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

Diagnosis: Dental Caries. 
Treatment: D2750 white glass with high gold content crown, on tooth 29. 

The insurer denied coverage for D2750 white glass with high gold content crown, on tooth 29. 

The denial is upheld. 

The documentation consists of an appeal letter from the patient. A photograph has been received which appears to be of a discolored tooth #8 and radiographs which do not show large caries in #29. There is no documentation showing that a crown is needed for #29. 

Crowns are needed for: 

- Large, previously placed restorations. When a tooth appears to require an intracoronal preparation that exceeds one-half of the facial-lingual cusp tip-to-cusp tip distance, placement of an intra-coronal direct or indirect restoration is a questionable procedure. Cusps often break off during service, in spite of the placement of "bonded" restorations. 
- Cracked-tooth syndrome 
- Asymptomatic cracks in teeth If the tooth has deep horizontal cracks and an intracoronal restoration, there is a significant possibility that a piece of the tooth will break off during service. If the tooth has vertical cracks, the possibility of tooth breakage appears to be less. 
- Endodontically treated, heavily restored teeth 
- Broken cusps 
- Hemisected teeth 
- Mobile teeth requiring splinting 
- Need for esthetic upgrading. 

There is no documentation of any of the above. The crown is not medically necessary for #29. 

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

The insurer's denial of coverage for D2750 white glass with high gold content crown, on tooth 29 is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus.
Treatment inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is overturned.

This is a male with a history of asthma. He had a cough, a runny nose and increased work of breathing for 2 days prior to admission to the hospital. The patient's mother and sister were also sick. The patient was vomiting all liquids and foods and the mother was administering albuterol to the patient every 4 hours. The mother noted worsening difficulty breathing and she noted that he appeared to be tiring out, so she brought him to the Emergency Department (ED) for further treatment.

In the ED, the patient was noted to be in respiratory distress with wheezing. He had nasal flaring, retractions, and tachypnea on physical examination. A chest x-ray was unremarkable. A blood gas was significant for an elevated partial pressure of carbon dioxide (PCO2) level of 42 which is elevated for a tachypneic child. The patient's pulse oxygen reading was low at 89-90% (percent) and he was started on 2 liters (l) of oxygen. He was treated with 3 doses of Combivent, dexamethasone, magnesium and an intravenous (IV) bolus of normal saline. When the patient's respiratory symptoms did not improve with treatment in the ED, the decision was made to admit him with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 2 hours.

Children with asthma with rising pCO2 levels despite tachypnea are at risk for respiratory failure. This patient had been taking albuterol for 2 days at home and failed to improve with outpatient therapy. He was treated appropriately in the ED for a cough, wheezing and respiratory distress. Following treatment in the ED, he continued to have ongoing respiratory distress with persistent wheezing and increased work of breathing. He had an elevated pCO2 of 42 on a blood gas.

Based on the review of the medical record, it was appropriate and consistent with the standard of care to admit the patient to the hospital for ongoing treatment with albuterol every 2 hours, as he continued to be in respiratory distress with a diagnosis of status asthmaticus and was not stable enough to be discharged home. The inpatient hospital admission was considered medically necessary treatment for the patient's condition.

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metacarpal Fracture

Treatment: Hospital admission

The insurer denied coverage for hospital admission.

The denial is upheld.

This is the case of a patient with no known past medical history who presented to the Emergency Department (ED) with a chief complaint of injury to the right hand after he punched a wall. X-ray showed displaced 4th and 5th metacarpal fracture. Hand Surgery was consulted and recommended splint and admission for operative repair. The patient was admitted to General Surgery for closed traumatic displaced fracture of multiple metacarpal bones. The patient underwent open reduction internal fixation (ORIF) of the right hand and tolerated the procedure well. He was discharged home with outpatient Plastic Surgery/General Surgery follow-up.

