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

Diagnosis: Supraventricular tachycardia 
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a man who presented to the emergency department after calling Emergency Medical Services (EMS) for sudden onset palpitations and chest pain. EMS found the patient to have supraventricular tachycardia at a rate of approximately 180 beats per minute. The tachycardia was terminated with intravenous adenosine and the patient was transported to the emergency department. His medical history was remarkable for hypertension, diabetes and myocardial infarction. In the emergency department, his blood pressure was 153/72 millimetre of mercury (mmHg) with a heart rate of 98 beats per minute. His room air oxygen saturation was 94%. An electrocardiogram showed sinus rhythm with occasional ventricular ectopy. There were no acute ischemic changes. Chest X-ray showed no acute pathology. The patient's serum troponin level was minimally elevated. 

The inpatient hospital admission was not medically necessary.
This patient presented with hemodynamically stable paroxysmal supraventricular tachycardia (PSVT). The rhythm was terminated with an intravenous adenosine bolus and the repeat electrocardiogram showed no acute changes. While there are no established guidelines regarding disposition for patients presenting to the emergency department with PSVT, most authors suggest that, in the absence of serious unstable comorbidities, syncope, or rapid pre-excited atrial fibrillation or flutter, hospital admission is not necessary for adults whose PSVT is converted to sinus rhythm without complications. One single-center, retrospective study of patients presenting to emergency department with PSVT found that 71% were discharged home after an average stay of four hours. The 24-hour recurrence rate in those patients was less than 5%. Likewise, data from the National Hospital Ambulatory Medical Care Survey 1993-2003 database revealed a 76% discharge rate for PSVT after evaluation in the emergency department. While this patient complained of chest pain and had a minimally elevated serum troponin level, this is common in PSVT, even in the absence of coronary artery disease. In fact, it is not recommended that cardiac biomarkers be checked based on PSVT alone but only when there is reasonable suspicion of acute coronary insufficiency. In summary, this single episode of hemodynamically stable PSVT that was terminated with intravenous adenosine did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental crowding and overjet. 
Treatment: Orthodontic treatment. 

The insurer denied coverage for orthodontic treatment. 

The denial is overturned. 

This female patient has class II molar, class II canine, severe lower crowding, moderate upper crowding, overjet of 6 millimeters, overbite of 4 millimeters, recent crowns at upper right (UR) 6 and lower left (LL) 7 with cement present on marginal borders, partial eruption of the third molars, and centric relation (CR)- centric occlusion (CO) discrepancy shifts to the left side at CO. She has been denied orthodontic treatment as her Handicapping Labio-Lingual Deviation (HLD) score was below 20 and she did not qualify for a functional handicapping malocclusion.  The provider states that the patient's HLD score was 26. The patient exhibits a mandibular retrognathia with an overjet of 5 to 6 mm.  The upper incisors are proclined and there is significant crowding in the lower anterior. This reviewer agrees with the provider's HLD scoring. 

As per Mitchell (2020), one or more of these dental traits that would have an adverse effect on the longevity of dentition, indicating high need for correction: (1) Increased Overjet; (2) Increased traumatic Overbites; (3) Anterior crossbites causing decreased periodontal support; (4) Unerupted impacted teeth (where there is danger of pathology); (5) Crossbites associated with mandibular displacements. 

As per Schatz et al. (2020)'s prospective study, "overjet stood out among variables as the most significant risk factor of [traumatic dental injury (TDI)]: an increased overjet of 6 mm or more had a major impact on the risk of trauma, which would speak in favor of early orthodontic correction of an increased overjet to reduce the prevalence of dental trauma." 

