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

Diagnosis: Pulsatile Tinnitus
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission. 
The denial was upheld.  

This is a male patient with a medical history of diabetes, hypertension and asthma who presented to the ambulatory surgery unit for a scheduled inner ear procedure.  Per the operative report the patient underwent a Dural venous sinus stent placement for the pre- and post-operative diagnosis of right pulsatile tinnitus.  The patient tolerated the procedure without complication and was transferred to the Post-Anesthesia Care Unit (PACU) in stable condition with vital signs stable. The patient's blood pressure was initially 116/70 which elevated to 136/93 during post-op course.  The patient was continued on his hypertension medication.  After an uneventful overnight hospital stay, the patient was discharged in stable condition with instructions for surgical follow-up care.

Based on the review of the medical record, inpatient admission status is not medically necessary for this patient.  This procedure is an outpatient procedure.  The patient's clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating circumstances in this case which warranted inpatient admission status following elective Dural venous sinus stenting.  The patient could have been appropriately monitored for 23-hours under ambulatory surgery level of care. Thus, inpatient admission was not 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 the inpatient hospital admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned in Part

Diagnosis: GERD
Treatment: Laparoscopic Esophageal Surgery and Hospital Admission (43284) (Pre-Service)
The insurer denied the Laparoscopic Esophageal Surgery and Hospital Admission (43284) (Pre-Service). 
The denial is overturned. 

The patient is a female with Gastroesophageal Reflux Disease. Symptoms of bile in her mouth after meals if she lies down or bends over.  Endoscopy revealed no Barrett's esophagus or Malignancy.  pH testing of the esophagus revealed a DeMeester score of 41, which is about 2.5x the upper limit of normal.  Manometry revealed 60% normal swallows. Upper GI barium x-ray revealed mild esophageal dysmotility.  

Yes, the health plan should cover the proposed LINX procedure and the related hospital admission.

Yes, the requested health service or procedure is likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease.

This patient suffers from GERD causing regurgitation.  Even with medications, there is refluxing gastric contents.  Surgical therapies exist that resolve this very well. Without LINX procedure, a Laparoscopic Nissen Fundoplication (LNF) would have been recommended.  Other techniques have been tried endoscopically and otherwise, but none have been able to demonstrate long term efficacy and safety.  The side effects of LNF make it a less than ideal operation.  Linx is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been shown to dramatically improve patient satisfaction long term.  It is approved by the FDA.  There is published data on patients who have had the device for six years, showing a very low complication rate and a high resolution of GERD.

I do not believe any evidence has been published in support of this operation being performed at a level of care lower than inpatient, and the standard of care is to perform the operation as an inpatient.  Therefore, it is recommended to approve this operation as an inpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient substance use rehabilitation treatment 
The insurer denied the Inpatient substance use rehabilitation treatment.
The denial is upheld.

The Inpatient substance use rehabilitation treatment was not medically necessary for this patient in keeping with NY State OASAS LOCADTR 3.0 Guidelines/Criteria.

The inpatient substance abuse rehabilitation treatment, in this case scenario, was amenable to treatment at a lower level of care. The patient was motivated and able to effectively engage in rehabilitation services, and, the patient did not need the structure or 24-hour monitoring of an inpatient setting in order to safely and effectively participate in rehabilitation substance abuse treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted inpatient level services and treatment. Moreover, the patient demonstrated his motivation for continued involvement in the substance use disorder treatment during his detoxification, as noted in the clinical summary. Thus, the requested benefit of Inpatient substance use rehabilitation treatment was not medically necessary for this patient.

This answer is consistent with prevailing standards of professional practice, ASAM Criteria, and the scientific literature, referenced below, as well as New York State instruction for medical necessity reviews together with the NY State OASAS LOCADTR 3.0 Criteria, applicable in this case.

The structure and intensity of services necessary for a successful rehabilitation/substance use disorder treatment can be/could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports. There is no evidence that inpatient level structure and 24-hour monitoring is medically necessary for a successful outcome with regard to the DOS.  There were no biomedical, psychiatric or general medical issues that warranted the admission and the continued inpatient level treatment in this case scenario.
 
