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

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

The patient is a male with Crohn's, previously treated with Avsola. He presented with abdominal pain and coffee ground emesis. He had recently been treated with azithromax for pneumonia, and had been off biologics. Recent colonoscopy and MRCP (Magnetic Resonance Cholangiopancreatogram) had revealed ileiits.

The patient was febrile and tachycardic, with an elevated WBC (white blood count). Hgb (hemoglobin) was 12.7. He was kept NPO (nothing by mouth) and placed on PPIs (proton pump inhibitors). EGD (esophagogastroduodenoscopy) revealed gastritis and active Crohn's of the stomach. CT (computed tomography) revealed active Crohn's of the ileum and stomach.

The patient received IV (intravenous) Remicade. He started a regular diet. There was no further coffee grounds or vomiting. Hgb (hemoglobin) remained stable. He was discharged on Pantoprazole once daily.

No, the Inpatient admission was not medically necessary.
The patient presented with abdominal pain, fever and vomiting. He was tachycardic with fever and an elevated WBC (white blood count). Observation status was medically appropriate on day one  EGD (esophagogastroduodenoscopy) and CT (computed tomography scan revealed active Crohn's of the stomach, and he was treated with Remicade and tolerated a diet without further vomiting. Observation status was medically appropriate on day one. On day two, when there was no active bleeding, he was hemodynamically stable, a diagnosis of gastric Crohn's had been made, and he was tolerating a diet without ongoing vomiting or GI (gastrointestinal) bleeding, he was medically stable for discharge. Therefore, observation status was medically appropriate, he was medically stable for discharge the next day. Acute inpatient hospital stay was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
As acute inpatient stay was not medically necessary, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epigastric discomfort; abdominal pain.
Treatment: Scope Test (EGD) (43239) .
The insurer denied the Scope Test (EGD) (43239) .
The denial is overturned.

The patient is a female. She had an EGD (esophagogastroduodenoscopy), which revealed esophagitis and gastritis.

Per the denial letter, the health plan denied coverage, indicating that EGD (esophagogastroduodenoscopy) was denied due to lack of documentation of trial of antacid medications for two months.

Per the appeal letter, the patient has a history of symptoms of gastro-esophageal reflux with epigastric discomfort and abdominal pain. The procedure revealed esophagitis and chronic gastritis, which was confirmed with biopsies taken, and pathology.

Per the plan clinical guideline Upper Gastrointestinal Endoscopy in Adults (CG-MED-59), An EGD (esophagogastroduodenoscopy) can be approved under the plan clinical criteria for people age 18 and over when used to diagnose certain conditions. These include, but are not limited to heartburn (reflux) after two months of treatment; persistent vomiting; a new feeling of fullness (dyspepsia) when age 50 or older; internal bleeding; problems during weight loss surgery; or suspicion of cancer or blockage.

Yes, the requested health service is medically necessary.
Per the appeal letter, the patient has a history of symptoms of gastro-esophageal reflux with epigastric discomfort and abdominal pain. The procedure revealed esophagitis and chronic gastritis, which was confirmed with biopsies taken and pathology. Thus, the diagnosis of dyspepsia is possible.

Per the clinical guideline for Upper Gastrointestinal Endoscopy in Adults, an EGD (esophagogastroduodenoscopy) is indicated for people with a new feeling of fullness (dyspepsia) when age 50 or older. The patient meets this criterion.

Based on the American College of Gastroenterology (ACG) and the Canadian Association of Gastroenterology (CAG) guidelines on dyspepsia in a joint ACG/CAG dyspepsia guideline, they suggest that patients 60 years of age presenting with dyspepsia are investigated with upper gastrointestinal endoscopy to exclude organic pathology.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The EGD (esophagogastroduodenoscopy) is indicated, based on the clinical history and the clinical standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Chiropractic Services. 
The insurer denied Chiropractic services. 
The denial is upheld.

The patient is a female who presented for chiropractic treatment of chronic low back pain and left shoulder pain, which was rated using the Visual Analog Scale (VAS) as 4/10 (low back), 4-5/10 (neck), 6/10 (mid-back) and 6/10 (left shoulder). The initial examination was limited in scope and detail, but subluxation and spasm were noted, and the patient was treated with spinal and extra-spinal manipulation, mechanical traction and use of a vibration plate as a therapeutic procedure. The subject under review is the medical necessity for the chiropractic treatments.

