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

Diagnosis: Rashes
Treatment: Removal of excess skin and subcutaneous (beneath the skin) tissue surgery (procedure codes 15847, 15830, and 15877 x 1 unit each)
The insurer denied coverage for removal of excess skin and subcutaneous (beneath the skin) tissue surgery (procedure codes 15847, 15830, and 15877 x 1 unit each).
The denial is upheld.

The plastic surgeon's note describes a history of rashes, not represented in the medical record documentation in the form of PCP (primary care physician) or dermatology progress notes, which describe ongoing clinically significant dermatologic problems that have either 1) never responded to physician directed topical therapy or 2) despite initial response, have recurred and caused significant functional impairment. Supervised medical management for rashes is not documented in any of the progress notes. The photos are black and white and do not show rashes or skin changes. The patient is not sick from her excess skin, and has not had ulcerations, panniculitis or sepsis from her infections. A dermatologist has not evaluated the rashes. The patient has not required hospitalization or treatment with intravenous (IV) or oral antifungal or antibiotic medications. The excess skin has not jeopardized health.  

Physician supervised treatment is the simplest, safest and most cost-effective method of managing this patient's problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting the condition. In a multiple regression analysis of postoperative complications after body-contouring surgery written by Parvizi, et al, the authors found that the overall rate for major complications that required operative revision and/or antibiotics was 10.2% (percent). In addition, 41% had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscences. Conservative, non-operative treatment would be recommended, such as improved hygiene, topical creams or powders, and watchful waiting. Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. Summary treatment letters and member appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised 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 removal of excess skin and subcutaneous (beneath the skin) tissue surgery (procedure codes 15847, 15830, and 15877 x 1 unit each) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism

Treatment: medical equipment, E1399 x 6, special enclosed cubby bed

The insurer denied coverage for medical equipment, E1399 x 6, special enclosed cubby bed
The denial is overturned

The patient is a female with autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD). She receives physical, occupational and speech therapy services at school. Under review is the medical necessity of requested medical equipment, E1399 x 6, special enclosed cubby bed.

The insurer denied the request for medical equipment, E1399 x 6, special enclosed cubby bed, citing "no indication that standard covered medical supplies failed to meet the patient's needs. There is no indication that less intensive alternatives to improve the patient's safety have been tried. These include bed rails, mattress on the floor, removal of all safety hazards, bed alarms, and video/audio monitors." However, in a letter, the patient's mother discusses several fewer intensive alternatives to improve the patient's safety that have been tried without success, including toddler bed, bed rails, audio/visual monitoring as well as other strategies such as child proofing home and other features (e.g., white noise machine, night lights, bed/door alarms, doorway gates). Given the failure of the other less intensive alternatives, the requested special enclosed cubby bed, is a reasonable safety measure and should be considered medically necessary.  

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 the medical equipment, E1399 x 6, special enclosed cubby bed, is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied gabapentin suppository. 
The denial is upheld.

The patient is a female with chronic anal pain and levator ani syndrome. It has been difficult for the patient to get consistent relief. The treating physician has prescribed gabapentin suppositories.
The subject under review is the medical necessity for the gabapentin suppository for this patient.

The health plan's determination is upheld. 

Gabapentin suppository is not medically necessary because it is not supported by scientific literature. The data supporting a gabapentin suppository is extremely limited, largely relegated to small case series, which represent the lowest quality of evidence. There are no prospective comparative studies, and few to no retrospective comparative analyses. The use of suppositories for pelvic floor dysfunction, especially more transient forms such as levator syndrome, is also problematic as it is unclear if the rectal formulation has any local effect on the puborectalis muscle, while there is no support for a systemic form of gabapentin for pelvic floor dysfunction. 
Taken together, there is no data to support gabapentin, via any route, as a standard, non-experimental treatment for pelvic floor dysfunction, pelvic pain, or anorectal pain. While anecdotally this patient or others may report relief, evidence must be supported by clinical science, and not on case reports or patient anecdotes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Decline in functional ability.
Treatment: Skilled Nursing Facility Stay.
The insurer denied the Skilled Nursing Facility Stay. 
The denial is upheld.

