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

Diagnosis: Polymicrogyria

Treatment: Trio Whole Exome Sequencing

The insurer is denied coverage for Trio Whole Exome Sequencing

The denial is overturned. 

This female patient has a history of microcephaly, polymicrogyria, and developmental delay.  The submitted documentation indicates that this patient has been recommended to previously undergo genetic testing.  The patient previously underwent a series of tests that included chromosomal MicroArray, and the prior testing was negative.  The documentation indicates that, the patient was seen via telehealth for a neurogenetic evaluation.  The patient was noted to have mild microcephaly at birth with mild speech delay, normal motor function and good developmental progress.  The patient did not initially qualify for early intervention. However, the patient's parents noted that the patient's language is not as developed as her brother's was at 20-month-old.  The patient was able to play well with her brother.  The patient was born at 38 weeks weighing 6 pounds 2 ounces.  There were no complications during pregnancy or delivery.  The patient's prenatal and birth history was uncomplicated with the exception of the patient's mother having hand-foot-and-mouth disease.  There is a family history of mild learning disability, and the patient's dad and mom struggled with school. However, both parents are cognitively normal and work skilled jobs.  The physical exam revealed that the patient was microcephalic with no distress.  There was suspicion for lumpy and bumpy appearance of the cortex in bilateral frontal lobes concerning for polymicrogyria which may be evaluated with MRI.  The physician detailed that the patient was doing quite well and her condition was discussed as possibly being genetic or secondary to environmental exposure.  It was recommended that the patient undergo additional testing to include Trio Whole Exome Sequencing (Trio WES).

Malformations of cortical development, particularly if diffuse, often have a genetic etiology. Chromosomal microarray can identify only a small portion of these causes.  Whole exome sequencing is appropriate to enable diagnosis in this patient, is considered 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 is Trio Whole Exome Sequencing is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Back Pain
Treatment: Surgical Services
The health plan denied the requested surgical procedure due to the lack of medical necessity. 
The health plan's determination is upheld.

At the time of service, the patient was a male with a history of low back pain radiating into the left leg and left leg weakness including a left foot drop. There are no preoperative office records to review but there is a letter from the physician detailing the patient's preoperative history and exam. The patient was initially seen in the office for the complaints noted above. At that time, the patient demonstrated weakness in the left psoas and extensor hallucis longus muscles graded 4/5, as well as decreased sensation in the left (lumbar) L3 and L4 dermatomes. After a review of the magnetic resonance imaging (MRI) scan and the electromyography (EMG) report, the physician apparently discussed treatment options with the patient and recommended surgery for grade 1 L34, L45 and (lumbar-sacral) L5-S1 retrolisthesis and spondylosis resulting in a left L4 radiculopathy and partial footdrop. A computed tomography (CT) scan was obtained for surgical planning. In that letter, there is no record of any attempt at prior conservative therapy such as physical therapy (PT) or epidural steroid injections (ESIs), smoking status or body mass index (BMI). There is also no notation as to whether the left leg weakness was progressive or static.

The records provided for review support upholding the health plan's determination of medical necessity, in full.

No, the requested health service/treatment of implant or graft was not medically necessary for this patient as the entire procedure of the L3 to S1 decompression and fusion cannot be considered to have been medically necessary or appropriate at the time of service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 

Treatment: White glass with high gold content crown.

The insurer denied coverage for a white glass with high gold content crown.

The denial is upheld. 

This is a female patient who presented to the dentist who recommended dental services including a full coverage crown for tooth #3 which has a preexisting metallic restoration(s).  The insurer has denied these services stating that the clinical circumstance does not meet the insurer's criteria for approval of this service for medical necessity, due to insufficient documentation and that the radiographs do not indicate recurrent decay or other findings that would necessitate placement of a crown.  

The radiographs are the sole objective documentation provided for review. There is no periodontal charting provided for review.  The radiographs indicate a stable intact restoration on tooth #3.  There does not appear to be any radiographic change or pathology that would necessitate replacement of the existing restoration with a crown.  The documentation provided fails to substantiate the recommended dental service and therefore it is deemed not medically necessary.

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

A white glass with high gold content crown for tooth #3 is not considered medically necessary for this patient.

