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

Diagnosis: Enlarged nodular goiter.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with a history of an enlarged nodular goiter with compressive symptoms. The patient underwent a total thyroidectomy and was admitted as an inpatient.

The inpatient stay was denied coverage by the health plan as not medically necessary, and the provider is appealing the denial.

No, the Inpatient admission was not medically necessary.
All records were reviewed. The patient underwent a total thyroidectomy with no intraoperative or postoperative complications. Vital signs were stable, and drain output was 35 CCs (cubic centimeters). There was no respiratory compromise and no hematoma was noted. The pain was controlled and the patient was tolerating a diet. Therefore, based on the information provided, the medical necessity of the inpatient stay cannot be confirmed, as the patient could have been treated at a lower level of care, Observation.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient, as the patient could have been treated at a lower level of care, Observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld. 

The patient is a female that presented to the emergency department (ED)  with vomiting, diarrhea, and loss of appetite. She had no fever. She had one episode of vomiting but was not eating or drinking. Vital signs included temperature 37.4, heart rate 121, respiratory rate 30. Examination was significant for no apparent distress, no drooling or stridor or grunting, dry oral mucosa, abdomen non-tender, and non-focal neurologic exam. Laboratory evaluation was significant for hypoglycemia (glucose), metabolic acidosis (carbon dioxide [CO2] 12.5). Abdominal x-ray revealed non-specific bowel gas pattern. She was diagnosed with severe dehydration and hypoglycemia. She was treated with dextrose 10 percent (D10) and a normal saline bolus followed by maintenance intravenous (IV) fluids. She was also given a glycerin suppository with Miralax to start the following day. She did not have a bowel movement but was otherwise had returned to baseline. She was deemed stable for discharge. 

The subject under review is the medical necessity for the inpatient stay. 

According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications. Hospitalization may be necessary for those that do not respond to oral hydration and anti-emetic treatment, as well as those with severe dehydration.
This young child presented with decreased appetite and vomiting. Evaluation revealed hypoglycemia and metabolic acidosis consistent with significant dehydration. She responded well to fluids and was able to advance her diet. While it was appropriate to monitor her ability to tolerate an advancing oral diet, she was overall hemodynamically stable with no evidence of circulatory collapse or sequelae from hypoglycemia or dehydration. She did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Vascepa 1GM OR CAPS. 
The denial is upheld.

This case involves a male patient with a history of type 2 diabetes, hypertriglyceridemia, and hypertension (HTN), who has been treated with maximally tolerated statin therapy and has been prescribed Vascepa 1 gram (gm) capsule for additional lowering of triglycerides. The patient's health plan has denied coverage for the non-formulary medication, Vascepa 1gm capsule, because clinical documentation has not demonstrated treatment failure and intolerance to the generic version icosapent ethyl nor documented treatment failure to the preferred list of medications for the treatment of hyperlipidemia. The patient's treating provider is appealing this denial.
At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug or would have adverse effects.

The health plan's determination is upheld in whole. 

The REDUCE-IT trial published in The New England Journal of Medicine (NEJM) in 2019 was a multicenter, randomized, double-blind, placebo-controlled trial that enrolled patients with established cardiovascular disease or with diabetes and other risk factors treated with maximally tolerated statin therapy and who had a fasting triglyceride level of 135 to 499 milligrams (mg)/deciliter (dL). (1) Patients randomized to receive 2 gm of icosapent ethyl twice daily (total daily dose, 4 gm) experienced a significantly lower risk of cardiovascular events including cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, coronary revascularization, or unstable angina compared to placebo. Based on these results, Vascepa (icosapent ethyl) was granted United States Food and Drug Administration (FDA) approval as an adjunct to maximally tolerated statin therapy to reduce the risk of cardiovascular (CV) events in adult patients with elevated triglyceride levels greater than or equal to (>=)150 mg/dL and established cardiovascular disease or diabetes mellitus along with 2 or more additional risk factors. According to the patient's records provided for review, there has been no case documentation indicating treatment failure, intolerance, or adverse effects to Vascepa 0.5gm. Vascepa 0.5gm, as a listed formulary medication, would be medically appropriate to treat this patient's hypertriglyceridemia and reduce his risk of future cardiovascular events.
Therefore, the formulary drugs have not been ineffective, and would be as effective as the non-formulary drug.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diarrhea and Vomiting. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient is a female who presented with diarrhea and vomiting. She was previously hospitalized for these symptoms and a computed axial tomography (CAT) scan showed colitis. She was told that it was a viral syndrome, but her symptoms persisted. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The renal function was normal. Intravenous (IV) hydration and Reglan were given. A stool test for Clostridium difficile was positive and she was treated with oral Vancomycin. Her symptoms improved on the Vancomycin. 