The patient is a male with history of general weakness and tremors with decreased balance and decreased fine and gross coordination. He also had frequent falls, decline in self-care and functional mobility. He had history of recent COVID-19 pneumonia.

The patient had relevant past medical history of Diabetes Mellitus, Hypertension, Anemia, CAD (coronary artery disease), CHF (congestive heart failure), GERD (gastroesophageal reflux disease), (Coronavirus Disease 2019) COVID-19, etc. He was admitted to SNF (skilled nursing facility).

Prior to admission to SNF (skilled nursing facility), he required supervision for transfers. He could ambulate 150 feet using single-point cane, contact guard for stairs, and able to negotiate more than 15 steps with contact guard with handrail and single-point cane. He was a resident of the SNF (skilled nursing facility) nursing home.

The patient was ambulating 150 feet using single point cane, required supervision for transfers, upper body dressing/bath, requiring minimum assistance for lower body dressing/bath, toileting, and independent with feeding and grooming.

No, the Skilled Nursing Facility Stay was not medically necessary.
The plan has appropriately denied coverage for continued stay in SNF (skilled nursing facility). The SNF (skilled nursing facility) care was not medically necessary and should not be covered by the health plan. The patient has not met all the criteria for sub-acute rehabilitation care under INTERQUAL Criteria for Subacute/SNF (skilled nursing facility) Criteria Acute Neurological (SAC-SNF). He was ambulating 150 feet using single point cane, required supervision for transfers, upper body dressing/bath, requiring minimum assistance for lower body dressing/bath, toileting, and independent with feeding and grooming. He had no ongoing clinical issues that required management in an SNF (skilled nursing facility) setting.

Therefore, the SNF (skilled nursing facility) stay was not medically necessary, and the patient could have been better served in a lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting. 
Treatment: Inpatient Stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female with a past medical history significant for diabetes mellitus, hypertension, and hyperlipidemia who presented to the hospital with intractable vomiting for several days. It was reported that the patient did not tolerate oral intake and vomited everything she tried to eat. She took Zofran without improvement in her symptoms. 

The patient's symptoms, which included nausea and vomiting, were not associated with hemodynamic instability or severe pain. There was no evidence that the intractable nausea was related to central nervous system problems. There was no mention that the patient had an abnormal abdominal exam including peritoneal signs. The imaging studies did not reveal evidence of ileus or small bowel obstruction. There was no evidence that the patient's symptoms were related to severe infection or bacteremia.
The lipase level and liver function test (LFT) were completely normal, therefore, there was no suspicion for acute pancreatitis or cholecystitis. Acute kidney injury was very mild and the patient's kidney function normalized within the first day of the hospitalization. Prolonged QT interval was not associated with any cardiac arrhythmias of immediate concern. 
The evaluation and treatment of the skin rash did not require admission at the acute inpatient level of care. Taking into consideration all these facts, a lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder - overbite.
Treatment: Braces and Office Visits.
The insurer denied the Braces and Office Visits.
The determination is upheld.

The patient has a Class II cuspid malocclusion, moderate maxillary crowding and moderate mandibular crowding, moderate overjet, and moderate overbite. The issue for review is whether the requested service/treatment, braces, and office visits, are medically necessary.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 23 with no auto qualifiers. Auto qualifiers include cleft palate deformity or craniofacial anomaly, impacted permanent anterior where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater, and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary.
Thus, according to the standard of care, the requested service/treatment for braces and office visits are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Benign prostatic hyperplasia (BPH).
Treatment: prostate artery embolization/ambulatory surgery.
The insurer denied coverage for prostate artery embolization/ambulatory surgery.
The denial is overturned.

This case involves a male who was diagnosed with lower urinary tract symptoms, nocturia, increased frequency, urgency, weak stream, and straining and is being considered for prostatic artery embolization (PAE) for benign prostatic hyperplasia (BHP). According to the documentation, the patient was seen and evaluated by a vascular and interventional radiologist who agreed that prostatic artery embolization would be the best treatment option to manage the patient's benign prostatic hyperplasia. The patient previously received a notice of adverse determination regarding the proposed surgery, which indicated that the criteria were not met as the role of the service remains uncertain. It is not fully proven that it improves health outcomes of the usual standard of care and the health plan did not cover investigational (unproven) tests or treatments. The physician is appealing the denial, stating that prostatic artery embolization techniques for treatment of benign prostatic hyperplasia have already been established and once a candidate is deemed eligible for embolization, the choice of embolization modality should lie on the performing physician to be able to use a modality to best serve the patient with comparable efficacy and equal safety. This review is about the coverage of prostate artery embolization/ambulatory surgery.