Thus, as the health plan asserts, the patient's substance use disorders were amenable to treatment at a lower level of care in this case scenario, and the health plan's determination of medical necessity was consistent with the application of NY State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below, as well as ASAM Patient Placement Criteria and the scientific literature and published guidelines, also referenced below.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: D8080 - Comprehensive orthodontic treatment of adolescent dentition
D8760 - Periodic orthodontic treatment visits x 12

The insurer denied D8080 - Comprehensive orthodontic treatment of adolescent dentition and D8760 - Periodic orthodontic treatment visits x 12.  The denial is overturned.

The Comprehensive orthodontic treatment of adolescent dentition and Periodic orthodontic treatment visits x 12 are medically necessary. 

The patient has a deep, impinging overbite that traumatizes her palatal tissues. This is an "automatic qualifier" for orthodontic benefits according to the handicapping index scale. Orthodontic treatment is medically necessary for this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right ankle fracture
Treatment: Inpatient stay

Summary:
The patient is a male with a history of hypertension. He sustained an injury to his right ankle. He was diagnosed with a fracture and underwent open reduction internal fixation and deltoid ligament repair. He was admitted to hospital and underwent surgery. His post-surgical course was non-complicated. 

The patient required an immediate closed reduction. He received high dose parenteral narcotics. He required open reduction internal fixation to his ankle. The procedure was complex and extensive. The operative report was significant for attention to several structures. He underwent fixation to his medial malleolus, plate fixation to the distal fibula, repair of syndesmosis and repair to deltoid ligament. 

This operation would be expected to be painful and require parenteral narcotics post-surgery. The injury, type of treatment provided and post-surgical course support necessity of services provided, i.e., inpatient admission and all length of stay. 

These services could not have been provided in outpatient facility.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal bleeding

Treatment: inpatient hospital admission

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

This patient is a female with a history of a diverticular bleed and presented to the hospital with rectal bleeding.  In the Emergency Room (ER), the patient's vital signs were stable, and the patient's abdominal exam was benign.  The patient's hemoglobin was 11. The impression of the gastroenterology (GI) consult was that the patient was hemodynamically stable and was not having active bleeding.  Both endoscopy and colonoscopy of the patient were negative for active or stigmata of recent bleeding. 

According to the MCG guidelines for lower gastrointestinal bleeding (M-182), the clinical indications for admission includes ongoing or active bleeding, failure to control bleeding after a colonoscopy, hemodynamic instability, severe anemia, severe thrombocytopenia, and/or a severe coagulopathy. In this case, the patient did not have these clinical criteria necessitating inpatient level of care.

This patient had rectal bleeding most likely from diverticulosis.  However, the bleeding was self-limited. It was neither evident on physical exam nor gastrointestinal (GI) imaging with colonoscopy. The patient's vitals and labs were stable. The patient did not meet the MCG criteria for inpatient admission for lower GI bleeding. The patient could have been safely and effectively managed at an observation care level. Thus, inpatient hospital admission was not medically necessary to treat this patient's medical condition. 

The health plan acted 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: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea
Treatment: hypoglossal nerve stimulation (inspire upper airway stimulation system)
The insurer denied coverage for hypoglossal nerve stimulation (inspire upper airway stimulation system).
The denial is overturned.

This is a male patient diagnosed with obstructive sleep apnea (OSA). This patient has been recommended to receive a hypoglossal nerve stimulation unit. He has undergone a prior polysomnogram that revealed an apnea hypopnea index (AHI) of 30.3. The patient has tried and failed continuous positive airway pressure (CPAP) device use; he had intolerance to the use of CPAP. He had trialed multiple different masks and machines.  

The patient had a drug-induced sleep endoscopy with no concentric collapse noted. His most recent body mass index (BMI) was noted to be 30.8. The patient had complaints of being tired and falling asleep all the time. He reported that he snored loudly and woke up frequently gasping for air.  His physical examination revealed no significant abnormalities. The physician detailed that the patient was unable to tolerate an oral CPAP as well as an oral appliance due to jaw pain and prior injury. The physician also detailed that the patient was a good candidate for a hypoglossal nerve stimulation implant.