The medical records demonstrate the patient sustained a closed hand injury two days prior. He was found to have displaced metacarpal fractures and required operative intervention. This was a low energy type of injury with no open wound. His procedure was not complex and of short duration. His operation was completed in 42 minutes. There was no blood loss. His vital signs remained stable. There was no evidence of fever. He did not have problems with his wound (splinted). He was able to tolerate oral pain medication. He did not require physical therapy (PT) nor occupational therapy (OT). He did not require treatment for an underlying medical condition. This type of surgery is performed electively in an ambulatory surgery unit (ASU). There were no findings to substantiate an admission and length of stay. There were no extenuating circumstances to warrant the level of care provided. 

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

Diagnosis: Chronic low back pain
Treatment: Additional Physical Therapy Visits
The insurer denied the Additional Physical Therapy Visits
The denial is upheld.

The patient is a female. She has a history of chronic low back pain. The back pain
is associated with weakness and muscle spasms. This has been affecting her ADLs
(activities of daily living). She is into yoga and regular stretching exercises. She did
not achieve long-term relief from lumbar spinal injections, including epidural.

The patient started PT (physical therapy) earlier this year, for PT (physical
therapy) sessions until spring, with significant relief. Additional visits were
approved.

The patient's Oswestry low back pain rate was 38% disability, movement loss in
flexion and extension minimal, trunk muscle power average 4/5, all showing
improvement compared with previous report. However, she was still experiencing
pain with stiffness, lumbosacral hypo mobility with spasms, restricted function and
ADLs (activities of daily living), core weakness and difficulty with prolonged walking
or sitting. The request is for more additional physical therapy visits.

No, the Additional Physical Therapy Visits after the already-approved additional
sessions are not medically necessary.

The patient has shown adequate improvement from prior 20 PT (physical therapy)
sessions. Her Oswestry low back pain rating was 38% disability, movement loss in
flexion and extension minimal, trunk muscle power average 4/5, all showing
improvement compared with previous report, but still experiencing pain with
stiffness, lumbosacral hypo mobility with spasms, restricted function and ADLs
(activities of daily living), core weakness and difficulty with prolonged walking or
sitting.

The already-approved additional sessions were adequate towards transition to a
home exercise program for long term improvement. Therefore, continued PT
(physical therapy) sessions are not medically necessary.

As noted above, the continued Physical therapy after the already-approved
additional sessions is not medically necessary. The patient has shown adequate
improvement from the prior PT (physical therapy) sessions. Further PT (physical
therapy) sessions beyond the approved extra sessions were not medically
necessary, as further PT (physical therapy) session is not reasonably expected to
be health beneficial for the patient, and/or withholding it, in whole or in part, is not
reasonably expected to affect the patient's health adversely.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient is status post C (cesarean)-section delivery for a diagnosis of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. She was initially hospitalized and discharged. The patient was experiencing headaches at home. She also reported swelling in her hands and feet. The patient presented for evaluation. Examination revealed positive 3 pedal edema bilaterally. The patient's blood pressure was 136/85, and her heart rate was 96. Her laboratory evaluation was normal. The patient's headache resolved with Tylenol. The patient was discharged with instruction to continue Procardia and to follow up with outpatient Obstetrics for blood pressure check.

This patient presented 4 days after delivery with headache and swelling of hands and feet.

The diagnosis of preeclampsia is based on the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman:
1) Systolic blood pressure greater than or equal to 140 mmHg (milliliter of mercury) or diastolic blood pressure greater than or equal to 90 mmHg, and 2) Proteinuria greater than or equal to 0.3 grams in a 24-hour urine specimen or protein: creatinine ratio greater than or equal to 0.3, or signs of end-organ dysfunction (platelet count less than 100,000/microliter, serum creatinine greater than 1/1 mg/dL [milligrams per deciliter] or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration).

This patient had a headache that resolved after Tylenol and hand and feet swelling; no protein in the urine was documented and no elevated liver function test (LFTs) or end organ dysfunction. 

Ideally this patient would have been observed for a few hours. Once her lab results came back reassuring and she was determined to be stable, she could have been discharged home on home blood pressure monitoring and to return if any worsening of her blood pressure. Admission to the hospital was not medically necessary. Note that nothing was done in the hospital except for giving her Tylenol.

