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

Diagnosis: Multiple Rib Fractures

Treatment: Inpatient Admission

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

This is a female patient who presented to the Emergency Department (ED) with complaints of right sided chest pain after falling over a cement block. She reported falling and landing on her right chest and shoulder. The patient denied loss of consciousness at the time of the fall. A physical exam was performed that revealed clear breath sounds bilaterally, and tenderness noted upon palpation of her right ribs. A chest x-ray was performed that showed nondisplaced fractures of the right anterior third and fourth ribs and the lungs were clear. A shoulder x-ray was done that showed no acute fracture or dislocation. A computed tomography (CT) scan of the chest revealed nondisplaced fractures of the right anterior third and fourth ribs, but her lungs were clear.   Trauma/Surgery consulted on the patient. The patient was admitted to the hospital for pain management. She received oxycodone for pain with relief noted. The patient was discharged home with instructions to follow up at the Trauma Clinic.

According to MCG Health Inpatient and Surgical Care 24th Edition Rib fracture ORG: M-545 (ISC)  admission is indicated for 1 or more of the following: hemodynamic instability; Flail chest; Acute respiratory failure (e.g., mechanical ventilation needed or imminent); Pain (e.g., inhibiting ability to cough or clear airway) that requires inpatient treatment (e.g., not controllable in observation care, outpatient regimen cannot be established); Injury (e.g., intra-abdominal, vascular, neurologic, pneumothorax) identified that requires inpatient care; Rib fracture associated with infection that requires inpatient care (e.g., pneumonia too severe for outpatient treatment);  hypoxemia that persists despite observation care treatment;  tachypnea that persists despite observation care treatment; Immediate inpatient surgery needed (e.g., for displaced rib fracture).  The patient did not have any of these factors that would have necessitated inpatient admission.  She did not have a flail chest. She was managed with nonsteroidal anti-inflammatories (NSAIDs) and was hemodynamically stable.
The health care plan did act reasonably and with sound medical judgment and in the patient's best interest.  
The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Community acquired pneumonia  
Treatment: Inpatient admission  

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

This patient is a female who was admitted for the treatment of community acquired pneumonia. On arrival to the Emergency Department (ED), the patient's vitals were: temperature 98.9, respiratory rate 20, heart rate 89, and blood pressure 153/70. On exam, the patient's lungs revealed some crackles on the right lung but the patient was noted not in acute distress. The patient's neurological exam was normal without any clinical signs of altered mental status. The patient's lab showed normal white blood cell (WBC) count, electrolytes, and lactate. The patient's chest x-ray showed patchy right lower lobe infiltrate.  

Based on the review of the medical record provided, the patient did not have hypoxia or altered mental status associated with her community acquired pneumonia. The patient's electrolytes were within normal limits, and the patient did not have signs or symptoms of dehydration. The patient's pneumonia severity, CURB 65 score was zero. The patient did not have confusion, urea >7mmol/L, respiratory rate >=30, or low blood pressure noted by either systolic blood pressure <=90 mmHg or diastolic blood pressure <=60 mmHg. The patient's age was not >65, and there was not documentation that this patient's condition was refractory to outpatient treatment. The patient was tolerating oral intake and was ambulatory. The patient remained afebrile, and hemodynamically stable after admission. The patient's oxygen saturation ranged from 93-95% room air. Based on the review of the clinical criteria for inpatient admission, this patient did not need acute hospitalization. The patient's care could have been safely and effectively provided at an observation level of care. The patient was stable for discharge home on oral medications after overnight observation, which could have been done as observation status.  

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

Diagnosis: Chest Pain.
Treatment: Inpatient Hospital.
The health plan denied the inpatient admission. 
The health plan's determination is upheld.

This case involves a female with a history of hypertension, hyperlipidemia, diabetes mellitus, and pulmonary embolism no longer on anticoagulation, who was sent by her cardiologist to the emergency room (ER) for evaluation of intermittent chest pain and shortness of breath occurring with talking and laughing lasting less than a minute for the last 3 weeks. The report of the initial electrocardiogram (ECG) showed T wave inversions in the inferolateral leads. A coronary computed tomography angiography (CTA) was performed showing nonobstructive coronary disease. The patient was ruled out for myocardial infarction with three negative cardiac troponins, D-dimer negative. The patient was admitted to inpatient telemetry service for chest pain evaluation and an echocardiogram which was normal. The patient's health plan has denied coverage for inpatient level of care due to the lack of medical necessity.