The carrier's denial of coverage for a white glass with high gold content crown is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease, Parkinson's disease,
Paraplegia, Gait Ataxia, Low Back Pain and
Hypertension
Treatment: Increase Personal Care Worker (PCW) Services to 7 Days per Week 12 Hours per Day, Total of 84 Hours per Week
The insurer denied the Increase Personal Care Worker (PCW) Services to 7 Days per Week 12 Hours per Day, Total of 84 Hours per Week
The denial is overturned. 

The patient is a female with a history of Coronary Artery Disease, Parkinson's disease, Paraplegia, Gait Ataxia, Low Back Pain and Hypertension. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 84 hours per week Personal Assistance Services to offer increased activities of daily living support.

Yes, the proposed treatment of 84 hours per week Personal Assistance Services is deemed medically necessary.

A recent assessment of the patient's functionality and ability to perform activities of daily living was completed and determined that the currently approved plan of 42 hours per week Personal Assistance Services is sufficient to meet the patient's current needs. 

However, more additional documentation noted in multiple medical progress notes from the patient's medical provider reveal that due to worsening functional decline, the patient has sustained further functional loss since the date of this last assessment. Specifically, her mitral regurgitation and atrial fibrillation has resulted in worsening fatigue, gait ataxia and exertional dyspnea. In addition, she has experienced intermittent chest pain. 

For these reasons, the currently approved plan of 42 hours per week Personal Assistance Services is insufficient to meet the patient's current needs. Hence, the proposed treatment of 84 hours per week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: crossbite
Treatment: Braces and Monthly Visit x 12 
The insurer denied the Braces and Monthly Visit x 12. The health plan's determination is overturned.

The patient in question is a female with a crossbite of anterior tooth 10. She presents with a skeletal Class III malocclusion with minor crowding in the maxilla and the mandible. She is treatment planned for of 24-30 months of orthodontics to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity.

Braces and Monthly Visit x 12 are medically necessary for this patient.
This patient presents with an anterior crossbite on tooth 10, as well as spacing. 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. It appears the lower anterior teeth are migrating labially in the arch.
If left untreated 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. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infertility
Treatment: In-Vitro Fertilization (Pre-service)
The insurer denied the In-Vitro Fertilization (Pre-service)
The denial is overturned.

The patient is a female. Both she and her partner are carriers of autosomal recessive polycystic kidney disease (ARPKD). To prevent the birth of a child affected by this condition, the patient is requesting coverage for IVF (in vitro fertilization), ICSI (intracytoplasmic sperm injection), and PGT-M (preimplantation genetic testing for monogenic disorder).

Yes, the proposed treatment is medically necessary.

Both the patient and her partner are carriers of the autosomal recessive polycystic kidney disease (ARPKD) gene. This couple has a 25% odds of having a child affected by this condition. Performing preimplantation genetic testing for this disease is standard of care and medically necessary.

In order to perform PGD (preimplantation genetic diagnosis), IVF (in vitro fertilization) is medically necessary as it is the only option to recover eggs and create embryos.

So, even though the patient does not have a diagnosis of infertility, both IVF (in vitro fertilization) and PGT-M (preimplantation genetic testing for monogenic disorder) are medically necessary and standard of care.

By stating that the patient does not have a diagnosis of infertility and therefore denying medically necessary treatment, the health plan did not act reasonably.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute kidney injury. 
Treatment: Inpatient admission. 

The insurer denied coverage for the inpatient admission. 

The denial is upheld. 

This is a male patient with a past medical history of gastroesophageal reflux disease (GERD), recurrent chest pain, herniated disk and leg pain, stage 3 kidney disease, and hypertension who presented to the hospital for worsening generalized body weakness, chest pain and shortness of breath. He was tachycardic on admission with elevated blood pressure; physical exam was normal except for chest wall tenderness and unspecified weakness. He was found to have elevated creatinine secondary to dehydration and was treated with intravenous (IV) fluids, creatinine improved from 2.15 to 0.93 in 24 hours and he was discharged in stable condition. 

The inpatient admission was not medically necessary for this patient.  He was diagnosed with acute kidney injury on admission which was secondary to prerenal azotemia and had no signs of acute tubular necrosis, he had stable electrolytes, no signs of uremia, did not require dialysis therapy and his condition resolved within 24 hours with IV fluids. 