Literature states that prostatic artery embolization (PAE) is effective and safe for the treatment of men with Lower Urinary Tract Symptoms (LUTS) from benign prostatic hyperplasia in the setting of concomitant, localized, non-obstructive PCA (prostate cancer). The procedure is a minimally invasive procedure for men with benign prostatic hyperplasia that was originally utilized for the treatment of refractory hematuria of prostatic origin. Previously, the patient received a notice of adverse determination for this procedure with claims that it was investigational/experimental, and therefore not covered under the policy. However, the current medical literature has verified that this is now being utilized with effectiveness for the treatment of the patient's condition.

Scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes.

Prostate artery embolization/ambulatory surgery has final approval from the appropriate regulatory bodies for this diagnosis.

The patient is a good candidate for prostate artery embolization/ambulatory surgery.

Prostate artery embolization/ambulatory surgery is one of the best available treatments for this patient at this time.

The adverse risks are not increased over standard treatment/services.

The requested services are likely to be as beneficial or more beneficial than any of the standard treatment/procedures for this patient.

The insurer's denial of prostate artery embolization/ambulatory surgery is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain; syncope.
Treatment: Inpatient admission.

The insurer denied Inpatient admission.  The denial is upheld.

The patient is an adult male with a past medical history of diabetes, hyperlipidemia, protein C deficiency, pulmonary embolism, and depression. He presented to the emergency department for evaluation of chest pain and syncope. He reported an episode of passing out where he struck the back of his head. Prior to his syncopal episode, he reported chest pain that radiated to his left arm.

On arrival to the ED (emergency department), the patient was afebrile and hemodynamically stable he was saturating well on room air. Initial labs demonstrated a normal initial troponin. Twelve-lead EKG (electrocardiogram) demonstrated normal sinus rhythm without acute ST changes. He was admitted to the inpatient unit with plans to undergo cardiac catheterization. He was pre-medicated with prednisone and Benadryl, but before his catheterization, the patient decided to leave AMA (against medical advice).

The inpatient admission was not medically necessary.

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion. His EKG (electrocardiogram) did not demonstrate acute ST changes, and he was ruled out for acute coronary syndrome with serial troponins. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care. Observation level of care would have been appropriate in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: rhinovirus

Treatment is an inpatient admission 

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

This is a female who had been sick for 2 days with a cough and nasal congestion. Her mother brought her to the ER (emergency room) when she was noted to have difficulty breathing.

In the emergency room she was noted to have respiratory distress with abdominal breathing, suprasternal and subcostal retractions. On physical examination she was described as having grunting and shallow breathing. The oxygen saturation was 91% on room air. On physical examination she was noted to have nasal congestion and rhinorrhea. Examination of the left ear showed erythema of the tympanic membrane. There was wheezing noted in the right middle and upper lung fields. She was begun on oxygen supplementation of 45% at 8 liters of flow. She was treated with one dose of albuterol and Atrovent via a nebulizer and upon reexamination there was moderate improvement in her breathing and clearing of her wheezing. She was also treated with an intravenous (IV) bolus of IV fluids. A respiratory viral panel was positive for the rhinovirus. Based on the increased work of breathing upon presentation to the ER and the continued need for oxygen supplementation the decision was made to admit her to the hospital for continued treatment with oxygen, IV fluids and albuterol every 4 hours with a diagnosis of bronchiolitis.

The patient was treated appropriately in the ER for a respiratory illness related to the rhinovirus with coughing, wheezing and persistent low oxygen saturation which required oxygen supplementation. When attempts to wean the oxygen supplement were unsuccessful the decision to admit for continued oxygen supplementation and albuterol was consistent with the standard of care for a child with bronchiolitis and hypoxemia. The child could not have been discharged safely with hypoxemia. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Plus-two (+2) mobility of tooth # (number) 9
Treatment: Bone graft and a guided tissue regeneration (GTR) resorbable barrier on tooth #9
The insurer denied: Bone graft and a guided tissue regeneration (GTR) resorbable barrier on tooth #9
The denial is overturned.