Clinical indications for admission for Gastroenteritis- Milliman Care Guidelines (MCG) M-170 include having a suspected severe infection such as bloody diarrhea, severe abdominal pain, peritoneal signs, hemodynamic Instability, severe vomiting that is persistent after receiving antiemetic therapy, severe electrolyte abnormalities that persist after observation care, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had persistent diarrhea and then had a stool test that was positive for Clostridium difficile toxin. IV hydration, antiemetics, and stool testing could have been done with Observation status. She responded well to the treatment with oral Vancomycin. Her renal function was normal. She did not meet MCG criteria for admission for Gastroenteritis and could have been managed with Observation care. 

The denial is upheld. 

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

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

Diagnosis: Dental Problems/Other/Malocclusion. 
Treatment: Dental/Orthodontic Procedure/ Braces and Monthly Visits. 

The health plan denied Orthodontic Procedure/ Braces and Monthly Visits. 
The health plan's determination is overturned. 

The patient is a male with a Class I malocclusion, severe crowding, and an anterior crossbite of #7. He is treatment planned for orthodontics to correct his malocclusion.
At issue is the medical necessity for the requested dental treatment plan. 

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

This patient presents with an anterior crossbite and severe crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.[1,2,3] These problems are much more time consuming and costly to correct than the patient's current orthodontic problem. 
The patient has severe maxillary and mandibular crowding with #7 in crossbite. This tooth has a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time [4], which will make treating this occlusion at a later time more difficult. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, atrial fibrillation and osteoarthritis. 

Treatment: Personal care aide (PCA) services level 2 of 12 hours per day, 7 days per week for a total of 84 hours per week. 

The insurer denied coverage for personal care aide (PCA) services level 2 of 12 hours per day, 7 days per week for a total of 84 hours per week. 

The denial is overturned. 

This patient has progressive dementia, atrial fibrillation and osteoarthritis status bilateral knee replacements.  She lives in a 3-bedroom apartment with her daughter.  Under review is a requested increase from PCA services of 8 hour/day, 7 days/week for a total of 56 hours/week to 12 hours/day, 7 days/week for a total of 84 hours/week. 

According to the Uniform Assessment System (UAS), the patient requires maximal assistance for activities of daily living including bathing, personal hygiene, dressing and toilet transfers/use.  She is incontinent of bowel and bladder.  Her cognitive status is described as "severely impaired" and continues to decline.  She requires maximal assistance for bed mobility, which resulted in her falling when getting out of bed.  Over the past 90 days, the patient's activities of daily living (ADL) status and self-sufficiency have declined and deteriorated, respectively.  The combination of the patient's progressive dementia and continued functional decline support the requested PCA increase of 12 hours/day, 7 days/week for a total of 84 hours/week, as medically necessary.  The increased PCA will allow the patient to continue living safely at home. 

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).  

From a physical medicine and rehabilitation perspective, the requested Personal Care Aide (PCA) Services Level 2 of 12 hours per day, 7 days per week for a total of 84 hours per week, is considered medically necessary for this patient. 

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

The insurer's denial of coverage for Personal Care Aide (PCA) Services Level 2 of 12 hours per day, 7 days per week for a total of 84 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Maxillary and Mandibular Crowding. 
Treatment: Braces and Monthly Visits. 

The insurer denied braces and monthly visits. 
The health plan's determination is upheld. 

The patient is a female with maxillary and mandibular crowding and many unerupted permanent teeth. The orthodontist stated that tooth #6 and #11 are impacted. The patient is treatment planned for braces and monthly visits. 

Braces and monthly visits are not medically necessary. Neither teeth #6 nor #11 appear to be erupting at a poor angle on the radiograph, and it is too early to determine if it will require an exposure as maxillary canines usually erupt at 11-12 years of age. However, there is a great discrepancy in this timing. There is still much time to see if the maxillary canines will erupt successfully on their own without orthodontic intervention. The patient does have maxillary and mandibular crowding and treatment may be indicated in the future. However, the patient does not exhibit any of the criteria to suspect her canines are, in fact, impacted. For this reason, braces/monthly visits not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

The patient is a female who presented to the hospital complaining of chest pain and lightheadedness that developed while she was playing with her grandchildren. Past medical history was significant for hypertension, diabetes mellitus, bipolar disorder, and breast cancer status post left mastectomy. Upon arrival to the hospital, vital signs were stable with blood pressure (BP) 163/83 and pulse 66. No significant findings were noted on physical examination. Serum blood testing revealed no elevation of troponin x (times) 3 with levels less than 0.012ng/ml (nanograms per milliliter). A 12-lead electrocardiogram (EKG) demonstrated sinus bradycardia and no evidence of ST (interval on EKG) or T (interval on EKG) wave abnormality. The patient was admitted to the hospital for observation and treatment. Consultation by the heart rhythm service for lightheadedness led to a recommendation to avoid sinus and atrioventricular (AV) nodal blocking agents. Following echocardiography and stress testing the patient was discharged on medical therapy. 

This patient presented with chest pain and lightheadedness. Serum troponin and electrocardiography revealed no evidence of an acute coronary syndrome. Her pretest probability of coronary artery disease is intermediate (1). Utilizing the HEART (History, EKG, Age, Risk factors, and troponin) score, she was considered low risk (2). Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (3). Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati, et al. (3) Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. This patient could 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. 