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

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

Diagnosis: Genetic Diseases/Sickle Cell Disease
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay due to the lack of medical necessity. 
The health plan's determination is upheld.

The patient is a female who was admitted to the hospital for back and leg pain. She has a history of hemoglobinopathies (HbSS), acute chest syndrome, beta thalassemia trait, and asthma. On presentation she had report of fevers, chills, sweating and diarrhea. She has a recent admission for an acute sickle cell vaso-occlusive pain crisis. A chest x-ray was normal. Her white blood cell count (WBC) was 14.9. Vitals were significant for a heart rate of 104 beats per minute (bpm). She was treated with intravenous (IV) fluids, Benadryl, Hydroxyurea, folic acid, IV Dilaudid, and IV Morphine. The patient was evaluated by Hematology/Oncology and was determined to not be in a sickle cell crisis as there was no evidence of hemolysis on lab-work. Hematology/Oncology recommended discharging the patient. The patient improved and was discharged in stable condition.
The question at hand is whether the patient met medical necessity for the acute inpatient level of care.

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

The patient in question did not meet medical necessity for the acute inpatient level of care per Milliman Care Guidelines (MCG) criteria. In order to meet medical necessity, the patient must have signs or symptoms of central nervous system (CNS) injury, acute chest syndrome, hypoxia, aplastic crisis, underlying condition requiring hospitalization, acute renal failure, or worsening condition past observation level of care. Additionally, the patient does not meet medical necessity for the acute inpatient level of care per current literature or standard of care. According to Smith et al., (2008) and Rees et al., (2010), the patient has a diagnosis of sickle cell trait with no evidence of acute pain/sickle cell crisis. There were no extenuating circumstances or unstable elements of this case that would require the acute inpatient level of care. Observation would have been appropriate for the duration of the admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Periapical radiolucency (recurrent infection).
Treatment:  D3347 Bicuspid Tooth Nerve Canal Repair Tooth 12, Pre-service.
The insurer denied the  D3347 Bicuspid Tooth Nerve Canal Repair Tooth 12, Pre-service.
The denial is overturned. 

The patient is a female requesting endodontic retreatment benefits for tooth #12.

Yes, the proposed treatment is medically necessary.

The x-rays provided show there is a periapical radiolucency (recurrent infection) at the tip or apex of tooth #12. The only way to treat the infection is to retreat the tooth or re-do the root canal procedure. This will remove the source of the new infection and allow the area to heal.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness, headache and fatigue
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She presented with dizziness, headache and fatigue.

The patient's BP (blood pressure) was initially elevated at 164/73, and normalized upon admission. CT (computed tomography) head was normal. CXR (chest x-ray) was normal. Her labs were normal, and her enzymes were normal. Her differential was described as possible ACS (acute coronary syndrome) or cerebral event.

IVF (intravenous fluids) were given, and oral medications were prescribed. Her headache resolved on day of admission, her dizziness improved, and she was discharged with an outpatient appointment with ENT (otolaryngology).

No, Inpatient admission was not medically necessary.

All of the care that was provided, all of the tests that were performed, and all of the treatment given would have been appropriate, safe, and normally performed in a lower level of care.

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care.

In this case, the patient's symptoms were atypical and unlikely to be representative of acute coronary syndrome or CVA (cerebrovascular accident). The patient's exam and cardiac findings were normal. Her blood pressure normalized. Biomarkers and EKG (electrocardiogram) showed no evidence of acute ischemia. CXR (chest x-ray) was normal. Echocardiogram was ordered. The physicians' treatment did not reflect any serious concern about patient's cardiac condition or an acute CVA (cerebrovascular accident).  The orders did not include medical therapy for ACS (acute coronary syndrome) such as IV (intravenous) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV (intravenous) NTG (nitroglycerin).

A "17% risk of a cerebral event in next 10 years" did not mandate acute inpatient work up. The patient was referred to an outpatient ENT (otolaryngology) to complete evaluation.

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right-sided groin swelling
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This male to female transgender patient was admitted through the emergency room (ER) with right groin swelling consistent with either an abscess or epididymitis.  The patient had tried outpatient doxycycline but had worsening of symptoms.  The patient had been having severe pain and worsening erythema.   

