Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Abnormal uterine bleeding (AUB).
Treatment: Outpatient procedure 0404T, ablation of uterine fibroids.
The insurer denied coverage for outpatient procedure 0404T, ablation of uterine fibroids.
The denial is upheld.

The patient is a female with a history of abnormal uterine bleeding (AUB) and fibroids. She presented to the Gynecologist's office with complaints of AUB. She was on Aygestin for three weeks. The patient was anemic and had two blood transfusions. She tried Mirena but it was expelled immediately after insertion. Ultrasound showed a 3.5 cm (centimeter) submucosal myoma. The physician recommended ablation of uterine fibroids to treat AUB. The insurer has denied coverage for outpatient procedure 0404T, ablation of uterine fibroids. In a Final Adverse Determination letter, they stated that there was no indication that the requested procedure improved health outcomes. It was considered experimental. The requested procedure was denied based on the guideline named Centene Radiofrequency Ablation of Uterine Fibroids.

The Sonata System combines intrauterine ultrasound (IUUS) with radiofrequency (RF) ablation in a single handpiece. Sonata is suitable in an inpatient or outpatient setting and is intended for diagnostic intrauterine imaging and transcervical treatment of symptomatic uterine fibroids, including those associated with heavy menstrual bleeding.

The Sonata system is Food and Drug Administration (FDA)-approved for the management of fibroids. There are multiple studies documenting the safety and efficacy of this procedure in controlling symptoms due to fibroids. Symptomatic improvement is observed within the first three months post-procedure, and this improvement has been maintained at least through 24 to 36 months of follow-up. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.

The outpatient procedure 0404T, ablation of uterine fibroids has final approval from the appropriate regulatory bodies for this diagnosis.

This patient is a good candidate for outpatient procedure 0404T, ablation of uterine fibroids

The patient could also undergo an endometrial ablation, a myomectomy or a hysterectomy that would lead to an immediate improvement in her condition. These procedures for the management of fibroids have been used and are well established.

Note that there are no studies documenting a better or safer outcome using the Sonata system versus a myomectomy, hysterectomy or an ablation.

The outpatient procedure 0404T, ablation of uterine fibroids is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of the outpatient procedure 0404T, ablation of uterine fibroids is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: D4341 deep gum and root cleaning - all quadrants

The insurer denied coverage for D4341 deep gum and root cleaning - all quadrants

The denial is upheld

Based on the submitted documentation which includes copy of panoramic radiograph, and insurer correspondence, it appears that this patient presented for 
evaluation for dental service and periodontal therapy. The dentist recommended 
treatment was scaling and root planing of all four quadrants. The insurer has denied the service as the information provided does not show evidence of moderate to severe 
periodontal disease or other clinical or radiographic criteria to justify the services and therefore does not meet clinical criteria to support scaling and root planning. The patient is appealing. 

Upon review of the submitted documentation, the only objective information submitted for review was the panoramic radiograph. The radiograph indicates minimal if any loss of alveolar bone height affecting these teeth. The insurer has correctly applied the clinical criteria in denying scaling and root planning services.

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

The insurer's denial of coverage for D4341 deep gum and root cleaning - all quadrants is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Blood Disorder/Anemia.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with a history of metastatic poorly differentiated carcinoma who is status post chemotherapy with Carboplatin/Paclitaxel, spinal cord radiation and surgical fixation for spinal cord compression and was recently started on Pembrolizumab. She presented to the hospital with vaginal bleeding x 1 week from a vaginal metastasis and was found to have a hemoglobin of < 5. On admission, she was noted to be tachycardic to the 130s beats per minute and with a 2-liter oxygen requirement. She was transfused with 3 units of packed red blood cells in the observation unit and was admitted after it was clear that she needed ongoing transfusion support. The patient was seen by radiation oncology who delivered several fractions of radiation to the vaginal mass to slow down bleeding. She was also seen by pulmonology for a new onset of hypoxia and was evaluated for Pembrolizumab pneumonitis. The patient was discharged home after blood counts had stabilized.
At issue is the medical necessity for the inpatient admission.

