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

Diagnosis: Dental erosion/perimolysis 
Treatment: Preservice request for dental services (codes 21085, D2644, D2740, and D2962)  

The insurer denied coverage for preservice request for dental services (codes 21085, D2644, D2740, and D2962). The denial is upheld. 

This patient is a female. Based on review of the submitted documentation which includes copies of narrative letters from the patient, relevant portion of the Medical Benefits guidebook, narrative letter, medical record/treatment notes, montage of undated intraoral clinical photos, undated panoramic radiograph, dental treatment records and treatment plan, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding  dental rehabilitation of teeth exhibiting evidence of erosion stated to be due to the patients underlying gastroesophageal reflux disease (GERD).  The insurer has denied the aforementioned services stating that these dental services are exclusions from the patient's medical plan coverage, and the insurer will only cover certain oral surgical services under the medical coverage with very specific criteria to be met.  As these dental services do not meet the criteria they are considered not medically necessary and no benefit is allowed. 

Upon review of the objective documentation it is evident that the patient exhibits significant dental erosion/perimolysis. The erosion is ascribed to manifestations of the patients well documented GERD. The patient and doctor are claiming that the dental services recommended should be covered under her medical insurance contract due to the underlying medical condition and they indicate that she meets the insurer's criteria under oral surgical services. The insurer claims that these dental services do not meet their criteria for approval under the medical insurance contract. 

The services to be performed are strictly dental and not oral surgical in nature and therefore these services are best covered under any dental insurance coverage the patient may have. The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for the preservice request for dental services (codes 21085, D2644, D2740, and D2962) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation 
Treatment: Inpatient admission 

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

The patient is a male with a history of persistent atrial fibrillation status post left atrial catheter ablation, morbid obesity, hypertension, diabetes, and obstructive sleep apnea.  The patient presented to the hospital for elective redo- left atrial catheter ablation for treatment of recurrent atrial fibrillation. The patient underwent left atrial catheter ablation that included posterior wall and coronary sinus lesions sets. His post-operative course was uneventful and the patient was discharged the following day on antiarrhythmic therapy. 

No, the proposed inpatient admission was not medically necessary. 

This patient presented to the hospital for an elective electrophysiologic (EP) study and ablation. According to hospital records, the ablation was successfully performed without complication. Observation following ablation was unremarkable and no post-operative issues were noted. The patient was discharged home the following day. In this case, there were no clinical reasons for hospital admission and the patient could safely be managed at a lower level of care. 

In two multicenter registry studies looking at healthcare utilization after EP study catheter ablation, more than 80% of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity. 

Another study demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day. 

The current standard of care in an uncomplicated atrial fibrillation ablation is to manage patients at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma.

Treatment: Inpatient stay.

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

This patient is a male with history of asthma.  The patient presented to the Emergency Department (ED) with a prior two day history of cough, wheezing and shortness of breath.  The patient's cough was productive of clear sputum. The patient denies fever, chills, and chest pain.  The patient did not respond to his home inhalers and nebulizer so came to the ED.  In the ED Vital Signs (V/S) were temperature (T) 97.4 F, blood pressure (BP) 134/92 mm Hg, heart rate (HR) 109, respiratory rate (RR) 18 and oxygen (O2) saturations 93 %.  The patient was in no acute distress.  Pulmonary effort was normal.  Wheezing and rhonchi were reported.  The patient's peak expiratory flow (PEF) before treatment was 350 LPM.  The patient was treated with intravenous (IV) steroids, bronchodilator via nebs and given empiric antibiotics.  The patient was noted to be feeling better after treatment in the ED.  The patient was described as ambulatory.

Labs at presentation were white blood cell (WBC) count 9.1 K, hemoglobin (Hb) 15.6 and electrolytes were within normal limits.  Chest x-ray showed no acute infiltrates. The patient was admitted to the hospital for asthma exacerbation.  As per History & Physical vital signs were T 97.5 F, HR 98, RR 20, BP 130/71 mm Hg and O2 saturations 93%.  The patient was in no acute distress.  Bilateral wheezing is noted.  Cardiovascular system was normal.  The patient was alert and oriented x3.  Labs were as above.  The patient was breathing more comfortably post treatment.  As per a note the patient was afebrile and hemodynamically (HD) stable.  Oxygen saturations were 98%.  The patient was in no acute distress.  Lungs were described as clear.  Abdomen was soft and non-tender (NT).  The patient was awake and alert X 3.  Neurological exam was within normal limits.  White blood cell (WBC) count was 7.5 K.  Electrolytes were within normal limits.  

