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

Diagnosis: pain and swelling in the left finger

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission.

The denial is upheld. 

This female patient has a history of diabetes, peripheral artery disease (PAD), hypertension, and cataracts.

There was no concern for infection. They recommended non-weight bearing on the left upper extremity, pain control, applying ice to the extremity, and elevating the extremity. Bilateral foot x-rays were obtained. Naproxen and oral steroids were given. Rheumatoid factor (RF) and cyclic citrullinated peptide (CCP) levels were tested. The physician suspected gout, seronegative arthritis and also Calcium Pyrophosphate Dihydrate Deposition Disease (CPPD) despite negative crystals. A steroid taper was continued. The patient's condition improved. She was discharged with instructions to follow up with the Rheumatologist and Primary Care Physician.
The level of care required in this case was reviewed using Milliman Care Guidelines (MCG) for Musculoskeletal Disease. The patient had multiple involved joints, no fever, normal white blood cell count, no trauma and no acute changes on X-ray. Infection was therefore not an important consideration at admission. Treatment was oral. This degree of arthritis (probable gout) did not require acute admission. It would typically be treated as an outpatient, and there were no features of severity of illness that required inpatient treatment.

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

Diagnosis: Deep Vein Thrombosis (DVT).

Treatment full hospital admission.

The insurer denied coverage for full hospital admission.

The denial is upheld.

This is the case of a male patient with history of asthma and hypertension (HTN) who presented to the Emergency Department (ED) with 2-day history of pain and swelling of left lower extremity (LLE). The patient has prior history of deep vein thrombosis (DVT). At the time of presentation, the patient's vital signs were temperature 98.5 Fahrenheit, respiratory rate (RR) 20 breaths per minute, blood pressure (BP) 198/97 millimeters of mercury (mm Hg), and heart rate (HR) 98 beats per minute. Oxygen (O2) saturation was 99% (percent) on room air (RA). The patient was in no apparent distress (NAD). He was awake and alert. Lungs were clear. Repeat vital signs noted the patient was afebrile, BP 178/109, HR 86, RR 20, and O2 saturations were 99%.

The patient's initial lab work showed white blood cell (WBC) count of 9.9 and hemoglobin (Hb) 13.7. Electrolytes, blood urea nitrogen (BUN)/ creatinine were within normal limits (WNL). A DVT study was done which was positive for LLE DVT. Computed tomography angiogram (CTA) revealed a saddle embolus 9 mm thickness with extension into both lungs. Electrocardiogram (EKG) was normal sinus rhythm (NSR), no acute changes. The patient was seen by Hematology who recommended anticoagulant with heparin drip and switching to direct acting oral anticoagulants (DOAC) once stable. 

An echocardiogram was done which revealed normal left ventricular (LV) and right ventricular (RV) function. No RV strain or evidence of cor pulmonale was noted. The patient remained stable after admission. He was tolerating orally (PO). The patient was afebrile and hemodynamically (HD) stable. He was not hypoxic. There was no right heart strain. This patient remained stable after admission. He was switched to PO Eliquis and discharged home.

This patent was stable and could have been placed in Observation status. Once it was determined that this patient was not hypoxic and remained stable with no right heart strain documented on EKG or echocardiogram, he could have been switched to PO Eliquis and discharged home with close follow up in the outpatient setting.

This patient did not need acute inpatient hospitalization. He could have been placed in Observation status while diagnostic testing and treatment were initiated. Observation status can be for up to 48 hrs.

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

Diagnosis: Handicapping labio-lingual deviation (HLD) score was 17

Treatment: comprehensive orthodontics with full maxillary and mandibular braces

The insurer is denied coverage for D8080 comprehensive orthodontic treatment of adolescent dentition and D8670 periodic orthodontic treatment visits.

The denial is upheld. 

This is a male patient who presented to the Orthodontist's office for an evaluation.

