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

Diagnosis: Respiratory 
Treatment: Durable Medical Equipment (DME) 
The insurer denied InCourage Airway Clearance Therapy High Frequency Chest Wall Oscillation (HFCWO). 
The denial is upheld.

The patient is a male who suffers from cough and excessive airway secretions. The treating provider is requesting the coverage of the InCourage Airway Clearance vest. The patient has history of diabetes. The patient was admitted to the hospital and was treated for post Covid (coronavirus disease) or aspiration pneumonia. The patient has been complaining of poor cough and shortness of breath. The patient's symptoms improved after using the vest. The subject under review is the medical necessity for the device. 

The requested health service/treatment of InCourage Airway Clearance Therapy High Frequency Chest Wall Oscillation (HFCWO) Device is not medically necessary for this patient. Excessive and airway secretion can at least in theory lead to bacterial superinfection and eventually pneumonia. Chest physical therapy and gravitational positioning should be effective if followed assiduously and done by experts. The chest percussion techniques include hand clapping of the chest by an assistant or application of a mechanical vibrator to the chest wall, or application of a vest with an external vibrator. When physiotherapy is performed regularly three to four times daily, enhanced sputum mobilization occurs in many patients.

Alternatives for patients who cannot perform chest physiotherapy include the Vest, a positive expiratory pressure device, which facilitates secretion drainage by maintaining airway patency, or a flutter device that enhances sputum clearance by generating oscillatory positive airway pressure.

The Vest has been studied mainly in patients with cystic fibrosis (CF) with bronchiectasis. For non-cystic fibrosis patients requiring assisted clearance of secretions, information on high frequency chest compression is very limited. There is no evidence that the Vest will be of any use in patients suffering from primary ciliary dyskinesia (PCD), recurrent and difficult to cough up airway secretion. There is in particular no evidence that the Vest will be of help in patients with difficulty to clear the airways from retained secretion.

There are no adequate or well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature that establish the long-term efficacy and safety of the Vest for the treatment of this patient's medical condition (post Covid infection) in absence of any history of bronchiectasis or CF. There is no high-quality literature showing an improvement in health outcomes with the use of Vest for this patient's condition. Therefore, based on the current evidence-based literature, the high frequency chest wall oscillation system is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, Knee.
Treatment: Hospital admission.

The insurer denied coverage for hospital admission.  The denial is upheld.

This is the case of a patient with a history of degenerative joint disease and knee osteoarthritis. The patient presented for evaluation and management of progressively worsening left knee pain. The patient was found to have complete bone on bone erosion of the trochlea. She had a left knee replacement. 

The medical records demonstrate a non-complicated post-surgical course. The patient's total knee replacement was performed with timely duration and limited blood loss. Her vital signs remained stable. There was no evidence of bleeding nor infection. Her laboratory values were satisfactory. She was able to tolerate oral pain medications. She did not require treatment for an underlying or new medical condition. Physician therapy (PT) services were provided. 

The physician records note "resting comfortably and pain controlled" on each occasion. 
There were no extenuating circumstances to substantiate the acute level of care admission. 

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

Based on the above, the medical necessity for the hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient Hospital

The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of Hodgkin's lymphoma who presented to the emergency room with right lower extremity pain (4/10) and swelling for 5 days. The patient has a history of recurrent cellulitis and was noted to have swelling and redness of the right leg. Her exam was otherwise unremarkable and she was afebrile. She was admitted for inpatient care  and was started on Unasyn. While hospitalized, she was seen by psychiatry due to a history of post-traumatic stress disorder (PTSD). She was also seen by infectious disease and podiatry. The patient was discharged on Augmentin. The medical necessity of an inpatient stay is under review.

The inpatient stay was not medically necessary.

Uncomplicated lower extremity cellulitis is typically treated with oral antibiotic therapy. This approach has been validated in multiple randomized trials including, but not limited to those by Moran, et al and Pallin, et al. This patient was hemodynamically stable, was immune competent, did not require intravenous (IV) therapy, did not require intensive nursing, had no risk factors of methicillin-resistant staphylococcus aureus (MRSA), and did not require surgery. The patient received Unasyn but for patients with uncomplicated cellulitis, oral antibiotics are indicated, appropriate, and recommended in the peer-reviewed literature based on the references provided.
For these reasons, support for inpatient care in the literature is sparse and medical necessity cannot be established for this service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services. 
The insurer denied livery biopsy. 
The denial is upheld.