This patient did not need acute inpatient hospitalization.  He had improved after treatment in the ED.  The patient was awake and alert.  The patient was ambulatory.  He was not hypoxic.  There was no evidence of pneumonia on chest x-ray.  PEFR was 350 before Rx.  

This patient could have been placed in Observation status while diagnostic testing and treatment were initiated.  The patient improved following treatment.  By a specified date the patient was afebrile and hemodynamically stable.  Lungs were clear.  Oxygen saturations were 98%.  The plan was to taper steroids.  Antibiotics were discontinued as no pneumonia was noted.  This patient was stable to be discharged home on oral steroids and bronchodilators and other asthma and maintenance medications with close follow-up in an outpatient setting.  

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

The carrier's denial of coverage for the inpatient stay is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Carious non maintainable #30 and carious #19

Treatment: Dental implants

The insurer denied coverage for dental implants. The denial is upheld.

This patient is a male who patient presented for dental evaluation, and carious non maintainable #30 and carious #19 were identified. The provider recommended extraction of both these teeth and replacement with endosteal implants. The insurer has denied these services stating that implants are covered only when a denture cannot be utilized to address the dental needs.

Upon review of the radiographs, in the area of #30, what remain of this tooth are carious root tips. Extraction is indicated. However, although implants would be an option to prosthetically restore this edentulous space a three unit fixed bridge would be the standard of care in dental practice. The adjacent teeth #29 and #31 would serve as suitable abutments based on the imaging provided. As a bridge is an acceptable alternative treatment plan, the implant is deemed not medically necessary.

As regards #19, the tooth exhibits a large distal carious lesion. Although the caries might be deep enough to extend into the pulp chamber necessitating endodontic therapy, there is no clear need to extract #19 and replace that tooth with an endosteal implant.  In fact if the caries is not deep enough to encroach on the pulp space a direct placement restoration might suffice. As there is no indication for extraction of tooth #19, the implant is deemed not medically necessary.

A 3 unit bridge is a standard of care in dentistry for restoring the edentulous area of #30, and extraction of #19 is not indicated based on the documentation provided for review.

The health care plan did act reasonably and with sound medical judgement and in the best interest of the patient.
The dental implants provided are not considered medically necessary for this patient.

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

Diagnosis: Urinary Tract Infection

Treatment: Inpatient Admission

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

This is a female patient 21.4 weeks gestation with a history of gallstones. She presented to the Emergency Department with complaints of sharp pain in the lower quadrant of her abdomen. A category one fetal heart tracing was performed. An obstetrical ultrasound was done that was negative for any anomalies. Intravenous (IV) fluids and antibiotics were administered. A magnetic resonance imaging (MRI) was performed that was negative for appendicitis. She was medically stable and discharged home.

This patient presented with abdominal pain.  However, the only anomaly detected was a UTI.  The treatment of a UTI does not necessitate an admission.  Ideally, this patient would have been observed for up to 24 hours.  If no worsening of symptoms were observed, then the patient could have been sent home to be followed up as an outpatient.  Based on the above, and based on physical examination and results of laboratory and imaging tests, an inpatient admission was not medically necessary.  The observation level of care would have been adequate to manage this patient.

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

The carrier's denial of coverage for the acute inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation

Treatment: Acute Inpatient admission 

The insurer denied coverage acute inpatient admission. 

The denial is upheld. 

This patient was female with a history of atrial fibrillation. She had been prescribed Digoxin and Eliquis. She presented to the emergency department (ED) with complaints of palpitations. In the ER, an electrocardiogram revealed atrial fibrillation with a heart rate of 126 beats per minute. The patient was given 15 milligrams of intravenous (IV) Cardizem.  Her heart rate improved to 75 beats per minute and she remained in atrial fibrillation.  Oral Cardizem 30 mg was also given. She was admitted to the hospital.  An echocardiogram came back within normal limits. Cardiology services consulted over the case, noting better rate controlled on oral Cardizem. The remainder of the cardiac workup was unremarkable, including unremarkable cardiac troponin. The patient underwent a successful external cardioversion. She was monitored after the procedure and remained stable with improved symptoms.  She was discharged home in good condition with instructions to follow up with the cardiologist on an outpatient basis.