Upon review of the submitted documentation, (study models were not provided for review), 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 claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of crossbite, gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 10 points (1 overjet, 8 anterior open bite, 1 labiolingual spread).

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 D8080 comprehensive orthodontic treatment of adolescent dentition and D8670 periodic orthodontic treatment visits is upheld.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee pain.
Treatment: Surgeon and Assistant Surgeon Service for a knee replacement.

The insurer denied the Surgeon and Assistant Surgeon Service for a knee replacement.  The denial is upheld. 

This is a female with right knee pain. The duration was ten years. She had pain with walking and several other activities. She had tried several treatments which did not provided benefit (medications, injections, viscosupplementation and six months of physical therapy [PT]).   Her x-rays showed "bone on bone" arthritis.  Her physician recommended a total knee arthroplasty.

No, the Surgeon and Assistance Surgeon Service were not medically necessary.
Indications for surgery require a history and physical examination with correlative imaging for diagnosis. There should be failure to improve with conservative treatment. The records do not include a physical examination.

The applicable criteria are as follows:  1) Limited ROM (range of motion), 2) Crepitus, and 3) Joint effusion or swelling.

There were no records provided of a physical examination. Therefore, the criteria were not met. The patient had subjective complaints, Imaging Studies, and Failure to improve with conservative management, she had no physical findings to substantiate indications at this time.

The treatment would thus not be medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory. 
Treatment: Durable Medical Equipment. 
The insurer denied one month rental of Zoll defibrillator vest. The denial is overturned.

The patient is a male with a history of coronary artery disease, myocardial infarction and ischemic cardiomyopathy (ejection fraction [EF] 15-20%) who was prescribed a wearable cardiac defibrillator under approved indications following the myocardial infarction (MI). He was scheduled for a permanent implantable cardioverter defibrillator (ICD), but this was cancelled secondary to COVID-19 infection. He continued to use the LifeVest until receiving an ICD. At issue is the medical necessity of the wearable ICD beyond initial approved duration.

Yes, the requested health service one month rental of Zoll defibrillator vest is medically necessary and in the patient's best interest. As noted above, the wearable ICD is medically necessary for patients who have an indication for permanent ICD placement but a medically appropriate reason for delaying the procedure. The delay secondary to COVID-19 was appropriate.
The patient had a myocardial infarction with residual severe left ventricular dysfunction. It is both reasonable and appropriate for a patient to have a wearable ICD in the months following a myocardial infarction (and this was appropriately approved initially).
During the pandemic, hospitals across the country were forced to adapt into different care patterns in order to provide safety for patients and healthcare workers. During that time (and even today), patients are tested for COVID-19, and even if asymptomatic, elective cases will be cancelled in the setting of a positive test. These policies are in the best interest of patients, especially when the treatment delay will not cause harm.
The wearable ICD is approved for patients who have an indication for a permanent ICD but have medically appropriate reasons to delay implantation of the permanent device. These include recent MI (where some patients get better) or severe systemic infection (where it is unsafe) or awaiting transplant (where it is unnecessary). The unifying concept is that treatment delay is appropriate, and the wearable defibrillator provides protection during that time. A delay for COVID-19, is also an appropriate delay, and therefore, extension of the wearable ICD duration is an appropriate and medically necessary treatment for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperhidrosis of Axilla.
Treatment: Botox Injection Dosed Every Three Months, Pre-service.

The insurer denied the Botox Injection Dosed Every Three Months, Pre-service.  The denial is upheld. 

The patient is a female with primary axillary hyperhidrosis for whom Botox injections every three months are requested. The patient has tried and failed Drysol and glycopyrrolate.

No, the proposed treatment is not medically necessary.

The major therapeutic options for axillary hyperhidrosis include antiperspirants, botulinum toxin, microwave thermolysis, topical glycopyrronium, oral medications, and surgery. Topical antiperspirants are the preferred initial treatment for axillary hyperhidrosis because they are widely available, inexpensive, and well-tolerated therapies.