The patient is a male who underwent bariatric surgery (laparoscopic roux en Y gastric bypass and concomitant liver biopsy) performed. The records support that he had a body mass index (BMI) of 50 kilograms per square meter (kg/m2). The operative dictation states that the surgeon obtained a wedge liver biopsy from the left lobe of the liver. The submitted records do not include any pre-surgical lab, imaging, or clinical data to indicate liver pathology. The pathology report provides the diagnosis of steatohepatitis.
The subject under review is the medical necessity for the liver biopsy.

The health plan's determination is upheld.

The submitted documentation does not support the medical necessity of concomitant liver biopsy at the time of roux en Y gastric bypass performed. There is no documentation of liver pathology as might be obtained by pre-operative imaging or lab data to warrant liver biopsy.
Accepted indications for liver biopsy include Documentation of signs or symptoms of liver disease (abnormal liver function tests of unknown etiology, knowledge of a specific diagnosis that will likely alter the treatment plan, known liver disease where prognostic information about fibrosis may guide subsequent treatment, the presence of a mass or lesions or focal or diffuse abnormalities seen on imaging studies of unknown etiology). In this case there is no such documentation to warrant wedge liver biopsy. Routine liver biopsy is not an accepted or standard aspect of bariatric surgery.[1]
According to generally accepted criteria, routine liver biopsy is not medically necessary in conjunction with bariatric surgery. [1] Liver biopsy is indicated if there is a suspicious growth on the liver, if there is scarring of the liver or if there is a condition of the liver as indicated by pre-operative imaging or lab data that requires biopsy.
In this case the patient is morbidly obese with a body mass index of 50 kg/m2. Lab data and pre-operative imaging are not included with the review material. There is no description of clinical symptomatology to indicate liver pathology.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services. 

The insurer denied livery biopsy. 
The denial is upheld.

The patient is a female who underwent bariatric surgery (laparoscopic roux en Y gastric bypass and concomitant liver biopsy) performed. The records support that she had a body mass index (BMI) of 50 kilograms per square meter (kg/m2). The operative dictation states that a wedge liver biopsy was obtained from the left lobe of the liver. There is no description of suspected liver pathology. The submitted records do not include any pre-surgical lab, imaging, or clinical data to indicate liver pathology. The pathology report provides the diagnosis of moderate steatosis. The health plan rationale for denial of coverage for liver biopsy is that there is no documentation of signs or symptoms of liver disease to warrant liver biopsy. The subject under review is the medical necessity for the liver biopsy.

The health plan's determination is upheld.

The submitted documentation does not support the medical necessity of concomitant liver biopsy at the time of roux en Y gastric bypass performed. There is no documentation of liver pathology as might be obtained by pre-operative imaging or lab data to warrant liver biopsy.

Accepted indications for liver biopsy include documentation of signs or symptoms of liver disease (abnormal liver function tests of unknown etiology, knowledge of a specific diagnosis that will likely alter the treatment plan, known liver disease where prognostic information about fibrosis may guide subsequent treatment, the presence of a mass or lesions or focal or diffuse abnormalities seen on imaging studies of unknown etiology). In this case there is no such documentation to warrant wedge liver biopsy.

According to generally accepted criteria, routine liver biopsy is not medically necessary in conjunction with bariatric surgery. Liver biopsy is indicated if there is a suspicious growth on the liver, if there is scarring of the liver or if there is a condition of the liver as indicated by pre-operative imaging or lab data that requires biopsy.

In this case the patient is morbidly obese and had hepatic steatosis and moderate steatohepatitis on biopsy. Lab data and pre-operative imaging are not included with the review material. There is no description of clinical symptomatology to indicate liver pathology. The operative dictation also does not describe specific liver pathology to warrant liver biopsy. The steatohepatitis identified on the biopsy is an anticipated pathologic condition in the setting of morbid obesity and does not mandate biopsy. [1,2]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive/Gastrointestinal. 
Treatment: Surgical Services. 
The insurer denied liver biopsy. 
The denial is upheld.

The patient is a female who underwent bariatric surgery (laparoscopic roux en Y gastric bypass and concomitant liver biopsy) performed. The records support that she had a body mass index (BMI) of 47.7 kilograms per square meter (kg/m2). The operative dictation states that the surgeon observed a fatty liver. A wedge liver biopsy was obtained from the left lobe of the liver. The submitted records do not include any pre-surgical lab, imaging or clinical data to indicate liver pathology. The pathology report provides the diagnosis of marked steatosis. The subject under review is the medical necessity for the biopsy procedure.