The health plan's determination that inpatient level of care was not medically necessary is upheld, in whole in this case.

No, it is not. Given the patient's resolution of symptoms, negative cardiac troponins, normal cardiac function, and nonobstructive coronary artery disease seen on cardiac CT (computerized tomography), inpatient level of care was not medically necessary. Observation level of care was medically appropriate in this case.
This patient presented with chest pain with atypical features, was ruled out for myocardial infarction with negative cardiac troponins and had a coronary CTA (computed tomography angiography) which showed nonobstructive coronary artery disease. Her cardiac function was normal by echocardiogram. The patient was asymptomatic while in the ER with no further episodes of chest pain. The patient's Heart Score, a well validated risk stratifying tool to determine need for admission, was calculated to be 4. In the presence of negative cardiac troponins, it was indicated that the patient could be safely monitored under observational level of care [1,2]. In addition, the 2014 American College of Cardiology (ACC) / American Heart Association (AHA) guideline for the management of patients with non-ST-elevation acute coronary would also support observation level of care in this case given her negative cardiac workup, negative cardiac troponins, and resolution of her symptoms [3].
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems.
Treatment: Mandibular Partial Denture- Cast Framework with Resin Denture Bases for Lower Arch.
The insurer denied coverage for the Mandibular Partial Denture- Cast Framework with Resin Denture Bases for Lower Arch.

The denial is overturned. 

This is a male patient who presented for evaluation and comprehensive dental care. Recommended treatment was for mandibular removable partial denture to restore function. The insurer has denied these services stating that there is adequate posterior occlusion and therefore, the services are deemed not medically necessary. 

Upon review of the documentation, in particular the panoramic radiograph, the patient exhibits oligodontia in the maxilla and mandible. Review of the remaining dentition on radiograph indicates a level of moderate periodontal alveolar bone loss corresponding to periodontal disease but otherwise essentially stable alveolar bone height without severe periodontal disease. The teeth that would be supported for the removable partial denture are stable and would be adequate abutment teeth. This treatment is a standard of care in dental practice for this clinical circumstance. As this is a covered service and indicated for restoration of function and occlusal stability, the partial denture is considered medically/dentally necessary for this patient.

The recommendation is to overturn the denial and approve lower partial denture as partial dentures are designed for use in this clinical circumstance, are a covered service for this patient, are a standard of care in general dental practice, and would be an appropriate treatment to restore function and occlusal stability.

The mandibular partial denture- cast framework with resin denture bases for lower arch is considered medically necessary for this patient.

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

The medical necessity for the Mandibular Partial Denture- Cast Framework with Resin Denture Bases for Lower Arch is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid obesity.
Treatment: 43775 - Laparoscopic sleeve gastrectomy.
The insurer denied the 43775 - Laparoscopic sleeve gastrectomy. 
The denial is overturned. 

This patient is a female. She has a body mass index of 52.5 kg/m2 (kilograms per meters squared). Her weight related co-morbid conditions include the following: HTN (hypertension), GERD (gastroesophageal reflux disease) and sleep apnea.

Dietary and psychiatric clearance were obtained by the patient. The patient participated in support groups and was cleared by the provider after completing a comprehensive multidisciplinary evaluation. EGD (esophagogastroduodenoscopy) revealed gastric polyps without need for further treatment.

Yes, the 43775 - Laparoscopic sleeve gastrectomy is medically necessary.

This patient meets all standard nationally accepted criteria for bariatric surgery at this time. This patient is an adult, no prior bariatric surgery with documented morbid obesity and a BMI (body mass index) of 52 kg/m2 (kilograms per meters squared). The patient completed a psychological, dietary and medical evaluations specifically for candidacy for bariatric surgery and was not identified to have any barriers to treatment. The requested bariatric procedure is therefore determined to be medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problem (Anterior crossbite with gingival attachment loss). 
Treatment: D8080 braces and D8670 x 12 monthly visits. 

The insurer denied coverage for D8080 braces and D8670 x 12 monthly visits. 

