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

Diagnosis: peripheral vascular disease
treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a man who was admitted to the hospital. He had a history of hypertension, hyperlipidemia, gunshot wound to the abdomen and chest and radiculopathy. He presented with worsening numbness and tingling in the lower extremities, left worse than right, over the past three hours. He denied chest pain, shortness of breath, headache, fevers and chills. It was noted that he had a history of chronic peripheral vascular disease based on imaging at an outside hospital. On physical exam, the bilateral straight leg raise was positive but there were no focal neurologic deficits. Strength and sensation were equal bilaterally. Heart was regular and breath sounds were normal. Vital signs showed blood pressure 121/54, temperature 97.1 Fahrenheit, heart rate 104, and respiratory rate 18. Labs showed lactate 5.1, creatinine 2.7, Hemoglobin 12.3, platelets 215, sodium 138, and potassium 4.9. A computed tomography (CT) imaging demonstrated chronic aortic occlusion at the level of the renal arteries. The patient was admitted for acute on chronic bilateral lower extremity PVD (peripheral vascular disease), acute kidney injury and lactic acidosis. The plan of care included vascular surgery admission, consideration of vascular intervention, aspirin, Statin, cardiology consult, incentive spirometry, heparin drip, monitor kidney function, and additional lower extremity imaging. 

The inpatient hospital admission was medically necessary. The patient was clinically unstable at the time of presentation with acute on chronic peripheral vascular disease and, while there was no plan initially to perform an acute intervention during the hospital stay, there was concern for worsening ischemia, worsening acute kidney injury, and worsening lactic acidosis. He did receive a preoperative evaluation but also required additional care for peripheral vascular disease and hypertensive urgency. Because of his comorbidities and complicating signs and symptoms, it was reasonable to manage this patient at the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied comprehensive and periodic orthodontic treatment for medical necessity. 
The denial was overturned. 

The patient is a female with an anterior crossbite on teeth 7 and 11. She presents with a skeletal Class I malocclusion with spacing in the maxilla and mandible. She has treatment planned for orthodontics to address the spacing and crossbite.
At issue is the medical necessity of comprehensive and periodic orthodontic treatment.

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

The requested health service/treatment of comprehensive and periodic orthodontic treatment is medically necessary for this patient.
This patient presents with anterior crossbites on teeth 7 and 11. The side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. If left untreated the damage that will occur to the patient's teeth will be more time consuming to correct than the patient's existing orthodontic problem. The orthodontic treatment is medically necessary.
Therefore, the requested health treatment of comprehensive and periodic orthodontic treatment is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems/Other/ Malocclusion
Treatment: Orthodontic Procedure/Braces and monthly visits
The health plan denied the requested dental treatment plan as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with an anterior crossbite on tooth 10. Tooth 22 is completely blocked out of the arch to the labial. She presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and severe crowding in the mandible. She is treatment planned for 30-36 months of orthodontics with extraction of first premolars to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity.
At issue is the medical necessity of the requested dental treatment plan.

I overturn, in whole, the health plan's determination of medical necessity.

This patient presents with an anterior crossbite on tooth 10, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.1,2,3.
Teeth 10 and 22 are not currently touching, but when 10 erupts fully it will be in a traumatic crossbite with 22. If not corrected before this happens the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. Orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class III skeletal relationship (hypoplastic maxilla); right posterior crossbite and a right anterior crossbite (mandibular right lateral incisor).
Treatment: D8080 Braces and D8670 Monthly Visit x12.
The insurer denied the D8080 Braces and D8670 Monthly Visit x12.
The denial is overturned.

The patient is a female.  The request is for dental benefits for orthodontic therapy (braces) and monthly visits.  X-rays and photos were taken.  The patient exhibits a Class III skeletal relationship (hypoplastic maxilla); the maxilla has not grown to its regular size; typically it would be slightly longer than the mandible, so that the maxillary front teeth sit just slightly ahead of the mandibular front teeth.

The patient has moderate crowding in the maxilla and mild crowding in the mandible.  The patient has a right posterior crossbite and a right anterior crossbite (mandibular right lateral incisor).  The patient was advised that this treatment will not correct the skeletal jaw relationship; she may need possible future surgical intervention based on her jaw growth in the next two years.