The submitted documentation does not support the medical necessity of concomitant liver biopsy at the time of roux en Y gastric bypass performed. There is no documentation of liver pathology as might be obtained by pre-operative imaging or lab data to warrant liver biopsy.
Accepted indications for liver biopsy include documentation of signs or symptoms of liver disease (abnormal liver function tests of unknown etiology, knowledge of a specific diagnosis that will likely alter the treatment plan, known liver disease where prognostic information about fibrosis may guide subsequent treatment, the presence of a mass or lesions or focal or diffuse abnormalities seen on imaging studies of unknown etiology). In this case there is no such documentation to warrant wedge liver biopsy.
According to generally accepted criteria, routine liver biopsy is not medically necessary in conjunction with bariatric surgery. Liver biopsy is indicated if there is a suspicious growth on the liver, if there is scarring of the liver or if there is a condition of the liver as indicated by pre-operative imaging or lab data that requires biopsy.
In this case the patient is morbidly obese with a body mass index of 47 kg/m2. Lab data and pre-operative imaging are not included with the review material. There is no description of clinical symptomatology to indicate liver pathology. While the operative dictation does describe an fatty liver per the surgeon, this is not substantiated by preoperative clinical data.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Increase Home Care/Personal Care Home Health Care (HHC) Level 2 per 15 minutes to 84 Hours Per Week.

The insurer denied the Increase Home Care/Personal Care HHC Level 2 per 15 minutes to 84 Hours Per Week.
The denial is upheld.

The patient is a male and has medical conditions including dementia. Denial of an increase home care/personal care Level 2 to 84 hours per week is being appealed. He has been approved for 42 hours per week (Testing tool estimates allow for 36.25 hours per week).

Denial information notes the patient recently received a catheter, which he cannot care for. He was admitted to the hospital for infection and bladder hemorrhage. Assessments were performed twice within one year. The telephone assessment performed shows the patient's self-directing functional has decreased. He requires extensive, maximum or total assistance with all basic ADLs (activities of daily living) and IADLs (instrumental activities of daily living), except eating. His ADL (activities of daily living) status has decreased compared to 90 days.

An appeal letter from the patient's provider notes the patient has severe dementia, chronic urinary retention, and hematuria. States he is unable to manage ADLs (activities of daily living) and care for himself. Notes needs care with Foley catheter.

No, the Increase Home Care/Personal Care Level 2 per 15 minutes to 84 Hours Per Week is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of an increase home care/personal care Level 2 to 84 hours per week is being appealed. The patient has been approved for 42 hours per week, which is more than testing tool estimate of 36.25 hours per week.

This patient has conditions including dementia and Foley catheter. UAS (Uniform Assessment System) evaluation shows he requires extensive, maximum, or total assistance with all basic ADLs (activities of daily living) and IADLs (instrumental activities of daily living), except eating, and ADL (activities of daily living) status has decreased compared to 90 days. Additional hours are requested for assistance with recent Foley catheter management. The appeal statement from his provider notes that the patient needs assistance with ADLs (activities of daily living) and care of Foley catheter. Personal care service is not indicated for supervision or management of medical conditions. The documentation provided does not support the medical necessity for additional personal care service hours. The approved 42 hours per week is appropriate and medically necessary to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. The proposed increase in personal care service to 84 hours per week is not medically necessary.

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

Diagnosis: Dental Disorder
Treatment: Braces and monthly visit x4

The insurer denied Braces and monthly visit x4.
The determination is overturned.

The patient has a Class II Division 1 malocclusion with spacing and protrusive maxillary incisors. She has an 8 millimeter (mm) overjet. She is treatment planned for orthodontics with extractions to correct the spacing and protrusion.
At issue is the medical necessity of braces and month visit times (x) 4.

There is strong medical evidence that the correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. (1) Orthodontics will make these teeth significantly less protrusive. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and morbidity of repairing these teeth. There is scientific evidence that oral health quality of life is reduced in patients with 6 plus (+) mm overjet, which this patient has. (2) For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional.
Treatment: Surgical Services-Liver Biopsy during Gastric Bypass.
The health plan denied the liver biopsy as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This patient has a body mass index (BMI) of 43 kilograms per meter squared (kg/m2), sleep apnea, hypertension (HTN), type 2 Diabetes Mellitus (T2DM) and osteoarthritis (OA) and underwent a laparoscopic roux en y gastric bypass. Intraoperative findings of fatty liver were identified and a liver biopsy from the edge of the left lobe of the liver was obtained. Findings reported severe steatohepatitis without fibrosis, cirrhosis, or malignancy. 