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 is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Triple-Vessel Coronary Artery Disease

Treatment hospital admission

The insurer denied coverage for hospital admission

The denial is overturned

This case involves an adult male patient with history of chest pain. History and physical indicated the patient had a history of three vessel disease on catheterization as well as non-ST (interval on EKG [electrocardiogram]) elevated myocardial infarction (NSTEMI) [non-ST segment elevation myocardial infarction]. He had a history of stenting. The patient reported occasional exertional angina. The patient underwent selective coronary angiography with stent placement. He was noted to have triple-vessel coronary artery disease. The procedure report indicated there was no complications. Cardiology note reported post procedure, the patient had some chest discomfort which improved on Tridil drip. At the time of the evaluation the Tridil drip continued to be weaned and the patient denied any chest pain, shortness of breath, or palpitations. The patient was hemodynamically stable. He was recommended for continued medication management and monitoring for symptoms. The patient was discharged in stable condition.  

Milliman Care Guidelines (MCG) recommends inpatient stay after percutaneous coronary intervention for patients requiring glycoprotein IIb-IIIa (receptor on the platelet surface) receptor inhibitors in elective situations to include administration regimens include single bolus, 12-hour, and 18-hour infusions with an expect minimal to brief stay extension (1-3 days). The patient underwent selective coronary angiography with stent placement. Post-procedure, he had some chest discomfort which improved on Tridil drip. The patient was also treated with medication management to include Aggrastat. Aggrastat is a glycoprotein IIb/IIIa inhibitor. Given the complications post-procedure and need for intravenous drips, inpatient admission was supported. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.                                                             
The hospital admission was medically necessary. 

The insurer's denial of coverage for the hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: malocclusion

Treatment: braces (comprehensive orthodontic treatment)

The insurer is denied coverage for braces (comprehensive orthodontic treatment)
The denial is upheld. 

This female patient has a history of impacted upper left molar #7 (UL7) and lower left molar #7 (LL7); anterior deep bite: 4 millimeters (mm); overjet (OJ): 3mm; class I molar; class II canine left side; moderate lower crowding; mild upper crowding; upper left wisdom #8 (UL8) developing; proclined incisors.

Upon review of the submitted documentation it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides six 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 completes the second portion of the index arriving
26 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 7 points on the HLD index (4 overjet, 2 overbite, and 1 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies.

Each of the peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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

The carrier's denial of coverage for the braces (comprehensive orthodontic treatment)  is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth Decay.
Treatment: Nerve treatment on teeth #8 and #9, Pre-service.
The insurer denied the nerve treatment on teeth #8 and #9, Pre-service.
The denial is upheld. 

The patient is an adult  female.  Clinical  records do not document the condition teeth #8 and #9.  There appears to be large composite restorations in/on teeth #8 and #9, however, it is not known if the composite restorations are superficially on the tooth (such as cosmetic) or if they are within the tooth structure (such as restorative).

No, the nerve treatment on teeth #8 and #9 is not medically necessary.

There are no abscesses seen on the x-ray of teeth #8 and #9.  There may be a small amount of decay present on the x-ray on the mesial of tooth #9, but that should not cause any discomfort.  Based upon the submitted x-ray, it is not known what the concerns are with the teeth and clinical records do not describe symptoms.  Therefore, medical necessity of the nerve treatment on teeth #8 and #9 is not supported.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain.
Treatment: Intracept Procedure, Pre-service.
The insurer denied the Intracept Procedure, Pre-service.
The denial is upheld.

The patient is a female with chronic low back pain. The patient has tried activity modification, anti-inflammatories and physical therapy for several months.  She has trouble sitting.

Magnetic resonance image (MRI) of the lumbar spine showed disc herniations at L3-4 and L4-5 with L4-5 spondylolisthesis and facet hypertrophy. There were Modic type II degenerative changes at L4-5. 

The attending physician (AP) has recommended the Intracept procedure.