In the absence of evidence of myocardial ischemia, hypoxemia, hemodynamic instability, or other end-organ dysfunction, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing.  Inpatient admission criteria were not met.  The acute inpatient admission was not medically necessary.

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

The carrier's denial of coverage for the acute inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pancreatic sufficient cystic fibrosis

Treatment: Durable Medical Equipment (DME) 

The insurer denied coverage for Relizorb - DME B4105 x 730 

The denial is upheld. 

This patient was a male child who was diagnosed with pancreatic sufficient cystic fibrosis (CF), scoliosis, failure to thrive, celiac disease, and recurrent pancreatitis. He has a gastrostomy tube (G-tube) and was prescribed pancreatic enzymes. His treating physician requested coverage for Relizorb, which is a tube containing products to help digestion for G-tube feedings. It was noted that the patient had an increase in abdominal bloating when not receiving the tube feedings through the Relizorb device. The CF medical care providers recommended the Relizorb device containing pancreatic enzymes during his nocturnal gastrostomy tube feedings to improve digestion of his absorption and increase his weight gain. 

Based on the review of the medical record, the patient had recent normal fecal elastase measurement. Pancreatic enzyme replacement therapy is not indicated for CF patients who are pancreatic sufficient but in view of the history of recurrent pancreatitis in this patient, there should be ongoing monitoring of fecal elastase and fecal fat to detect the development of pancreatic insufficiency over time. In addition, it should be noted that the L997F mutation which this patient has is not considered a CF causing mutation.  

The Relizorb device contains pancreatic enzymes and it is routinely employed to treat pancreatic insufficiency related to nocturnal tube feedings for children and adults with CF. This device is FDA approved and considered appropriate and is becoming the standard of care for all nocturnal gastrostomy tube feedings for CF with pancreatic insufficiency. If this patient develops pancreatic insufficiency in the future, then Relizorb would be appropriate for nocturnal gastrostomy tube feedings, but it is not clear from the available record that this patient's failure to gain weight has improved with pancreatic enzyme supplementation.

Thus, based on the review of the medical record submitted, the requested DME Relizorb is not considered medically necessary for this patient.

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

The carrier's denial of coverage for Durable Medical Equipment (B4105 x 730) should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Proximal LAD lesion, mid left circumflex lesion and a chronic total occlusion of the RCA 
Treatment: Inpatient hospital stay 

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

This patient is a woman with diabetes mellitus and chest pain that presented for elective cardiac catheterization following a positive stress test. Diagnostic findings revealed a proximal LAD lesion, mid left circumflex lesion and a chronic total occlusion of the RCA.  Drug eluting stents were placed in the LAD and LCX arteries without incident. Notes prior to discharge document an uneventful post-operative course. 

This patient presented for elective percutaneous revascularization. She underwent an uncomplicated procedure and was discharged the following day. Several investigators have studied the safety and cost savings surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital. (1-4)  Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care. (4) In conclusion this patient should have been treated at a lower level of care. 

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

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

Cancer
Pharmacy/Prescription Drugs

Diagnosis: Prostate Cancer, Erectile Dysfunction
Treatment: Testosterone Gel
The insurer denied Testosterone Gel. The health plan's determination is upheld. 

The patient is a male with a history of prostate cancer status/post (s/p) RALP. Associated symptoms include erectile dysfunction, and stress incontinences. Testosterone level was 98. Prolactin was slightly elevated. The provider is prescribing testosterone replacement therapy for treatment of low testosterone (presumed hypogonadism), which is a possible cause for his erectile dysfunction.