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

Yes, inpatient admission was medically necessary for refractory bleeding secondary to metastatic carcinoma requiring repeat transfusions and palliative radiation.
The patient is a female with metastatic carcinoma who presented with life-threatening bleeding due to a metastatic lesion in the vagina. She presented with signs of class 2 hemorrhagic shock with an elevated heart rate and respiratory rate [1]. The patient was initially appropriately placed in observation for the purposes of a blood transfusion, but when it became clear she would require more intensive interventions to stop the bleeding, she was admitted to the hospital. For patients presenting with malignant bleeding, radiation is often used to slow or stop bleeding, and this is often administered in the inpatient setting in cases of active bleeding [2].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gum disease.
Treatment: C4341 Deep Gum and Root Cleaning For Lower Left Quadrant, Lower Right Quadrant, Upper Left Quadrant, and Upper Right Quadrant.

The insurer denied the C4341 Deep Gum and Root Cleaning For Lower Left Quadrant, Lower Right Quadrant, Upper Left Quadrant, and Upper Right Quadrant.
The denial is upheld.

The patient is a female with permanent teeth. The patient has mild maxillary spacing and severe mandibular crowding and currently has dental braces on her upper teeth. Review of x-rays shows bone levels are normal. There were no other dental documents received, nor any information about the patient's medical history.

No, the requested health service is not medically necessary.

Medical necessity cannot be determined based on the clinical information submitted for this case.

The dental x-rays can show bone loss; however, they cannot be used to diagnose acute periodontal disease. This information is gathered by clinical examination of the gum tissue and assessment of periodontal probing depth, as well as bleeding indices and evaluation of gum levels / clinical attachment.

Based on the clinical records and documents provided for review, the proposed treatment D4341 (deep cleaning) at upper right, upper left, lower left, lower right is not considered medically necessary at this time. The x-rays do not show bone loss, which is a hallmark of chronic periodontal disease; however, this patient may have acute periodontal disease.  This cannot be assessed with the documents provided; periodontal charting would be needed to make a proper determination about medically necessary treatment.

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

The health plan acted reasonably and made a sound medical judgment based on the limited information received by the member and her dentist.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epigastric pain and reflux

Treatment: Esophagogastroduodenoscopy

The insurer denied coverage for esophagogastroduodenoscopy. 

The denial is overturned.

The patient was complaining of reflux for 5-6 months. She was also having epigastric discomfort and bloating. She was on Zantac 150 milligrams (mg) twice a day. An endoscopy revealed gastritis with an erosion and esophagitis. Hyperplastic changes were found at the gastroesophageal (GE) junction, but there was no intestinal metaplasia. 

Clinical indications for performing esophagogastroduodenoscopy (EGD) are listed in Milliman Care Guidelines (MCG) ACG: A-0203. Dyspepsia is an indication for the procedure under certain conditions. These conditions include failure of medical therapy such as a poor response to a histamine H2-receptor antagonists (H2 blocker). In addition, persistence of symptoms for 3 months or longer is listed as an indication for endoscopy.

This patient was having epigastric pain and reflux for 5-6 months. In addition, she remained with symptoms in spite of being on a H2 blocker twice a day. Since she had dyspepsia for over 3 months and remained symptomatic on Zantac, she met MCG criteria to have the EGD. The EGD was medically necessary.

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

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

Diagnosis: Genitourinary/Kidney Disorder.
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Stay. 
The denial is upheld. 

The patient is a female who was admitted with the diagnosis of urinary tract infection for intravenous antibiotics and hydration. She was coronavirus 2019 (COVID-19) positive at the time of the admission and had mild symptoms of upper respiratory disease. Over the approximately two-day stay, the urinary tract infection was confirmed, appropriate workup was completed, and the patient resounded well to the therapy as evidenced by improvement in her clinical state and laboratory parameters. She was switched to oral antibiotics and discharged to continue care at home with a planned follow up with her primary care provider.
At issue is the medical necessity of the Inpatient Stay.

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

The requested health service/treatment of Inpatient Stay is not medically necessary for this patient.
While the patient did have a urinary tract infection and had a COVID-19 positive upper respiratory infection, she was stable from a cardiorespiratory and neurological perspective and did not have any documented acute care needs. As stated in Mattoo et al, "many studies have revealed that children aged greater than (>) 2 months can be safely managed with oral antibiotics; thus, hospital admission for treatment should be avoided unless the child is unable to tolerate oral antimicrobial therapy." This child was without signs of systemic toxicity; there was no indication that she could not tolerate oral antibiotics. The submitted documentation does not support an acute inpatient level of care. 
Therefore, the requested health service treatment of Inpatient Stay is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal-Neck Problem/Pain
Treatment: Pain Management-Facet Joint Injections
The health plan denied the facet joint injections as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient has a history of chronic neck pain. A letter from his provider noted that the patient had conservative treatment with physical therapy, massage, and chiropractic care for more than 3 months. They were also treated with anti-inflammatories and activity modification. A request was made for cervical medial branch blocks at the bilateral cervical (C)4-5 C5-6 and C6-7 levels. A magnetic resonance imaging (MRI) study of the cervical spine revealed degenerative changes and facet arthropathy. 