The denial is overturned. 

This patient is a female child who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss among other findings.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements. 

It is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic index. The HLD index provides 6 specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  This reviewer finds that this automatically qualifying condition criterion is clearly met and does support comprehensive orthodontic care.  In this case, the clinical circumstance does meet the insurer and the plan criteria to justify orthodontic care. 
 
D8080 braces and D8670x 12 monthly visit 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 medical necessity for D8080 braces and D8670 x 12 monthly visits is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient admission.  The denial is upheld.

This case describes a female patient who sustained an acute fall in her bathroom. This incident resulted in right hip pain. She was evaluated in the emergency department where an evaluation and plain x-rays confirmed a right inter-trochanteric hip fracture. She was admitted for further orthopedic care and a plan was made for the patient to undergo fixation of the femoral fracture by the orthopedic consultant on the case. The patient's grandson, however, requested a transfer of the patient to another facility. This transfer was facilitated and completed as per the family's request. The subject under review is the medical necessity for the inpatient admission.

The health plan's determination is upheld.

The requested health service/treatment of inpatient admission was not medically necessary for this patient.
The rationale for this determination is based upon the provided medical records and the recommendations of the current, peer-reviewed orthopedic literature. The records documented that this patient sustained an acute intertrochanteric hip fracture after a fall. The plan of care detailed in the provided records was for operative fixation of the fracture. This plan was consistent with the recommendations of the peer-reviewed literature as documented by Egol and colleagues in the Journal of Orthopedic Trauma. The patient, however, did not undergo the recommended surgery and was transferred to another institution for definitive orthopedic care. The patient's inpatient hospital admission was not medically necessary since definitive care was not rendered for her injury. Based upon the provided records in this case, the care rendered prior to her transfer could have been completed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied full braces. 
The health plan's determination is overturned.

The patient is a male with a Class I, crowded occlusion and a 100% deep bite causing damage to his lower incisors. He is treatment planned for full braces to correct malocclusion. The subject under review is the medical necessity for the treatment.  

The health plan's determination is overturned in whole.

The requested treatment of braces is medically necessary for this patient. The patient's cephalometric radiograph indicates a palatally-impinging overbite. Palatal tissue damage is a known side effect of deep bite malocclusions.1 A deep bite on its own is not a reason to treat with orthodontics. However, the patient is already causing wear to the incisal edges of his teeth. This will worsen with time if left untreated and can lead to periodontal problems in the future that will be more invasive to correct than the orthodontic problem he currently has. 2  Therefore the treatment of full braces is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Immunologic Disorders-Alopecia.
Treatment: Pharmacy/Prescription Drugs-Xeljanz XR.

The health plan denied the treatment of Xeljanz XR as not medically necessary.  The reviewer has upheld the health plan determination in whole. 

The patient has alopecia areata of the left eyebrow, face, and scalp. The patient has tried and failed topical steroids such as Olux foam and intralesional Kenalog. The patient has documented hair loss of the left eyebrow and scalp. Discrete non-scarring patches of hair loss of the face and scalp have left her with 50% of her scalp surface area without hair.  In addition to topical steroids, and patient has failed topical bimatoprost for her eyelashes.

The requested Xeljanz XR is not medically necessary for this patient. While understandable to consider Xeljanz for this patient's condition, the requested medication merits further study before being presumed acceptable for widespread clinical use. At this time, the long-term safety of this medication is not as confirmed as short-term efficacy in the use of Xeljanz for this condition. Alopecia areata is notoriously difficult and unpredictable to treat, as well as unpredictable in its response to treatment. Oral immunosuppressants, light therapy, contact allergen treatment and related therapies have all resulted in variable and unsatisfactory outcomes. While Xeljanz has some promising preliminary results in open-label studies (5, 6), the overall literature and reviews on alopecia areata (1-4) mention Xeljanz only as investigational. Xeljanz was denied FDA approval for use in psoriasis, in large part for safety reasons, and is not without a significant risk of side effects that preclude an acceptable risk for use outside of the investigational setting for the condition of alopecia areata.
At this time, Xeljanz is only FDA-approved for rheumatoid arthritis patients who have failed methotrexate, for psoriatic arthritis, and for ulcerative colitis--all three conditions have indications whereby the safety risks of not using treatment are significantly greater than treatment itself. The same cannot be said for Xeljanz in the treatment of alopecia areata, where physical/functional impairment and overall health impacts are minimal to nonexistent--despite the social/psychological impacts that can occur in some patients. The proper dosing, anticipated side effects and long-term outcomes are not known at this time for Xeljanz in the treatment of alopecia areata, as well as short-term and long-term safety risks of relevance to this patient's overall health. There are no large, randomized, controlled, prospective trials demonstrating and proving the safe and effective treatment of alopecia areata with a specific dosing of Xeljanz.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: HIV
Treatment: Pyrimethamine 25MG TAB
The insurer denied the Pyrimethamine 25MG TAB.
The denial is overturned. 