The Health Plan has denied the claim because the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) Index as required for approval.  The Provider is appealing the decision because he states that the Health plan did not consider the patient's crossbite condition.

Yes, the proposed treatment of orthodontic therapy and monthly visits are medically necessary.
The patient has a substantial posterior and anterior crossbite that is evident in the photos. A crossbite is when the mandibular (lower) teeth sit outside the corresponding maxillary (Upper ) teeth - this is the opposite of what the normal relationship should be.
This degree of misalignment can cause difficulty with chewing and speech; it can also lead to difficulty with maintaining proper oral hygiene and possibly development of gum disease over a period of time.

The provider made the appeal because the crossbite was not considered. The claim was denied on the basis of the patient not scoring a 26 on the Handicapping Labio-Lingual Deviation (HLD) index.  According to the instruction on the index, if a patient has an anterior crossbite, it is to be noted and this is an automatic qualifier for treatment. Failure to treat this crossbite condition causes difficulty with normal function and can lead to progressive gum disease that can compromise the patient's overall oral health.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever and Leg Cramps. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female with hypertension, hyperlipidemia, type 2 diabetes and hypothyroidism. She presented with complaints of fever, myalgias, nausea, and vomiting. 

The patient was diagnosed with pyelonephritis and hyperglycemia. Her vitals were as follows: T (temperature) 98.6, HR (heart rate) 82, RR (respiration rate) 22, BP (blood pressure) 109/57. She was alert and oriented. Her glucose was 320 mg/dL (milligrams per deciliter). Her CO2 (carbon dioxide) was 25. Her potassium was 5.2. Her urinalysis was positive for glucose, nitrite, leukocyte esterase, and bacteria. She was treated with intravenous fluids and ceftriaxone. Inpatient stay is the topic of this review. 

No, the inpatient admission was not medically necessary. 

This patient was diagnosed with a urinary tract infection and hyperglycemia in the setting of known diabetes. She did not have signs of sepsis. She was afebrile at the time of presentation. She was hemodynamically stable. She had hyperglycemia in the setting of known type 2 diabetes after not taking her medication the day prior. She did not have acidosis to support a diagnosis of diabetic ketoacidosis or altered mental status to support a diagnosis of hyperosmolar hyperglycemic syndrome. The documentation does not indicate that she tried and failed a lower level of care. Therefore, the proposed inpatient stay was not medically necessary. 

The submitted documentation do not support the requested inpatient stay, which was appropriately denied. Therefore, yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Radiculopathy of Lumbosacral Region

Treatment: an Implanted Electrical stimulator, code 63650

The insurer denied coverage for an Implanted Electrical stimulator, code 63650

The denial is upheld

This is a female with a history of degenerative disc disease, chronic pain syndrome, radiculopathy of lumbosacral region, and hypertension. The patient has been seen by multiple providers for back pain and has failed conservative measures. The patient has not had any surgical procedures or intra-thecal medications. The patient does not have an evidence-based indication for a spinal cord stimulator trial.

Dones et al.(1) conducted a systematic review of the indications for spinal cord stimulator trials and concluded: "To date, however, there are only two clinical pain syndromes that clearly benefit from spinal cord stimulator treatment: the failed back surgery syndrome (FBSS) and type 1 and 2 of the complex regional pain syndrome (CRPS)." Other indications with less robust support include post herpetic neuralgia, angina pectoris, phantom limb pain and critical limb ischemia. This patient has none of these problems.

Similarly, Rock et al.(2) reviewed the literature and came to a similar conclusion.
	
UpToDate notes that spinal cord stimulator is an option in patients with persistent pain following surgery. However, "no randomized trials have evaluated spinal cord stimulator for low back pain not associated with prior surgery." 

There are other evidence based modalities available for this patient. This procedure is 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 an Implanted Electrical Stimulator, code 63650 is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Generalized weakness.
Treatment: Continued inpatient rehabilitation services.
The insurer denied coverage for the continued inpatient rehabilitation services.
The denial is upheld. 