The patient is an elderly female. The request is for dental benefits for a bone graft on tooth #9 (upper left central incisor). Per the Provider's dental clinical summary - the patient presents with plus-two (+2) mobility of tooth #9, periodontal charting states a four-millimeter pocket, and the provider clinical notes indicate a five-millimeter pocket.

The health plan denied the claim because they stated that the pocket depth was not sufficient to warrant bone grafting.

The provider appealed based on the diagnosis and clinical condition of tooth #9.

The proposed treatment of bone grafting on tooth #9 is medically necessary.

In this case, the claim was denied based on the pocket depth that was submitted on the periodontal chart; it stated that there was a four-millimeter pocket. Typically, one would consider a graft when pocket depths exceed six to seven millimeters. However, in addition to pocket depth, the x-rays can show the bone level relative to the tooth and also the amount of mobility that tooth displays. 

The patient's x-ray submitted supports that there is a low level of bone on the mesial of tooth #9 and the clinical exam stated that there is a plus-two (+2) mobility of tooth #9; this is consistent with a low level of bone.  Since, the bone is what holds the teeth in place, the higher the level the more stable the tooth will present and the lower the level the more unstable and mobile the tooth becomes.  Given that this is an upper front tooth, the patient did not want to lose this tooth and was given a viable option to stabilize the tooth.

The function of the incisors is to cut or shear the food during the chewing process. The central incisor being the larger of the incisors plays a very important role in carrying out this function. The retention and the stabilization of this tooth is needed given the information seen on the x-ray (reduced bone level); the health plan did not take all these circumstances into consideration.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sepsis secondary to pneumonia
Treatment: Inpatient Admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

The patient is a male who was sent to ED (emergency department) from urgent care for an abnormal CXR (chest x-ray) and possible pneumonia. The patient had complaints of weakness, body aches, headache, loss of appetite and weight loss. Laboratory results were white blood cells count 16.6, hemoglobin 14.5, sodium 128, blood urea nitrogen 18, and creatinine 1.0. Lactate was within normal limits and liver function test (LFTs) had mild elevation.

Chest x-ray showed right infrahilar and medial right lower lobe infiltrate consistent with pneumonia. The patient was started on Rocephin and Azithromycin and admitted to hospital. The patient continued treatment and once improved was discharged.

This patient had Sepsis secondary to pneumonia. He was febrile to 103.6F (Fahrenheit), heart rate 119, respiratory rate 20, blood pressure (BP) 123/87 Hg (millimeters of mercury). Oxygen (O2) saturation 94 % (percent) on room air which dropped to 91 % requiring O2.  He was alert and oriented to person, place, and time. Neurology exam was non-focal. The patient had hyponatremia and elevated LFT's which was consistent with multi organ involvement. Procalcitonin was elevated to 0.7. 

The patient continued to be febrile in the hospital and needed supplemental O2. LFT"s remained high. Na+ (sodium) continued to remain low to 130. Given multiple medical issues with multi organ involvement, it was appropriate to admit the patient for treatment and close monitoring.

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 the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left ear infection
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This is a patient with past medical history significant for hypertension, diabetes mellitus, and hyperlipidemia who presented to the emergency room with complaints of left ear pain. 

Vitals on presentation included temperature of 97.6 Fahrenheit, blood pressure (BP) 142/82, pulse 75, respiratory rate 18, oxygen saturation 95% on room air. Laboratory results included the following: white blood cell (WBC) count 10.5, hemoglobin 15.2, hematocrit 45.6, creatinine 0.9, glucose 88.

Patient was admitted to the hospital for a left ear infection. He was started on intravenous antibiotics (vancomycin and cefepime). Maxillofacial computed tomography (CT) scan showed small amount of fluid within the left mastoid air cells. Patient remained afebrile and hemodynamically stable. He was discharged on oral antibiotics. 

Patient presented with left ear pain. Otherwise, he was afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC. CT scan showed no acute findings with maxillofacial bones. Patient was described as "resting comfortably." Based on above findings, patient met criteria for observation level of management.   

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

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.