The requested health service/treatment of Facet Joint injections is medically necessary for this patient.
Facet joint injections or medial branch blocks have therapeutic utility, in that a positive block predicts a good chance of obtaining complete relief of pain from percutaneous radiofrequency neurotomy. However, control blocks are essential to exclude false positive responses and to maximize the confidence of securing a true-positive response.
The available data on the sensitivity and specificity of comparative blocks were all based on complete relief of pain. There are no equivalent data for 75% relief or 50% relief of pain. Although it might be attractive to believe that the same values apply this is unlikely to be so. Theoretically, one would expect increasingly weaker specificities for criteria with lesser relief of pain.
A practical approach to this would be to use comparative local anesthetic blocks. A true positive response to comparative local anesthetic blocks is one in which the patient reports relief of pain for a shorter duration when a short acting agent is used and reports longer relief when a longer acting agent is used. A concordant response confirms that the joint is the source of pain with a confidence of 85%.
In this case it is clear that the patient had an appropriate amount of conservative treatment, unfortunately he has persisting pain. Therefore, the facet joint blocks are appropriate and therefore medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dehydration
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a boy who presented with vomiting and diarrhea. His mother reported that he threw up 9 times since 11pm on the night of presentation and had 5 episodes of diarrhea. He was described as alert but fussy with sunken eyes. His twin had similar symptoms, and they were both recently admitted for loose stools and vomiting. He was refusing to eat or drink, and therefore, was brought in for care.

The Inpatient Hospital Admission was medically necessary for this patient. He required intravenous fluids due to dehydration and ongoing fluid loses with inadequate oral intake, along with close monitoring.
This is an infant boy who presented with numerous episodes of vomiting and diarrhea. At the time of presentation he had a low bicarbonate level of 17 indicating dehydration, and he was unable to tolerate sufficient oral fluids to maintain his hydration. He continued to have watery diarrhea in the emergency department. He therefore required inpatient admission to ensure adequate hydration with intravenous fluids to compensate for his ongoing fluids losses.
The decision making at the time of admission for this patient was consistent with his very young age, the presence of dehydration with ongoing fluids losses from both vomiting and watery diarrhea, his inability to tolerate oral replacement fluids, and the need for prompt initiation of parenteral fluids along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible Seizure
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

This is a male who has multiple medical comorbidities and was admitted to hospital for suspicion of seizure activity.  The patient underwent a full workup and was seen by neurology who did not feel there was sufficient evidence for a diagnosis of epilepsy and that it was more likely the result of a disequilibrium syndrome following a session of dialysis,.  Nevertheless, the patient was admitted and monitored on telemetry and the health plan is therefore denying coverage on the grounds that the patient could have been safely cared without formal admission.

No, the proposed inpatient admission was not medically necessary.

The patient was back to baseline and conversant in the emergency department.  A neurological consult could have been made to the emergency department and there were no pressing medical issues that indicated a necessity to admit.  It is acknowledged that this patient has end stage renal disease, was on dialysis, has had previous strokes, is elderly, and was found unresponsive with the appearance of shaking, the sum total of all these factors does not indicate that admission to the telemetry floor is necessary.  Observation with serial reassessments and consultation with neurology could have just as easily been performed safely in an observation service.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The health plan did not deny medically necessary services because, per neurology, the patient's presentation was not consistent with seizure   The health plan stated that the admission was not necessary because no acute care was administered, the patient was stable, and the patient required no intervention.  These are all factors that contribute to reducing length of stay and therefore in the patient's best interests.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Viral Illness. 
Treatment: Inpatient hospital admission. 

The insurer denied the inpatient hospital admission. 
The denial is overturned. 

The patient is a male with history of CKD (chronic kidney disease) whose inpatient hospital admission is under review. The patient was diagnosed with Covid-19 (coronavirus 2019). He was treated with mAbs (monoclonal antibodies). He then presented with malaise, nausea, and vomiting, without ability to tolerate anything PO (by mouth) for 48 hours. 