CPAP is the first-line of treatment for OSA; however, long-term use for many patients is suboptimal. The hypoglossal nerve stimulator is US Food and Drug Administration (FDA)-approved for the treatment of moderate and severe OSA. A five-year study indicated that the treatment was effective and improved sleepiness, quality of life and respiratory outcomes. In the position statement, the American Academy of Otolaryngology-Head and Neck Surgery stated it considers upper airway stimulation via the hypoglossal nerve for the treatment of adult OSA syndrome to be an effective second-line treatment of moderate to severe OSA in patients who are intolerant or unable to achieve benefit with positive pressure therapy. Candidates for this therapy are selected based on appropriate polysomnographic testing, age, BMI, and objective upper airway evaluation. US FDA eligibility criteria for upper airway stimulator implantation includes an AHI of 15-65, a lack of central apnea, and a favorable pattern of the palatal collapse during drug-induced sleep endoscopy. The cited literature also notes that patients with OSA, who have an elevated BMI and are unable to tolerate CPAP, can be successfully treated with upper airway stimulation therapy.

In this case, this patient meets all the criteria for hypoglossal nerve stimulation for the treatment of his OSA.  Thus, the requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of hypoglossal nerve stimulation (inspire upper airway stimulation system) for OSA should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea
Treatment: hypoglossal nerve stimulation (inspire upper airway stimulation system)
The insurer denied coverage for hypoglossal nerve stimulation (inspire upper airway stimulation system).
The denial is overturned.

This is a male patient who was unable to use a continuous positive airway pressure (CPAP) device. The patient had an apnea hypopnea index (AHI) of 30.3 and a body mass index (BMI) of 30.88. A sleep induced endoscopy revealed that the patient did not have complete concentric collapse of the upper airway.

Literature shows the efficacy of hypoglossal nerve stimulation and the treatment of obstructive sleep apnea (OSA). The use of nerve stimulation has been approved by various international and national professional societies. The Food and Drug Administration (FDA) has twice approved the use of hypoglossal nerve stimulation for the effective treatment of OSA. In this case, the patient fulfilled all of the FDA requirements for the uses of hypoglossal stimulation which included an AHI of greater than or equal to 15 and less than or equal to 65. The patient has tried and failed CPAP use, and does not have a complete concentric collapse of the upper airway that would be a contraindication for this procedure. The scientific evidence of peer-reviewed literature supports positive results of efficacy and improvement in health outcome with the use of hypoglossal nerve stimulation for patients, such as in this case.

This patient is considered an excellent candidate for hypoglossal nerve stimulation for treatment of his OSA. He fulfills all the conditions noted in the two FDA approvals for this procedure use. Hypoglossal nerve stimulation for OSA is considered the best available treatment for this patient at this time. Other interventions, such as chronic tracheostomy, carry increase morbidity and mortality. 

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.
The carrier's denial of hypoglossal nerve stimulation (inspire upper airway stimulation system) for OSA should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Humeral fracture. 

Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is overturned. 

This is a male patient who fell and was evaluated in Emergency Department (ED). He was diagnosed with a right proximal humerus fracture. The patient was referred to the orthopedic clinic for definitive orthopedic management. The patient returned to hospital and underwent open reduction internal fixation (ORIF) of his proximal humerus fracture. A drain was placed. The surgery and post-operative course was uncomplicated. The patient had the drain removed and was discharged on the same day. 

Based on the review of the medical record and clinical guidelines, the inpatient admission and length of stay were medically necessary. The patient underwent a complex and extensive surgical procedure. The patient underwent the operation approximately 3 weeks after his injury. This would increase the difficulty as the fracture had begun to heal. A large incision was placed over his proximal arm and shoulder area. The patient required fixation with screws, plates and suture. The patient's blood loss was listed as 600cc. That would be considered higher than expected. The patient's anesthesia time during the surgery was almost 6 hours. The patient's surgical time was 4 hours. A drain was placed and was monitored until the date of discharge. That would be indicative for concern of fluid/blood accumulation. Drain monitoring is not provided at a lower level of care. This clinical presentation and needs substantiate the need for acute level of care, which is inpatient admission. 

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

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

Diagnosis: Mercury toxicity

Treatment: Dental services

The insurer denied coverage for dental services.

The denial is upheld.