The health plan's determination is upheld.

The chiropractic services in question are not medically necessary for this patient. The initial allowance was for a number of treatments, after which treatment would continue to be necessary if there was objective evidence of ongoing clinical improvement. However, the patient's VAS scoring barely changed, there were no detailed objective examination or re-examination findings supporting ongoing clinical improvement, and no ongoing Oswestry scoring to give a more quantitative scoring to any improvements being made. It is also noted that there was no non-supervised home rehabilitation program in place to make treatment more effective. Treatment beyond the medical endpoint, with lack of improvements being made is not medically necessary. This applies here to chiropractic spinal manipulation,  extra-spinal manipulation, therapeutic procedure and  mechanical traction. This applies to all treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Abdominal/Stomach Pain
Treatment: Lab Work/Blood Tests - Calprotectin fecal test
The health plan denied the Calprotectin fecal test as experimental/investigational. 
The health plan's determination is overturned.

The patient is a  male. He presented with abdominal pain, constipation and at times loose bowel movements, and an unintentional weight loss. The patient had fecal Calprotectin testing to assess for inflammatory bowel disease.

At issue is whether the proposed health service for a Calprotectin fecal test is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The health plan's determination regarding the proposed health service is overturned, in whole.

The use of fecal Calprotectin is supported as likely to be more beneficial than any standard treatment or treatments for the insured's symptoms. The patient had abdominal pain, unintentional weight loss, and a change in bowel habits (with constipation and loose bowel movements), which can be consistent with inflammatory bowel disease, irritable bowel syndrome, and multiple other gastrointestinal diseases. The American College of Gastroenterology guidelines for irritable bowel syndrome state that "We suggest that fecal Calprotectin be checked in patients with suspected irritable bowel syndrome and diarrhea symptoms to rule out inflammatory bowel disease," as the patient has [1]. The test has proven effective to evaluate for inflammatory bowel disease without invasive measures such as colonoscopy, and to differentiate inflammatory bowel disease symptoms from functional disease symptoms [2,3]. In this case, the fecal Calprotectin testing was applied to evaluate symptoms, and was a less invasive method than alternatives such as colonoscopy to assess for inflammatory bowel disease as a cause for symptoms.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Abdominal/Stomach Pain
Treatment: Lab Work/Blood Tests - Calprotectin fecal test
The health plan denied the Calprotectin fecal test as experimental/investigational. 
The health plan's determination is overturned.

The patient in question is a male who was referred to a pediatric gastroenterologist for evaluation of abdominal pain and weight loss. As part of the initial evaluation, the physician ordered a fecal calprotectin for the purpose of eliminating inflammatory bowel disease (Crohn's disease, ulcerative colitis) as a possible diagnosis. Eventually, he was diagnosed with irritable bowel constipation.

At issue is whether the proposed health service of a Calprotectin fecal test is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

I overturn, in whole, the health plan's determination regarding the proposed health service.

Yes, there is abundant literature, including a recent Clinical Guideline from the American College of Gastroenterology, that clearly demonstrates that obtaining both celiac disease serology and a fecal Calprotectin is a cost effective, rapid, non-invasive way to exclude inflammatory bowel disease in the evaluation of children and adults whose symptoms might be consistent with either inflammatory bowel disease or irritable bowel syndrome. It is important to note that the normal fecal Calprotectin does not diagnose irritable bowel, rather it eliminates inflammatory bowel disease from consideration. This negates the necessity for more invasive and expensive modalities such as endoscopy, colonoscopy with biopsy, magnetic resonance imaging (MRI) or computed tomography (CT).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dysphagia
Treatment: Dexilant 
The insurer denied brand Dexilant. The health plan's determination is overturned.

The patient is a female with a history of laryngeal pharyngeal reflux and edema. Secondary to these issues, the patient has intermittent dysphagia despite taking her reflux medication on a regular basis. An Endoscopy performed noted 2+ edema and +1 erythema of the arytenoid tissues (consistent with reflux). Based on the history and examination, the patient was recommended a gastroesophageal reflux disease (GERD) diet and re-prescribed Dexilant 60 milligrams (mg) once a day.