There is currently a lack of any national guideline from the American Society for Metabolic and Bariatric Surgery (ASMBS) or large high level prospective trial or randomized controlled trial (RCT) documenting any benefit from routine liver biopsy during bariatric surgery. In general, many individuals who undergo bariatric surgery may have suggestion of some degree of steatosis of the liver, observed intraoperatively, however, it is also well understood and documented in numerous publications that bariatric surgery and weight loss improves non-alcoholic steatohepatitis (NASH) / non-alcoholic fatty liver disease (NAFLD). There are no clear outcomes benefit to perform liver biopsy in patients with normal synthetic liver function (LFTs) or who do not carry a clinical diagnosis of NASH as most patients will not undergo subsequent re-biopsy of the liver to actually document improvement/progression. There is no preoperative documentation of LFTs or diagnosis of fatty liver or other liver disease. Separately, there remains controversy over the best method of liver biopsy. In general, when overall liver evaluation is sought, a long core needle biopsy (performed via tru cut or core needle) can provide better information about the parenchyma and can include multiple passes, 1 to 2 centimeter (cm) in length by approximately (~) 0.2 cm in width. Although wedge liver biopsy will afford a larger amount of overall liver tissue (tissue sample), it is often taken from the edges of the left lobe of the liver (which is more steatotic) are often subcapsular, and therefore may give the false impression of increased steatohepatitis and fibrosis. Although both are general safe procedures, there are known complications that can occur, primarily bleeding, that do not support routine practice without a clear clinical indication of how the information is going to be tracked and utilized given that most patients will improve any degree of NASH/NAFLD after successful bariatric surgery/weight loss.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied D6010 implant placement, Tooth 18 D6010 implant placement, Tooth 20, D2791 all metal crown, Tooth 15, and D3330 nerve treatment on molar tooth, Tooth 15. 
The denial is upheld.

The patient is a is a female who presented to the office of her dental provider for evaluation and treatment of teeth #15, 18, and 20. Included for review are previous letters of appeal and denial, one page of American Dental Association (ADA) claim forms, and no other clinical documentation including any radiographs or clinical notes from examination of the patient. In question is the medical necessity of the planned treatment of implant placement for #18, 20, all metal crown for tooth #15, and root canal treatment for #15.

The medical necessity of dental implants, root canal treatment, and crowns in these sites has not been established. There is no diagnosis, no clinical findings, no evaluation of the patient or teeth involved in order to support the medical necessity of any of the planned treatment. The treatment of implant placement (6010) for #18, 20, all metal crown (2791) for tooth #15, and root canal treatment (3330) for #15 is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient was a female with a past medical history significant for alcohol abuse, depression, dyslipidemia, tobacco abuse, and fatty liver who presented to the emergency department after the lab work performed in the outpatient settings revealed that her serum magnesium level was 0.9. The patient stated that over the course of four weeks she developed some numbness and tingling in her fingers and toes. The patient admitted to drinking 1.5 liter (L) of liquor every day.

As a result of treatment with potassium and magnesium supplements, her electrolytes significantly improved. Additional testing that included vitamin B12 and folate levels was normal. In the hospital, the patient sustained a fall. She was evaluated by physical and occupational therapy who recommended discharge to subacute rehabilitation. However, the patient declined this. She was discharged home, with a prescription for magnesium and potassium supplements. The subject under review is the medical necessity for the inpatient stay.

The inpatient hospital stay was not medically necessary for this patient. 
Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The patient presented to the hospital because of a critically low serum magnesium level. However, the patient was minimally symptomatic. There was no evidence that she had any signs of hemodynamic instability, arrhythmias of immediate concern, altered mental status, seizures. Furthermore, the patient's magnesium level significantly improved during the initial observation period. The serum potassium level was diminished but not critically low and was not associated with significant clinical manifestations. Furthermore, there was no evidence that the patient developed severe alcohol withdrawal symptoms requiring admission at the acute inpatient level of care.
This determination coincides with Milliman Care Guidelines (MCG) Health General Recovery Care 24th Edition Systemic and Infectious Condition General Recovery Guidelines (GRG). According to those criteria, admission at the acute inpatient level of care is recommended for patients with magnesium levels less than 1 milligrams per deciliter (mg/dl) not corrected to near normal or near chronic baseline despite observation care treatment. In this clinical case, the serum magnesium level was corrected significantly.
Taking into consideration all these facts the patient could have been treated at a lower level of care status.