interest as there is no medical literature that prefers mesalamine 1.2 g DR over Apriso for the treatment of ulcerative colitis.