Brand Dexilant is medically necessary. The patient had documented failure of other GERD medications, in addition failure of the generic version (continued choking) of Dexilant.
GERD can cause significant morbidity with dysphagia and choking (such as with this patient), in addition to placing the patient at risk for development pre-cancerous (Barrett's) and cancerous esophageal disease (squamous cell carcinoma and adenocarcinoma). This patient has failed prior medical treatment with other H2 blockers and proton pump inhibitors. There is a certain population of patients that appear to have a more efficacious response to non-generic medications. In case of this patient, she experienced worsening symptoms when on the generic formulation of Dexilant (choking and dysphagia), and systems appeared to have better control on the initial brand Dexilant. The current research and clinical evidence support placing patients on non-generic medication when adverse events occur. While not a significant adverse event, this patient had poor control of symptoms on the generic for 4 months (an adequate trial). Without the brand medication, the patient is at a significant risk for continued dysphagia and progressive reflux disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vaginal Bleeding. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

The patient is a pregnant female at 32 weeks and 1 day of gestation who presented to the hospital on with complaints of a "large amount" of bleeding. Evaluation was suggestive of chronic abruption. The patient was admitted to antepartum service. She was given antenatal corticosteroids for fetal lung maturation. There was no more active vaginal bleeding. Complete blood count (CBC) was monitored. She was discharged home on pelvic rest. 

According to MCG (Milliman Clinical Guidelines) admission is indicated for one or more of the following: Condition requiring premature delivery: Fetal distress or demise, preterm prelabor rupture of membranes, significant maternal disease, vaginal bleeding, complications of tocolytic treatment, continued fetal monitoring that require inpatient care, tocolytic therapy needed that requires inpatient care, and inability to stop preterm labor. 

This patient had vaginal bleeding with concern about placenta abruption. 
Admission for monitoring and close follow up, possible emergent delivery was needed and medically necessary. 

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

Diagnosis: Right testicular pain, nausea and vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with right testicular pain, nausea and vomiting.  He had a scrotal ultrasound which demonstrated right testicular torsion.  The patient was admitted to the pediatric service prior to surgical intervention.  He was discharged to home after surgery.  The inpatient admission was denied as not medically necessary.

No, the requested inpatient stay was not medically necessary.
This male presented with right testicular pain, nausea and vomiting and was identified to have a right testicular torsion. The management of testicular torsion in the absence of other co-morbidities is an outpatient surgical procedure. There is lack of documentation of services provided to the patient that could not have been provided in the emergency room prior to the operating room or at a lower level of care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
This patient is an otherwise healthy male presenting with testicular torsion and nausea/vomiting. He was diagnosed with testicular torsion and the management is prompt surgical intervention which occurred. There was no documentation to support the need for acute inpatient care prior to the procedure and the patient was discharged to home after the surgery.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dyspnea and Wheezing
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a past medical history (PMH) of asthma who was admitted with complaints of (c/o) dyspnea on exertion and wheezing with worsening in-spite of home albuterol. Vital signs were notable for peripheral capillary oxygen saturation (SpO2) 91% on room air (RA), pulse 110, respiratory rate (RR) 25.
The physical exam was notable for prominent diffuse expiratory wheezing. Lab work was notable for a partial pressure of carbon dioxide (pCO2) of 52. A chest x-ray (CXR) showed vascular congestion. The patient was diagnosed with an asthma exacerbation and treated with albuterol nebulizer and steroids. The peak flow was 150. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

Yes, the hospital stay was medically necessary at an acute inpatient level of care.
This patient presented with a history of worsening shortness of breath (SOB) associated with wheezing. The patient was evaluated and found to have wheezing with a peak flow of 150, which is 35% of predicted. The patient was treated aggressively in the emergency department (ED) with nebulizers and intravenous (IV) steroids. This is compounded by the patient's tachycardia, tachypnea, elevated pCO2, concomitant vascular congestion, and worsening symptoms despite home nebulizer treatments. Overall, this patient suffered a severe exacerbation of asthma and could not have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: Braces.
The insurer denied the braces.
The determination is upheld.

The patient has a Class I occlusion with deep overbite and appropriate overjet. He has minor maxillary and mandibular spacing. He is treatment planned for 36 months of orthodontics to correct his malocclusion. At issue is the medical necessity of braces.

There is no medical reason to correct the malocclusion with braces. While the patient has spacing, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) However, this patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. (2) If his teeth were aligned it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health.
For these reasons, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End stage renal disease, Diabetes Mellitus. 
Treatment: Continued inpatient long-term care/custodial care level 1 service. 
 
The insurer denied Continued inpatient long-term care/custodial care level 1 service.
The determination is upheld. 