No, the proposed Intracept procedure is not medically necessary.
This patient has chronic low back pain with degenerative spondylolisthesis, facet arthropathy and disk degeneration - all of which can be contributing to her low back pain.  Facet injections should be done to determine if the facets are contributing to her pain.  She may require lumbar fusion as she has instability in the form of degenerative spondylolisthesis.  The Intracept procedure is intended for isolated disk degeneration when all other sources of pain have been ruled out and they have not.  Therefore, the proposed procedure is not medically necessary.

The source of this patient's low back pain has not been confirmed.  She has lumbar facet degeneration along with spondylolisthesis which could be contributing to her chronic symptoms.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypomagnesemia and Hypocalcemia

Treatment: Hospital admission

The insurer denied coverage for hospital admission.

The denial is upheld.

The patient presented with tingling in her extremities as well as pain in her calves. She had a previous episode of diarrhea. She was afebrile and her vital signs were stable. The abdominal exam was benign. There was no leukocytosis. The potassium was 3.2 and the magnesium 1.5. The calcium was 7.5. The electrocardiogram (EKG) did not have acute changes. She was given magnesium supplementation and calcium and potassium replacement were given. After her electrolytes improved her symptoms resolved. It was felt that the magnesium loss was related to the diarrhea. 

Clinical indications for admission for Gastroenteritis (M-170) include having a suspected severe infection, severe abdominal pain, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration, and a severe electrolyte abnormality that persists despite observation care. The patient did not have these conditions. She had significant hypomagnesemia and hypocalcemia. However, these conditions responded to treatment, and she could have received the electrolyte replacements with observation care. She did not meet Milliman Care Guidelines (MCG) criteria for admission for Gastroenteritis.

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient. An inpatient admission was not medically necessary.

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

Diagnosis: Major Depressive Disorder

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

This is the case of a female with a history of heart failure with preserved ejection fraction, rheumatic mitral stenosis, hypertension (HTN), hypothyroidism and depression that presented to the hospital with weakness for five days and multiple falls including a fall that resulted in head trauma. She also reported loss of appetite and depression.  Upon arrival to the emergency department (ED), her blood pressure was 169/80 and pulse was 46 beats per minute (bpm). Other findings on physical exam were unremarkable except for a body mass index (BMI) of 17 kilogram (kg)/meter(m)2(squared). The patient reported recent initiation of clonidine 0.2 milligram (mg) daily for hypertension and noncompliance with levothyroxine replacement therapy. An electrocardiogram (ECG) revealed sinus bradycardia at 40 bpm, and serum blood testing revealed an elevated thyroid stimulating hormone (TSH) level (82) and a low free thyroxine (T4) level. She was admitted to telemetry for observation and treatment. Cardiac monitoring revealed heart rates into the 30s, but ambulation ruled out chronotropic incompetence. Cardiology, endocrinology and psychiatry consultation was sought. The patient's clonidine was discontinued, she was restarted on levothyroxine and diagnosed with major depressive disorder by psychiatry. She was ultimately discharged several days following presentation. 

This patient presented with weakness and falls that persisted over a five-day period. Evaluation in the ED revealed multiple possible etiologies including symptomatic bradycardia, hypothyroidism and orthostatic hypotension due to clonidine treatment. This patient clearly had near syncope with falls and head trauma. Sinus bradycardia likely contributed to her weakness, consistent with a cardiac etiology (1-2). She was also recently started on clonidine therapy for hypertension that likely resulted in worsening bradycardia and orthostatic hypotension. These findings combined with hypothyroidism and a TSH level of 82 support a class I indication for inpatient evaluation according to the American College of Cardiology (ACC), American Heart Association (AHA) and Heart Rhythm Society (HRS) guidelines for evaluation and management of syncope (1). In conclusion, there was sufficient evidence to support that an inpatient admission was medically necessary for observation and treatment in this complicated case.

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

The insurer's denial of coverage for the inpatient admission is reversed. Medical necessity is substantiated.