Based on the review of the medical record and literature, this patient meets the requirements for comprehensive orthodontic treatment. This patient's increased overjet indicates a high need for correction the patient has increased overjet which indicates a high need for correction. If the teeth do not occlude properly, masticatory function can be impaired, with patients reporting difficulty in biting through food or poor chewing ability.  Damage to the long-term health of the teeth and periodontium can include risk of trauma to the maxillary incisors where the overjet is increased. Therefore, comprehensive orthodontic treatment of the adolescent dentition (code D8080) 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 comprehensive orthodontic treatment of the adolescent dentition (code D8080) should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nephrolithiasis

Treatment: MRI of the pelvis without and with contrast

The insurer denied coverage for MRI of the pelvis without and with contrast

The denial is overturned 

The patient is a female who presented for a follow-up regarding nephrolithiasis.  She does have a history of renal colic and iron deficiency.  She was found on imaging to have an obstructing ureteropelvic junction (UPJ) stone to the left side requiring a percutaneous nephrolithotomy.  She did have a 5 millimeter (mm) mid left renal stone and a punctate calcification to the right kidney.  The patient was placed on medication.  The documentation indicated the patient did admit to not being completely compliant with Polycitra.  She has a history of iron deficiency which she felt was secondary to menstrual blood loss.  The patient did have a creatinine of 0.89 with potassium of 3.4.  Her ferritin was 7.  The physician indicated a stone protocol computed tomography (CT) showed no change when compared to prior CT scan.  She has a small stable 4 mm stone or calcification in the lateral mid-portion of the left kidney with a tiny stone in the lower pole of the right kidney.  There was also a soft tissue mass centered in the pelvis measuring approximately 10 cm.  The mass was only 3.8 cm before presentation.  Although likely uterine fibroids it has increased significantly and should be further evaluated.  It was recommended she continue with medication and undergo additional imaging.  The documentation does indicate that the patient underwent magnetic resonance imaging (MRI).

MRI is the most effective modality for visualizing the size and location of all uterine myomas and can distinguish among leiomyomas, adenomyosis, and adenomyomas.  Due to the expense of this modality, its use is best reserved for procedural planning for complicated procedures.  It may also be useful before uterine artery embolization (UAE) since imaging patterns predict uterine artery embolization outcome.  This patient was considering a UAE at the time of the MRI and afterwards had a successful UAE.  The denial should be overturned, and the MRI should be covered.

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

The insurer's denial of coverage for the Magnetic Resonance Imaging (MRI) of the pelvis without and with contrast provided is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperreflexia

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This case involves a female who presented to the Emergency Department (ED) complaining of a near syncopal episode.  The patient's past medical history included gestational hypertension and anxiety.  The patient has a temperature of 98 degrees on physical examination with a heart rate of 104 beats per minute.  The patient's blood pressure was 192/104.  The patient was alert and oriented.  The patient was recommended to undergo laboratory and diagnostic studies.  Her laboratory studies did not reveal any significant findings.  The patient's computed tomography (CT) scan of the head and interval appearance of a faint 4 millimeter (mm) focus of high attenuation in the medial left temporal lobe most suggestive underlying calcification from small cavernoma as opposed to a focal small hemorrhage.  Follow-up is recommended in 6 hours to confirm stability.  The documentation detailed that the patient was seen and evaluated by neurosurgery and was found to have hyperreflexia.  It was recommended that the patient be admitted for further evaluation and management. By the time of discharge, the patient's temperature was 98.4 degrees with heart rate of 61 beats per minute and blood pressure of 133/77.

According to the Milliman Care Guidelines, the acuity of this case is considered to have required observation as the patient presented with a transient altered mental status and suspected syncope. Upon arrival to the hospital, the patient had an extensive workup to exclude structural causes. No worsening was appreciated. The patient had a CT scan showing an old, calcified lesion that did not require any intervention. The patient did not require an escalated level of care or intervention.

The current literature indicates that a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe persistent or there is evidence of hemodynamic instability. Within the documentation it was noted that the patient presented with near syncope without focal deficits. However, the submitted documentation does not detail the patient had a trial and failure of care at a lower level such as observation. The documentation does not detail any treatment interventions. Thus, the requested inpatient admission would not be the most appropriate level of care and therefore, is not considered medically necessary of this patient.

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral ptosis and dermatochalasis, and right lower lid ectropion.  
Treatment: Blepheroplasty. 

The insurer is denied coverage for surgical procedure blepharoplasty. 