In the ER (emergency room), the patient's vitals were as follows: T (temperature) 98.2, P (pulse) 115, BP (blood pressure) 98/75, RR (respiration rate) 19, O2 (oxygen) saturation 100% (percent) RA (room air). 

On general examination, the patient was NAD (no acute distress). Examinations of his CVS (cardiovascular system), chest, and abdomen were normal. 

The patent's labs and studies were as follows: Cr (creatinine) - 1.8 (HIGH), CPK (creatine phosphokinase) - 641 (HIGH), Troponin - 0.117 (HIGH), EKG (electrocardiogram) Sinus rhythm, PVC (premature ventricular contraction), prolonged QT, and ST elevation, CXR (chest x-ray)  RUL (right upper lobe), LLL (left lower lobe) infiltrate. 

In the ER, the patient was noted to have hypotension and tachycardia induced by vomiting from Covid-19. This was complicated by elevated troponins and creatinine, thus the team decided to admit the patient for close observation and treatment. He improved over the next day and was discharged home.

Yes, the inpatient hospital admission was medically necessary. 

The admission was medically necessary. The health plan denied the admission by noting that a viral disease was not cause for admission, unless accompanied by life threatening pneumonia. It is true that although the patient had COVID-19 with pneumonia, he was missing risk factors, signs and symptoms that are associated with poor outcomes (1). However, the admission was not for COVID-19 pneumonia. He was admitted for the following reasons: 

1) Severe dehydration and inability to take PO (by mouth). The patient had vomiting for 48 hours and was unable to consume anything. Evidence for this was the tachycardia, hypotension, and elevated creatinine. Standard of care would require admission and inpatient rehydration and monitoring in such cases, especially when other factors are involved (see below). 2) Elevated troponin and abnormal EKG changes in the setting of dehydration, Covid-19 pneumonia, tachycardia, and hypotension. 3) Elevated creatinine in setting of dehydration, Covid-19 pneumonia, tachycardia, and hypotension. 

Standard of care would require admission of such a patient, and failure to admit could lead to organ damage (renal, cardiac, pulmonary), or even death. 

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Exacerbation.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. The service under review is Inpatient admission. Coverage for this service was denied by the health plan as not medically necessary. This decision is being appealed.

The patient has past medical history of asthma and allergies. The patient presented to ER (emergency room). His symptoms were shortness of breath, wheeze, chest pain despite frequent use of albuterol. In the ER (emergency room), his vitals were as follows: HR (heart rate) 124-137, respiration rate 14-17, SpO2 (pulse oximetry) per vitals section 92-96%, but the physician stated SpO2 (pulse oximetry) remained 99-100%.

On examination, the patient was not in acute distress, not ill appearing, and respiratory effort was normal. His lungs were noted with diffuse wheeze. He tested positive for rhinovirus. His chest x-ray was without pneumonia. His blood tests were unremarkable.

The patient was treated with nebulized ipratropium-albuterol x3 and oral Decadron, then IV (intravenous) magnesium sulfate. The physicians documented that the patient "had significant improvement in his breathing symptoms following treatments," and also that, "he remains in stable condition."

The patient was admitted and treated with albuterol every 2 hours. On day two, he improved, and albuterol was spaced out to every 4 hours. On day three he was discharged.

No, the Inpatient admission was not medically necessary.
According to reference 1: "For children in an ED [emergency department], indications for hospitalization and ICU [intensive care unit] consultation can vary considerably. In general, children that should be admitted include those with ongoing need for supplemental oxygen; severe acute asthma exacerbations despite 12 hours of continuous nebulization salbutamol (potential ICU [intensive care unit] admission); continued moderate acute asthma exacerbations for more than 46 hours after corticosteroid administration; continued deterioration on conventional treatments; social environment limiting the delivery of care; and risk factors for fatal asthma with a child living  at a major geographic distance from appropriate care."  The patient did not meet any of these criteria for inpatient stay.

Another publication (2) touts the usefulness of using a standardized Respiratory Scoring Tool to determine necessity of inpatient stay, where a respiratory score 9 after 1 hour of treatment is felt to be sufficient to warrant hospitalization.  Using this tool, the patient would have a score of 1 out of 12, not meeting admission criteria.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient
The proposed treatment was not medically necessary.