The patient has a past medical history significant for chronic end-stage renal disease on hemodialysis, diabetes mellitus type 2, hyperlipidemia, hypertension, and morbid obesity.
This review is for the medical necessity of continued inpatient long-term care. The patient is asking for level 1 service. Services were denied stating the patient does not meet criteria for continued inpatient long-term care level 1 service because there is less than 1 hour of combined therapy for restoration of activities of daily living. At issue is the medical necessity of custodial long-term care. 

No, the requested health service is not medically necessary for this patient. 

The patient is a current resident of the long-term care facility and should remain in the facility for long-term care due to her underlying medical problems; however, more advanced therapy services such as physical therapy at a higher level of care are not medically necessary. 

The patient was discharged from physical therapy services. 

The patient may ambulate on the unit using a roller walker independently. The patient transfers independently, is independent with toilet use. She is able to do all functional bed mobility independently. Per a physical therapy note, patient discharged to reside in this long-term care facility. 

It is reasonable to say that based upon the patient's underlying medical conditions, and previous history of long-term care confinement, that the patient cannot function independently outside of a long-term care facility where the patient currently resides. However, continued therapy and restoration services are not medically necessary since the patient has been discharged from therapy services.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class III - canines, mild maxillary and mandibular crowding, bilateral posterior
crossbite, anterior crossbite with gingival attachment loss (maxillary canine). 
Treatment: D8080 Braces, D8670 Monthly Visits (12) and D8680 Retainer. 

The insurer denied the D8080 Braces, D8670 Monthly Visits (12) and D8680 Retainer. 
The denial is overturned. 

Patient is a female. The request is for dental benefits for braces, monthly visits, retainers, pre-service.  Per the provider's dental clinical summary--patient presents with class III - canines, mild maxillary and mandibular crowding, bilateral posterior crossbite, anterior crossbite with gingival attachment loss (maxillary canine). 

The health plan denied the claim because the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) Index Report; the score necessary for braces treatment to be approved.  The provider appealed the claim based on the diagnoses. 

Yes, the proposed treatment of braces, monthly visits, and retainers (pre-service) is medically necessary. 

Typically, the upper teeth come over the lower teeth when the mouth is closed; this is the normal occlusion. This patient presents with a bilateral posterior crossbite and an anterior crossbite where the upper teeth sits inside of the lower teeth.  These crossbites are evident in the x-rays and photos.  This malposition will have a negative effect on the patient's ability to speak  and chew effectively, and the ability to maintain proper hygiene. 

No, the health plan did not act reasonably with sound judgement and in the best interest of the patient. 

If these conditions are left untreated, the complications of decreased proper function as it relates to chewing, speech and compromised oral hygiene can only lead to more dental problems in the future.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Intracept Procedure
The insurer denied Intracept Procedure. 

The health plan's determination is upheld.

The patient is a female with chronic lower back pain (LBP) for an unclear period of time. Physician notes state > (greater than)12 months duration causing significant impact on her activities of daily living (ADL), including sleeping. The patient rates her pain on Visual Analog Scale (VAS) on average 8/10, without a good characterization of the pain in the records. There are no radicular or myelopathic symptoms. She reportedly received multiple interventions including epidural steroid injections although her response, number of injections etc is not detailed. The physical exam demonstrated pain over the L (lumbar) 3-4 spinous process and positive facet loading bilaterally. In addition, the record demonstrates that the patient had/has multiple other complaints of and therapies included cervical facet rhizotomy, left hip trochanteric bursitis with injections and myofascial pain with multiple trigger point injections. She was using Voltaren and taking Percocet, Valium, diclofenac and tizanidine. 

The Intracept Procedure: Intraosseous Basivertebral Nerve Ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. These cases can be frustrating because the diagnosis can be difficult and the etiology elusive. This is because the physical examination may or may not elucidate the cause of pain. With respect to this case the patient has limitations due to her chronic LBP and she is taking NSAIDs, Opioids and Benzodiazepines to manage the pain. The requesting physician notes that the pain is significant and limits activities of daily living (ADL) but there is no ODI (Oswestry Disability Index) score. Additionally, the MRI report does not detail the types of Modic changes. Therefore, it is difficult to determine with the information presented if this patient meets the criteria demonstrated in studies that predict she will benefit from the procedure. Due to the lack of substantiating evidence, the Intracept procedure is not indicated for this patient at this time.