The patient's vital signs were temperature 98.6, pulse 101, and blood pressure 127/66.  Scrotal ultrasonography demonstrated scrotal cellulitis and a three centimeter scrotal wall abscess.  The white blood cell (WBC) count was 10,800.  The urinalysis had trace leukocytes.

The patient was treated with intravenous antibiotics.  The patient was seen by urology, who noted that there was no clinical abscess on exam and that surgical intervention would not be needed.

The patient was discharged home.  The patient was having difficulty with oral medication pain control.

No, the inpatient admission was not medically necessary.

Care could have been provided at a lower level of care than acute inpatient.  The intravenous antibiotics and observation of clinical status did not require an acute inpatient level of care because care could have been provided at an observation level of care.  After admission, the patient was afebrile and hemodynamically stable.  There was no evidence of abscess that required operative intervention.  Complicating features were not present.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest tightness, wheezing, asthma
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with morbid obesity and asthma who presented to the emergency room with chest tightness, wheezing and dyspnea. The patient was admitted to acute inpatient hospital level of care for asthma exacerbation management.

The patient was admitted to acute inpatient hospital level of care for asthma exacerbation. The patient was treated with nebs and steroids. The patient's condition improved and she was discharged home the following day.

No, the proposed treatment was not medically necessary.

The patient's shortness of breath and wheezing improved with treatment within 24 hours. The asthma exacerbation improved with steroids and nebulization within 24 hours of admission. Since the patient improved significantly within 24 hours after emergency room care, a lower level of care was medically appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain, nausea, vomiting, and diarrhea
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a female with type 2 diabetes, hypertension, and seizure disorder. She presented with abdominal pain and nausea, vomiting, and diarrhea for one day. In the past she has taken her insulin intermittently.

The patient's labs and vitals were as follows: Glucose 458 mg/dL (milligrams per deciliter), CO2 (carbon dioxide) 19, pH (potential of hydrogen) 7.31, BP (blood pressure) 112/59, heart rate 99, and temperature 100.2. She had recently taken antibiotics for periodontal disease. She was treated with an empiric dose of metronidazole and Meropenem.

The patient's CT (computed tomography) showed mild/moderate colonic wall thickening due to under-distention or mild colitis. Inpatient stay is the topic of this review.

Yes, the inpatient admission was medically necessary.

The patient presented with diabetic ketoacidosis, with a pH of 7.31 and a glucose of 458. Her presentation was complicated by fever, elevated lactate level, and concern for infection with possible colitis on her CT scan. She was still acidotic with a CO2 of 20, which required ongoing management and evaluation. Therefore, yes, the proposed inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Moraxella Catarrhalis
Treatment: Inpatient admission

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

This patient is a male toddler with no significant past medical history. The patient presented to the Emergency Room (ER) with complaints of a 4-day history of fever, cough, and stuffy nose. In the ER, the patient was crying with tears. The physical examination revealed cervical adenopathy. The patient's temperature was 101.9 F (Fahrenheit). The patient was given Pedialyte, and his fever began to go down. The patient failed an oral challenge. In the ER, the patient was given Tylenol, Motrin, and ceftriaxone. Multi-inflammatory Syndrome in Children (MIS-C) workup was done and was unremarkable. The patient was admitted to the Pediatric unit with a fever. During the admission, the patient was given intravenous (IV) ceftriaxone. Contact and droplet precautions were maintained. The patient's vital signs were monitored every 4 hours (Q4H), and strict intake and output was maintained. The patient's rapid viral panel (RVP) was significant for Rhinovirus and Enterovirus. Ceftriaxone was discontinued. The patient's blood cultures were positive for Moraxella Cattarrhalis. The patient was discharged and the family was instructed to have the patient complete a 10-day course of oral (PO) antibiotics.

As per medical record, this was the second Emergency Department (ED) visit for this patient within a one week, time period. The patient was not tolerating oral (PO) fluids and had high fever.  In addition, an important factor was the patient's mother's discomfort if the patient was not to be admitted at this second visit, in light of the consult from the Social Work that revealed that the patient's mother has a history of domestic abuse, difficult home circumstances, and psychiatric disorders including post-traumatic stress disorder (PTSD), anxiety, and depression. A decision to discharge Jeremiah from the ED may have resulted in an adverse clinical outcome.

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 hospital admission is overturned.  The medical necessity is substantiated.