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

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Acupuncture. 
The insurer denied acupuncture. 
The denial is upheld.

The patient is a male with cervicalgia and right shoulder pain. The patient was previously treated with acupuncture visits. At issue is the medical necessity of acupuncture visits for this patient.

The health plan's determination is upheld.

The patient is a male with cervicalgia and right shoulder pain. The patient was previously treated with acupuncture visits. The patient had pain and tenderness in the right shoulder.  The patient had pain in the neck and right shoulder and tenderness in the right shoulder. There was no documentation of significant improvement in pain levels, range of motion, strength, or function during the relevant time frame, and therefore, the acupuncture would be considered maintenance treatment. Maintenance treatment, where the patient's symptoms are neither regressing nor improving is considered not medically necessary. The acupuncture treatments are not medically necessary. The peer-reviewed medical literature does not support acupuncture treatments on the days in question. Further the medical standard of care in the United States at this time would not include in acupuncture treatments during the relevant time period. 
The Official Disability Guidelines (ODG) acupuncture guidelines recommend an initial trial of 3-4 visits over 2 weeks and with objective functional improvement, up to 8-12 acupuncture visits total over 4-6 weeks. ODG notes that the evidence is inconclusive for repeating acupuncture beyond an initial short course of therapy of 12 visits. In this case, there was no documentation of objective functional improvement that would indicate that more than an initial trial of 3-4 visits was medically necessary. Acupuncture visits in question are not medically necessary. The peer-reviewed medical literature does not support acupuncture visits.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overjet; overbite.
Treatment:  D8080 Braces.
The insurer denied the  D8080 Braces.
The denial is overturned

The patient is a female. The request is for dental benefits for orthodontic treatment (Braces). Per the Provider's dental clinical summary, the patient presents with excessive overjet of 7mm (millimeters), overbite--5mm (millimeters), Class II molar and Canine, moderate crowding.

The health plan denied coverage for the braces, because the patient did not score a 26, the score necessary for approval of Braces on the Handicapping Labio-Lingual Deviation (HLD) Index Report.

The provider is appealing the claim based on the diagnoses as listed in the dental clinical summary.

Yes, the requested orthodontic treatment (Braces) is medically necessary.
As evidenced by the patient's x-rays and photos, the patient presents with an over jet (protrusion) of 7mm (millimeters). Normal overjet is 1-3mm (millimeters).

Any significant overjet beyond the normal limits puts the patient at risk for increased trauma due to the protrusion, sleep apnea, speech impediments and possible damage to the soft tissue (gums) from the position of the lower teeth contacting the upper gums.

Therefore, the requested braces are medically necessary.

No, the health plan did not act reasonably with sound medical judgement and in the best interest of the patient.
The severity of the overjet, if left untreated, can have a severe long term negative impact on the patient's ability to have normal chewing function and speech.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Irritable Bowel Syndrome with Diarrhea (IBS-D).
Treatment: Rifaximin.
The insurer denied the Rifaximin.
The denial is overturned.

The patient is a male with irritable bowel syndrome - diarrhea (IBS-D). He has failed loperamide and hyoscyamine. The attending physician (AP) is requesting treatment with Xifaxan.

Yes, the proposed treatment with Xifaxan is medically necessary.
Xifaxan is clinically appropriate, accepted standard of care and medically necessary for the treatment of irritable bowel syndrome - diarrhea (IBS-D). This patient has failed anti-diarrheals (loperamide) and anti-spasmodics (hyoscyamine), and therefore, the requsted Xifaxan is clinically appropriate, accepted standard of care and medically necessary for the treatment of this patient's irritable bowel syndrome - diarrhea (IBS-D).

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
As Xifaxan is medically necessary as above, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Hospital Admission. 
The denial is upheld. 

The patient is a male with mild dementia, hypertension, congestive heart failure (CHF), with an ejection fraction (EF) of 25%, diabetes, and hyperlipidemia. He presented with intermittent sharp, non-radiating chest pain and dyspnea with minimal exertion. He had initially undergone a left heart catheterization showing severe multi vessel disease, including distal left main, ostial left circumflex, and ostial left anterior descending bifurcation. Cardiothoracic (CT) surgery had been consulted, and a decision was made for percutaneous intervention.

Percutaneous coronary intervention was performed to the left main, left anterior descending and left circumflex coronary arteries. The procedure was performed with Impella support. His post procedure course was uneventful. He was discharged on dual antiplatelet therapy (aspirin and ticagrelor) and atorvastatin, among other medications.
At issue is the medical necessity of the Inpatient Hospital Admission.

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

The requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient.
The patient is an elderly man with multiple co-morbidities. However, he presented with stable angina, electively for a percutaneous coronary intervention. The procedure was uncomplicated. The patient does not meet criteria for inpatient hospitalization, based on current guidelines. He did not have unstable angina, acute intravascular or extravascular complications of the procedure, a need for urgent coronary artery bypass graft (CABG) surgery, periprocedural cerebrovascular accident (CVA) or myocardial infarction (MI).
Therefore, the requested health service/treatment of Inpatient Hospital Admission was not medically necessary.