Patients who do not achieve sufficient improvement in axillary hyperhidrosis with topical antiperspirants may benefit from botulinum toxin injections, microwave thermolysis, or topical glycopyrronium.

Additional therapies that may improve axillary hyperhidrosis include systemic agents, surgical interventions, and iontophoresis. Concern for adverse effects or limited efficacy data make these agents less favorable options for initial therapy.

This is the stepwise approach outlined by the International Hyperhidrosis Society for patients who cannot be managed with first-line and second-line therapies. Patients are first considered for an alternative local treatment (suction curettage), followed by systemic agents, then endoscopic thoracic sympathectomy (ETS).

Based on these guidelines, the patient has failed first line therapy with Drysol and second line therapy with glycopyrrolate.  Botox is the next medically appropriate step. However, the requested dose, 50 units per axilla every three months, is not standard of care.  A conventional dosing schedule of 50 units per axilla every six months first is standard of care.

The requested dose is not standard of care.  Conventional dosing is a schedule of 50 units per axilla every six months.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tear of rotator cuff

Treatment procedure code 29825 x (times) 1, lysis of adhesions

The insurer denied coverage for procedure code 29825 x 1, lysis of adhesions

The denial is upheld

This patient has a history of vertigo and shoulder pain. She presented to the Orthopedic Surgeon's office for the evaluation of her right arm. She stated that she slipped, fell on ice, and then fell on her right arm. X-rays revealed no fracture or dislocation of the right elbow and right humerus. The plan was for the patient to come out of her sling. Heat and anti-inflammatory medications were recommended. Magnetic resonance imaging (MRI) of the right shoulder performed revealed a full thickness disruption of the anterior half of the supraspinatus tendon, moderate partial thickness disruption of the posterior half of the supraspinatus tendon and infraspinatus tendon, a suspected tear in the superior aspect of the posterior labrum, and a large glenohumeral joint effusion with a moderate amount of fluid in the subacromial/subdeltoid bursa. The patient had a right shoulder arthroscopy, rotator cuff repair, subacromial decompression, extensive debridement, and an open subpectoral biceps tenodesis. 

The records show the patient underwent several procedures in addition to repairing her rotator cuff. The physician performed a bursectomy, subacromial decompression and biceps tenodesis. It would be necessary to obtain satisfactory exposure to the rotator cuff. The debridement and bursectomy would provide satisfactory exposure and be part of the operative procedure.

Lysis of adhesions would be global to the above. There was no evidence of adhesions noted in operative report.  There was no evidence of scar nor pathology to limit motion secondary to adhesions. 

There was no specified pathology of "adhesions." The procedure would be considered part of the global operation. To charge for such would be unbundling. 

There were no extenuating circumstances to support code 29825. 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 the procedure code 29825 x 1, lysis of adhesions is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right quadriceps tendon tear
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient sustained a right quadriceps tendon tear and was hospitalized. The client was pre-diabetic and had an elevated body mass index (BMI). He underwent a repair of the tendon. The procedure went well and there were no complications. He remained in the hospital  and had physical therapy and was able to ambulate 30 feet on postoperative day 1 with physical therapy. He did have pain and had pain medications adjusted to control the pain. He made consistent progress in therapy, achieved adequate pain control and was ultimately discharged  to a skilled nursing facility. He did not have a complex surgical procedure nor a major postoperative complication. The health plan denied the inpatient stay. At issue is the medical necessity of the inpatient stay.