This is a female patient with chronic medical problems including chronic obstructive pulmonary disease (COPD), alcoholic polyneuropathy and liver cirrhosis. She was admitted to a skilled nursing facility for subacute rehabilitation due to generalized weakness. Under review is the medical necessity of continued inpatient rehabilitation services.

The patient was initially an appropriate candidate for subacute rehabilitation at the skilled nursing facility. However, for the dates of service under review, the patient was at a physical functional level rendering her appropriate for a lower level of care. The patient was "(Modified) independent bed transfers, supervision ambulation 125 feet with walker, independent wheelchair level bathing/dressing, (modified) independent wheelchair level (and) supervision walker level bathing/dressing." In addition, there were no documented acute medical or complicated nursing issues necessitating continued inpatient rehabilitation.  

The health plan acted reasonably, with medical judgment and in the best interest of the patient in this case. From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued inpatient rehabilitation services were not medically necessary.

The insurer's denial of coverage for the continued inpatient rehabilitation services is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with end stage renal disease, hypertension, HIV (human immunodeficiency virus), poor medical compliance. He was admitted with shortness of breath. The patient had missed prior dialysis. He presented to the hospital with shortness of breath with stigmata of volume overload and also noted with hyperkalemia.

The patient underwent urgent dialysis with ultrafiltration. He was seen by infectious disease team, and PCP (pneumocystis pneumonia) pneumonia was ruled out. The patient was seen by Cardiology without plan for further inpatient workup. Shortness of breath was stabilized with dialysis with subsequent discharge.

No, the Inpatient admission was not medically necessary.
Based on available data, there is no documentation of altered mental status, hemodynamic instability, severe hypertension, cardiac arrhythmias of immediate concern, or significant respiratory findings that were severe or persist despite observation care treatment. There is no documentation of clinically significant electrolyte abnormality or metabolic abnormality that was severe or persisted despite outpatient or observation care treatment, acute treatment of renal failure (eg, dialysis) not feasible or appropriate in observational care setting, other diagnosis requiring inpatient care, other significant finding or clinical condition judged not to be within scope of observation care.   Inpatient level of care was not medically necessary, as the patient could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right ankle trimalleolar fracture dislocation and displaced intraarticular right calcaneus fracture. 

Treatment: Ambulance service, basic life support, non-emergency transport (code A0428) and ground mileage, per statue mile (code A0425). 

The insurer denied coverage for ambulance service, basic life support, non-emergency transport (code A0428) and ground mileage, per statue mile (code A0425). 

The denial is overturned. 

This is a female patient with a history of osteoarthritis, migraines, Raynaud's disease and asthma. The patient suffered a right ankle trimalleolar fracture dislocation and displaced intraarticular right calcaneus fracture following a fall from a ladder. 

The patient underwent open reduction internal fixation (ORIF) for the right ankle trimalleolar fracture at a hospital and was then transported to a rehabilitation facility. Approximately 2 weeks later, she was transferred back to the hospital to undergo ORIF for the intra-articular displaced fracture of the right calcaneus. The patient was then transported from the hospital to the rehabilitation facility via non-emergency ambulance transportation. 
 
The records show the patient underwent a complex and extensive surgical procedure. It would be essential to keep the extremity elevated after the procedure. She should not be transported in the seated position. There is likelihood of swelling which could compromise the surgical result. The service would be medically necessary. Transportation by any other means would not be appropriate. 