The denial is overturned. 

This is a male patient with a past medical history of ptosis of both upper eyelids, tearing eyes, and ectropion due to laxity of eyelid, right.  The patient was evaluated by Ophthalmology for consultation regarding ectropion-right lower lid (RLL).  According to the visit notes, the patient reported that he has been having issues with his eyelids getting in the way of vision or the past several years.  The patient has noticed the upper eyelids are like curtains, covering vision; constantly using eyebrows to help see better; also having trouble reading and keeps losing place on the line.  There were reportedly no alleviating/ aggravating factors.  The patient also reported that his eyes have been tearing for years; worse in the morning and better in the afternoon.  The surgical procedure, Blepharoplasty, procedure code 67904 was performed.

Cahill et al. 2011 (American Academy of Ophthalmology guidelines) states that repair of blepharoptosis and upper eyelid dermatochalasis provides significant improvement in vision, peripheral vision, and quality of life activities.  Preoperative indicators listed include superior visual field loss of at least 12 degrees or 24%, symptoms of discomfort or eye strain due to droopy lids, and patient self-reported functional impairment. 

The bilateral upper blepharoplasty procedure is medically necessary and within standard of care for this patient.  Frontal and lateral photos document redundant upper eyelid skin with clear extension of the upper lid over the lashes.  Visual field testing confirms functional superior field defects in both eyes that improved with taping of the eyelids.  In addition, the patient reported his eyelids affecting his vision and his eyelids feeling heavy.  The history, clinical exam and testing would support that blepharoplasty procedure is medically necessary (Fuller 2017, Cahill 2011). 

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 blepharoplasty is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fatty Liver

Treatment: MRI of the brain with and without contrast

The insurer denied coverage for MRI of the brain with and without contrast

The denial is upheld 

The patient is a male with a history of elevated cholesterol in the setting of normal weight.  He had a liver sonogram that demonstrated a fatty liver.  He denied jaundice and abdominal pain.  He had signs of nonalcoholic fatty liver disease (NAFLD) and a normal weight.  He did not have the stigmata of advanced liver disease.  He had elevated copper in his liver tissue.  The provider noted this possibly supported Wilson's disease.  The provider ordered magnetic resonance imaging (MRI) of the brain for testing of possible Wilson's disease.

There was no clinical documentation of an abnormal neurological examination that included clinical signs associated with Wilson's disease: dysarthria, dystonia, tremors, choreoathetosis, ataxia, or other gait abnormalities.  Also, the brain MRI was not requested by a neurologist.  The patient was seen by ophthalmology, who described the absence of Kayser- Fleischer rings, which are seen in nearly all patients with neurological manifestations of Wilson' disease.  The diagnosis of Wilson's disease should have been confirmed by genetic testing.  Other gastrointestinal causes of hepatic copper deposition should have been excluded before ordering advanced neuroimaging to evaluate secondary manifestations of a rare genetic diagnosis.

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

The magnetic resonance imaging of the brain with and without contrast is not considered medically necessary for this patient (pre-service).

The insurer's denial of coverage for magnetic resonance imaging (MRI) of the brain with and without contrast (pre-service) is upheld. Medical necessity is not substantiated
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female who had presented to the emergency room with the complaints of abdominal pain and constipation for the preceding two weeks. The patient was then diagnosed with acute sigmoid diverticulitis. The patient was admitted for further care and treatment of this condition. The patient was admitted. At the time of discharge, the patient was tolerating oral intake and the complaint of pain was controlled.

No, the proposed inpatient admission was not medically necessary. The treatment as provided was medically indicated; however, the level at which this care was provided was not medically necessary.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection in her large intestine called diverticulitis, yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain(diverticulitis). 
Treatment: Inpatient Admission. 

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

The patient is a female who had two weeks of abdominal pain prior to her presentation to the emergency room (ER). The patient had a known history of diverticulosis and prior diverticulitis. The patient presented with complaints of fever, body aches and epigastric pain. The patient noted nausea and emesis. A computed tomography (CT) scan showed active phlegmonous diverticulitis. 