The inpatient medical admission was not medically necessary.  The patient had a quadriceps tendon repair. Quadriceps tendon repair is a relatively common orthopedic procedure well within the scope of practice of a general board certified orthopedic surgeon. The medical record notes that the procedure went well, with no intraoperative or postoperative complications. The patient did well with an uneventful hospital course. This patient did have significant risks factors for a postoperative complication, the most important being the significantly elevated BMI. Obesity is clearly associated with increased risk for deep venous thrombosis, infection, delayed healing, poor progress in physical therapy.
In one study, Zacaria et al assessed the incidence and predictors of tendon ruptures requiring hospitalization of representative patients with diabetes. Subjects included patients with a mean age of 64.0 years and 48.6% (percent) of them were male. The main outcome assessed was any tendon rupture requiring hospitalization. The results showed and incidence rate ratio for any tendon rupture requiring hospitalization in patients versus control subjects was 1.44. Independent predictors of spontaneous ruptures in patients was an elevated BMI.
However, the patient had no complications. He had physical therapy and was able to ambulate 30 feet on post operative day 1 with physical therapy. He did have pain and had pain medications adjusted to control the pain. This type of procedure, quadriceps tendon repair, is routinely performed on an outpatient basis. Therefore, the care could have been performed safely at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chest pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld. 

This female patient has a history of hypertension and hypothyroidism.

The inpatient admission on is upheld because there is no evidence that this patient was at increased risk for short term adverse cardiovascular events requiring inpatient monitoring and management, based on her clinical presentation and results of testing performed in the emergency department (ED).
	
There is no evidence that this patient required an acute inpatient level of care to determine that her chest discomfort was not related to acute coronary syndrome or to perform diagnostic coronary angiography. This should have been performed while in the ED or an observation unit, followed by outpatient diagnostic testing including coronary angiography.

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 inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecomastia

Treatment: service 19300 (mastectomy for gynecomastia)

The insurer denied coverage for service 19300 (mastectomy for gynecomastia)

The denial is upheld.

According to the documentation submitted, this is the case of a male patient with a history of gynecomastia. Diagnostic mammogram noted marked left gynecomastia on both mammography and ultrasound. Digital bilateral diagnostic mammogram with computer-aided detection (CAD) revealed: Left breast larger than the right breast; extensive left breast gynecomastia was noted. Coverage for service 19300- mastectomy for gynecomastia is requested. 

The insurer denied mastectomy. The health plan acted reasonably with sound judgment. 

The patient has gynecomastia, but the records do not document an endocrine evaluation and exclusion of an endocrine cause. There is no documentation of a concern for a breast malignancy and mammogram and ultrasound are consistent with benign gynecomastia.  Gynecomastia is a benign condition that does not cause health or functional problems.  

According to a review article from the Mayo Clinic, "Overall, gynecomastia is a benign condition and is usually self-limited. Over time, fibrotic tissue replaces symptomatic proliferation of glandular tissue and tenderness resolves. If the appropriate work-up does not reveal considerable underlying pathology, reassurance and periodic follow-up are recommended. Patients with gynecomastia have a favorable prognosis. These patients present with 2 main concerns: ruling out breast cancer and cosmetic correction. The first concern is adequately addressed by following the appropriate diagnostic evaluation. Breast cancer is rare in males, representing less than 1% [percent] of all cases of breast cancer; only 1% of mammograms in men reveal breast cancer.  Therefore, the decision to treat and the choice of treatment should be based on the degree to which this condition has affected the quality of life and mental health of patients and on their desire for cosmetic correction."  

The records do not provide any evidence of a concern regarding breast cancer. The procedure will primarily improve appearance and self-esteem. Observation, reassurance and use of analgesics as needed are reasonable management approaches for this condition. 

The insurer's denial of coverage for service 19300- mastectomy for gynecomastia is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: uterine fibroids

Treatment: inpatient stay.

The insurer is denied coverage for inpatient stay.

The denial is overturned. 

This female patient has a history of uterine fibroids.

This patient underwent a laparotomy. Laparoscopies are ambulatory procedures, laparotomies are not. The standard of care is for patients who undergo an open procedure to stay in hospital for 48 hours. 

On postoperative day 1, the Foley catheter is removed, the patient is encouraged to get out of bed and ambulate, clear liquids are started. 
On postoperative day 2, if the patient is passing flatus, and tolerating regular diet she is discharged home.

This patient was managed according to the guidelines and the standard of care.

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

The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.