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

The insurer's denial of coverage for ambulance service, basic life support, non-emergency transport (code A0428) and ground mileage, per statue mile (code A0425) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who was seen in follow-up for headaches.  He had a history of a traumatic brain injury that required cognitive therapy, ocular therapy and vestibular therapy.  He was on nortriptyline with improvement in memory loss, mood problems and imbalance.  Headaches were being treated with candesartan.  He was prescribed Prozac and oxcarbazepine for mood stabilization.  The headaches became worse in 2016 when he tried to taper off on nortriptyline and then candesartan.  It was noted that since  2018 he had only 4 to 5 migraines and had Botox injections since 2018 that were helping him.  He noted tension type headaches and difficulty with memory and cognition especially short-term memory.  His migraines were noted to be occurring once or twice per month at that time and his memory had improved since stopping carbamazepine.  Other pertinent medications were Botox, melatonin, nortriptyline 75 milligrams (mg) at bedtime, Imitrex nasal spray and candesartan.  Examination revealed gaze evoked horizontal nystagmus bilaterally, weakness of the right shoulder due to shoulder surgery and normal general appearance, cortical function, voluntary movement, sensory, cerebellar, coordination, reflex and gait examinations.  Diagnoses are common with intractable migraine and intractable chronic migraine without aura and without status migrainosis.  It was noted that Botox and biofeedback had helped him greatly, and Emgality was added to his treatment regimen.
The health plan's determination is upheld.  This is a patient with a history of migraines. He was being treated with Botox and was experiencing one to two migraines per month.  Emgality is Food and Drug Administration (FDA) approved to treat episodic migraine and chronic migraine.  The threshold for episodic migraine is 4 to 14 headache days per month.  As the patient was experiencing one to two headache days per month at the time it was prescribed, its use is not medically necessary, as the patient was no longer having episodic migraine or chronic migraine.  Additionally, there is no information in the medical literature whether Emgality and any other calcitonin gene-related peptide (CGRP) targeting agents are safe in combination with Botox, and there is no evidence whether the combination of Botox and Emgality or any other CGRP targeting agents improves outcomes compared with either medication alone.  Therefore, the patient has successfully been treated with Botox, and there is no medical necessity for the addition of Emgality.
Appeal type: Medical necessity
Decision: Overturned in Part

This is a patient with multiple medical problems, most notably weakness secondary to a previous stroke, along with gait dysfunction, urinary incontinence and generalized medical deconditioning.
Personal care services 24 hours a day live in, 7 days per week, 91 hours total per week were requested and denied based upon medical necessity. At issue is the medical necessity of personal care services 24 hours a day live in, 7 days per week, 91 hours total per week.
The health plan's determination is overturned in part. Although live in services are not medically necessary, according to the information provided the patient requires more care than can be met with 60 hours a week of care. Increasing the services to 12 hours a day 7 days a week is indicated.
The health plan noted the following in regard to the denial. The patient needs help with preparing meals, housekeeping, laundry, shopping, dressing, bathing, toileting, medication management and personal hygiene. She is noted to have intermittent bladder and bowel incontinence. Her daughter manages her medications. Giving more hours to have someone in your home will not stop falls or accidents. Giving more hours to have someone in your home would be for safety and supervision and the plan is not required to provide services for this alone. Also hours for companionship is not medically necessary when the tasks are being provided.
Additional service hours for nocturnal care are not medically necessary. There is no notation that the patient has any complex medical condition which would require frequent care during the middle the night such as turning or repositioning. No wound ulcers or other conditions are noted in the medical chart. An evaluation in August, nursing visit, showed no pressure sores. A physician statement  states that the patient now developed pressure sores. There is no specific other documentation provided in regards to this.  There are no specific orders such as orders for frequent repositioning to be performed at night.  There are no other treatment orders in regards to the new pressure sores.
The Uniform Assessment System (UAS) State of New York, HELPS tool was provided and used to calculate activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The assessment noted the patient required more care for a total of 12 hours a day 7 days a week or 84 hours a week. Currently, the patient is receiving 60 hours a week. Additional service hours, as per the above rationale, are noted to be medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sleep apnea
Treatment: Additional rental of CPAP device and humidifier
The Additional rental of CPAP device and humidifier are medically necessary. The patient has sleep apnea, and when worn, the patient's CPAP is clinically efficacious.

The patient is non-compliant with use of the CPAP machine in mid-2019 unrelated to the facial injuries which occurred in later 2019. A new CPAP trial could be ordered by the treating physician, as the patient is motivated to continue therapy.  Supporting another CPAP trial would be in the best interest of the patient to obtain control of the patient's apnea, which presents an ongoing health risk.  Compliance and efficacy data should be appropriately monitored to continue coverage of CPAP therapy or to choose alternative therapy in the future.