The patient's presenting temperature was 100.9. The vital signs were otherwise normal. The patient had a history of a brain stent. The patient received intravenous (IV) antibiotics, intravenous (IV) fluids and supportive care. The presenting white count was 12.91. The patient was rendered nothing by mouth (NPO). The patient tolerated an oral diet and improved and was discharged. 

The care as provided was medically appropriate; however, the level at which the care was delivered was not medically necessary. 

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had a diverticular infection in a segment of her bowels, yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such, the care could have been rendered at a lesser level. 

The entirety of the care as received could have been provided within that time frame at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Confusion and dizziness
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The patient is a female with a history of Charcot Marie Tooth Disease, Sarcoidosis, Hypertension and Diabetes Mellitus She presented to the ER via ambulance for further evaluation/management of mental status changes while driving her car. 

The patient's intake vitals were notable for febrile temperature of 100.4 F. Her other vitals were hemodynamically stable. Her examination was notable for significant gait ataxia, different from her normal baseline. Laboratory testing was notable for elevated white blood cell count and elevated serum lactic acid levels.

The patient was subsequently admitted to the inpatient medical service, where she received treatment with aggressive IV fluid hydration and continued monitoring of her neurologic status along with reassessment of her laboratory tests to ensure improvement/normalization. She responded well to the prescribed therapies, and she was subsequently discharged in stable condition. 

An appeal review requested for potential approval of inpatient admission. 

The patient is a female with a history of Charcot Marie Tooth Disease, Sarcoidosis, Hypertension and Diabetes Mellitus who presented to the ER via ambulance for further evaluation/management of mental status changes while driving her car. 

The patient's intake vitals were notable for febrile temperature of 100.4 F. Her other vitals were hemodynamically stable. Her examination was notable for significant gait ataxia, different from her normal baseline. Laboratory testing was notable for elevated white blood cell count of 12.1 and elevated serum lactic acid level of 2.9. 

The patient was subsequently admitted to the inpatient medical service, where she received treatment with aggressive IV fluid hydration and continued monitoring of her neurologic status along with reassessment of her laboratory tests to ensure improvement/normalization. She responded well to the prescribed therapies, and she was subsequently discharged in stable condition. 

Evidence of febrile temperature, ataxic gait, acute mental status changes in this patient with multiple serious risk factors including Charcot Marie Tooth Disease, Sarcoidosis, Hypertension and Diabetes Mellitus and finally evidence of significantly elevated serum lactic acid levels of 2.9 made inpatient hospitalization medically necessary. This patient's care could not have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed treatment of inpatient admission is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied temozolomide 100 mg cap. 
The denial is overturned.

The patient is a male with a recurrent, bifrontal isocitrate dehydrogenase (IDH)-mutant anapestic astrocytoma (grade III). The patient was treated with resection followed by radiation+adjuvant Temodar (temozolomide) at diagnosis (10 cycles). Temodar has been recommended for therapy; this is under review for medical necessity.

The requested Temozolomide 100 milligrams (mg) cap is medically necessary. Temozolomide using a variety of dosing schedules has been studied in several phase II studies of patients with recurrent high-grade glioma. In the largest study (RESCUE), continuous daily temozolomide (50 milligrams per meters squared per day [mg/m2/day] for up to one year) was evaluated in 120 patients. For patients with glioblastoma, the six-month progression-free survival ranged from 15 to 29 percent, depending upon whether progression occurred during or after the original adjuvant temozolomide treatment. Patients who were re-challenged after completing an adjuvant regimen (such as this patient) were the most likely to respond. For patients with an anaplastic glioma, the six-month progression-free survival was 36 percent with dose-intense temozolomide. No therapy is known to be superior to this. For these reasons, both the authors of UpToDate and the National Comprehensive Cancer Network (NCCN) Guidelines recommend the use of this approach in the treatment of patients with recurrent gliomas. This approach is no longer the subject of ongoing investigation. For these reasons, criteria for medical necessity have been satisfied for this service.