The patent prescription for Pyrimethamine 25MG TAB is under review.

The patient has a history of AIDS (acquired immunodeficiency syndrome), CD4 (cluster of differentiation 4) count 86 (9%), noncompliance with HIV (human immunodeficiency virus) therapy, recent history of brain mass associated with headaches and right foot drop. Treatment was started but patient had been off toxo treatment (Pyrimethamine and sulfasalazine) for several weeks. The physicians would like to initiate proper course of uninterrupted treatment for toxoplasmosis, and reevaluate lesion. If it is smaller, then toxoplasmosis treatment would continue, but if unresponsive then a brain biopsy will be performed.

Yes, the proposed treatment is medically necessary.       

Toxoplasmosis in HIV (human immunodeficiency virus) patients is often diagnosed based on response to treatment because brain biopsies are invasive, difficult to obtain, and can cause permanent neurologic sequalae (1). After a period with anti-parasitic treatment, the MRI (magnetic resonance imaging) is repeated to evaluate the lesion and its response (1). In this case, as the patient was off of treatment for several weeks, the MRI can be difficult to interpret. Thus, the treatment must start anew, as the patient's physicians in this case requested. Failure to do so could lead to delay in proper diagnosis, which itself can cause permanent neurologic damage or death. Thus the Pyrimethamine should be approved.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis 
Treatment: Inpatient Hospital
The health plan denied the inpatient hospital stay. 
The health plan's determination is overturned.

The patient is a male with a history of anxiety who presented to the emergency department (ED) with complaints of fever and chills after a left leg injury. He reported that he had his leg problem one and one-half weeks prior and had developed fevers. He was seen at urgent care and was started on Bactrim and then as the illness persisted, he was seen again and was started on Doxycycline and Levofloxacin. A fluid collection over the wound had opened and was draining pus. On admission, vital signs included a temperature of 98.5 F, a heart rate (HR) of 82 beats per minute (bpm), a blood pressure (BP) of 111/69 millimeters of mercury (mmHg) and an oxygen saturation of 97%. Physical exam (PE) noted erythema, edema and induration of the left leg with an area of opening and dry blood. Labs included a sodium (Na) of 142, a potassium (K) of 4.1, a carbon dioxide (CO2) of 27.8, a creatinine of 1.2, a white blood cell count (WBC) of 7.78, a hemoglobin of 12.4, and platelets of 301. An x-ray of the left leg was negative for fracture. Blood cultures were obtained, and general surgery was consulted for possible drainage and he was admitted and started on Vancomycin and Aztreonam (due to penicillin allergy). Infectious disease (ID) recommended treatment with Vancomycin only and follow up with cultures. The patient requested discharge and after consultation with ID was discharged on oral antibiotics.

At issue is the medical necessity of the inpatient stay.

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

Yes, the admission is considered medically necessary at an acute level of care. The patient is considered to have a severe purulent infection based on Infectious Diseases Society of America (IDSA) guidelines that had failed outpatient therapy. "Severe infection: patients who have failed oral antibiotic treatment an antibiotic active against methicillin-resistant staphylococcus aureus (MRSA) is recommended for patients with carbuncles or abscesses who have failed initial antibiotic treatment" and IV antibiotics with close clinical monitoring is warranted given the concern there may be resistance to his outpatient regimen [1]. It would be important for general surgery and ID consultation to ensure more drainage of the abscess is not needed and that the patient remains clinically stable as he had been on an appropriate regimen of Levofloxacin plus Doxycycline without improvement [2].