Current medical literature does not support superiority of one testosterone replacement therapy over other. As such formulary drug will be as effective as the non-formulary drug and would not have more adverse effects.
The provider is prescribing testosterone replacement therapy for treatment of low testosterone (presumed hypogonadism), which is a possible cause for his erectile dysfunction.
However, it cannot be confirmed that he has a diagnosis of hypogonadism as he does not have 2 low morning testosterone levels and gonadotropins confirming the diagnosis.
As a diagnosis of hypogonadism cannot be confirmed, testosterone replacement therapy would not be appropriate for this patient as such either formulary nor nonformulary drug would be approved based on current medical literature.
Two AM testosterone levels below reference range prior to initiation of therapy are not documented. All guidelines (European Association of Urology (EAU), ISSM and Endosociety) recommend 2 morning testosterone levels below reference range prior to initiation of therapy.
There is no luteinizing hormone (LH) / follicle-stimulating hormone (FSH) documented. All guidelines recommend measurement of LH+/- FSH levels to evaluate the type of hypogonadism.
Only non-specific symptoms of hypogonadism are documented. The majority of patients with erectile dysfunction have a non-hormonal etiology. Most guidelines recommend treatment in carefully selected patients who have classical androgen deficiency symptoms. This does not appear to be the case in this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiovascular disease with gait ataxia
Treatment: Increase PCW Services to ten hours per day, seven days per week
The insurer denied the Increase PCW Services to ten hours per day, seven days per week. 
The denial is upheld. 

No, the proposed treatment of an increase in PCW services to ten hours per day, seven days per week is not deemed medically necessary. 

The patient is a female with a history of cardiovascular disease and gait ataxia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

However, numerous Physical Therapy and Occupational Therapy notes indicate that the patient is able to ambulate up to 80 feet with rolling walker and is now independent with bed mobility, sit to stand, requires contact guard/minimal assistance with toilet/tub transfers, dressing and bathing. For these reasons, the currently approved plan of seven hours per day, seven days per week from is sufficient to meet the patient's current needs. Hence, the proposed treatment of an increase PCW services to ten hours per day, seven days per week is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Inpatient Admission Substance Abuse

The insurer denied the inpatient admission substance abuse.

The denial was overturned.

This is a male patient who was admitted to inpatient hospital for detoxification treatment. The patient had withdrawal symptoms that included tremors, sweats, vomiting, teary eyes, elevated heart rate, irritable mood, and sleeping problems. The patient reported using multiple substances including alcohol, Xanax, opioids, cocaine, and cannabis. The patient had a positive toxicology for opioids, cocaine, PCP, THC, methadone, and benzodiazepines. The patient had a history of past inpatient detoxifications including several months prior to this admission. The patient was treated with Librium, Clonidine and Methadone detoxification as per protocol. The patient was discharged home upon the completion of his treatment.  

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  In this case, this patient had use of multiple serious substances daily in large amounts including alcohol, Xanax, opioids, cocaine, and cannabis. Thus, the patient was at risk for severe, complicated, and life threatening withdrawal and required inpatient medical hospital detoxification treatment. The patient also was at risk for overdose due to his alcohol, Xanax, and opiate use and was considered a high medical risk.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use multiple serious substances of use despite multiple past inpatient substance treatments. The patient also required two detoxification medications to modify his withdrawal symptoms from alcohol and Xanax and opioids. The patient also had a long history of multiple substances abuse that he was at risk for worsened withdrawal symptoms if not treated in an inpatient setting. The patient was likely to relapse again as evidenced by his relapsing episodes in the past, which indicated that the patient required inpatient substance detoxification and rehabilitation treatments. The patient required and received two detoxification medications including Librium and Methadone. The patient was at high risk and it was not considered safe for detoxification in a less intensive setting. Thus, inpatient admission was medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient admission substance abuse should be reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal Bleeding 
Treatment: Inpatient admission 
The insurer denied coverage for inpatient admission.
The denial is upheld. 

The is a female patient who presented to the hospital with complaints of heavy vaginal bleeding for several months with associated with cramps, weakness, lightheadedness, fatigue, and shortness of breath. Hemoglobin was 10.8. The patient was admitted to the hospital and underwent a dilatation and curettage (D&C) under general anesthesia. She was discharged later that day.

The D&C was uncomplicated with minimal blood loss. A D&C is an ambulatory procedure and does not require admission. It is unclear from the submitted clinical information why the patient was admitted. Note that the patient was stable at all times. Nothing was done in the hospital that could not be done in an ambulatory outpatient setting.

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

The inpatient admission was not medically necessary.

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