This is a female patient with a past medical history of hypothyroidism, anxiety and asthma who was diagnosed with elevated mercury levels. Due to this finding, it was recommended that she had her dental amalgam restorations removed and replaced with another restorative material as they ascribed the serologic findings to the presence of amalgam restorations. This treatment included replacing amalgams on teeth 10, 21, 29 and 31. Subsequently, blood mercury levels were assessed and decreased as compared to the initial result.  

Based on the review of the medical record, the patient and her doctor claimed link between this patient's elevated blood mercury levels, the constitutional symptoms described, and the 4 dental amalgam restorations to which the mercury levels were attributed. However, there is no scientific basis for this assertion. Although mercury toxicity has been identified and is clearly understood, the issue for this patient is whether the intact dental amalgams are responsible for this elevation. Peer-reviewed literature and the consensus and recommendations of the FDA, which regulates mercury, are clear that any minimal exposure to mercury from dental amalgam restorations does not pose an increased risk of mercury toxicity. Further, the FDA does not recommend removing amalgam restorations solely for the purpose of elimination of mercury containing restorations. Lastly, although this patient's blood levels of mercury were noted to decline during the treatment period (which the patient ascribes to the treatment), it is clear that her mercury level remained elevated even after removal of the restorations, so it is likely that the elevated mercury levels were due to another source of contamination and it remains unproven that her mercury levels were elevated due to the amalgam restorations.

Thus, the dental services provided were not medically necessary for this patient. There is no peer-reviewed evidence to show that amalgam restorations induce mercury toxicity. As such, the removal of these restorations was not medically necessary on that basis.

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 dental services rendered is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post myomectomy and ovarian cystectomy

Treatment: Inpatient hospital admission

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

This patient is a female who was admitted to the hospital for an abdominal myomectomy and ovarian cystectomy. The procedure was performed without difficulty and without complications. The patient was transferred to the recovery room and recovered without incident. The patient was transferred to the inpatient floor and recovered without incident. The patient's pain was controlled on oral pain medications on postoperative day #1. The patient's vital signs were stable and she was afebrile. The patient was discharged.

Upon review of these medical records, it is the standard of care for this patient to have been permitted to remain as an inpatient status. The surgical guidelines for inpatient treatment were satisfied for the exploratory laparotomy for gynecologic surgery, including myomectomy, left oophorectomy. It has been the standard of care to permit inpatient admission for a stay up to 2 days for open surgery, such as laparotomy. This patient underwent an exploratory laparotomy, the date of admission. The patient had a history that was compatible with her clinical diagnosis and was appropriately treated by her surgeon. It would not have been appropriate to discharge this patient on the same day of this patient's surgery. It was clinically reasonable and standard of care to provide adequate/appropriate post-operative care such as advancing diet according to bowel sounds, passage of flatus, and monitoring for hemodynamic instability, as well as pain management and abdominal incision. If this patient had undergone a laparoscopic procedure, then this procedure could have been considered an outpatient surgery. However, this was not the case for this patient. Thus, inpatient admission was appropriate and medically necessary for this patient. The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

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

Appendicitis
Inpatient hospital

The patient is a healthy male with 1 day of symptoms of right lower quadrant (RLQ) pain. Exam in the ED showed RLQ tenderness as well.
Ultrasound showed acute appendicitis with 9 millimeter (mm) appendix and no signs of complications (no surrounding fluid). White blood cell (WBC) count was normal with no shift. The patient was admitted for routine medical and surgical treatment of acute appendicitis. 

The health plan's determination is upheld. The inpatient admission was not medically necessary. A lower level of care was appropriate for this patient based on the documentation. Patients with acute non-perforated appendicitis like this child had can often be discharged home the same day from the hospital, without an overnight stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Extracted tooth
Treatment: D4266 Gum Surgery, tooth #3
The D4266 - Gum surgery, Tooth 3 is medically necessary.

The gum procedure being requested is for a membrane to be placed in the area where tooth #3 was extracted. It will help the bone graft to stabilize properly so a future implant can be placed. The tooth was failing, and it had already undergone a root canal procedure. However, the tooth had become reinfected. Extracting the tooth was the proper treatment, with replacement with an implant. To ensure a good result, with a good amount of bone support for the implant, a bone graft was performed. The membrane procedure helps to ensure that the graft takes, and that it heals properly. The procedure is to be considered medically necessary.