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

Diagnosis: Dental caries

Treatment: D5214- Partial lower denture

The insurer denied coverage for D5214- Partial lower denture. The denial was upheld.

This patient is a female who presented to discuss prosthetic options involving the anterior mandibular teeth. The dentist discussed treatment options with the patient but the patient preferred to proceed with a mandibular removable partial denture in lieu of other therapies.  

The insurer has denied the partial denture stating that it is denied due to poor long-term prognosis of the teeth that would serve as abutments due to severe bone loss, root decay, and inadequate crown to root ratio. 

Upon review of the documentation, particularly the pretreatment radiographs, the anterior mandibular teeth that would serve as abutments for a removable partial denture exhibit extensive recurrent caries and periapical pathology. In addition there is significant, approximately 50% or greater alveolar bone loss at the sites compromising the crown root ratios. Given standard clinical and radiographic and dental parameters of care these teeth are considered to have an extremely poor long-term prognosis and deemed non-maintainable with appropriate treatment being extraction. Lastly, the treating dentist alludes to and acknowledges the poor long-term prognosis of these teeth in multiple clinical notes.

D5214 - partial lower denture is not medically/dentally necessary as the teeth are significantly compromised periodontally due to caries that it would be deemed with a poor prognosis.

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

Based on the above, the medical necessity for D5214- Partial lower denture is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left ankle cellulitis
 
Treatment: Inpatient admission

The insurer denied the inpatient admission. The denial was upheld.

The patient is a male with a past history of hypertension and recent burn injury to his left lower extremity. He presented to the emergency department with complaints of left ankle swelling. His vital signs on presentation were: temperature 37.1C, blood pressure 142/87, pulse 112, respiratory rate 18.  The patient was started empirically on intravenous antibiotics (Unasyn) for a left ankle cellulitis following a recent burn injury. A Plastic Surgeon evaluated the patient for partial thickness burns and recommended warm soapy washes with Silvadene cream and smoking cessation. The patient remained afebrile, hemodynamically stable, and clinically improved. He was discharged to continue oral antibiotics as an outpatient.

According to documentation, the patient presented with a left ankle cellulitis. Otherwise, he was afebrile, hemodynamically stable with no significant laboratory abnormalities. The Plastic Surgeon evaluated the patient and recommended localized wound care; no surgical intervention was deemed necessary. Additionally, patient had no evidence of a systemic infection, no significant co-morbid conditions, and was capable of tolerating oral intake. Based on above findings, this patient did not meet criteria Milliman Care Guidelines criteria using the guidelines of Cellulitis (ORG: M-70) and Burn, Major, Noncritical for acute inpatient admission.

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

Diagnosis: Enlarged leiomyomatous uterus

Treatment: outpatient procedures 37243, 36247, 75736, 75774, and 76937

The insurer denied coverage for outpatient procedures 37243, 36247, 75736, 75774, and 76937. The denial was reversed.

This patient is a female with a past medical history of uterine fibroids, pelvic pain, and heavy menstrual bleeding requiring transfusion.  The patient underwent a MRI of the uterus that revealed an enlarged leiomyomatous uterus, 313.3 cc.  There was a dominant 5.7 cm intramural posterior wall fibroid at the left uterine body which contained a small hemorrhagic focus.  The patient underwent a pelvic ultrasound that revealed a large 5 cm heterogeneous fibroid in the body of the uterus central in location.  The endometrial echo-complex was not visualized.  The patient underwent a uterine artery embolization for clinical indications of pelvic pain and heavy menstrual bleeding requiring transfusion.

The appeal letter indicated the patient had been referred by the Gynecologist for severe menstrual bleeding and chronic anemia.  The patient had an anteverted enlarged heterogeneous fibroid uterus with multiple fibroids detected.  The patient had 3 vaginal deliveries and one caesarean section. For many years the patient experienced period changes with associated excessive bleeding and weakness.

The referenced medical literature notes that uterine artery embolization (UAE) is a treatment option for patients with symptomatic uterine leiomyomas. The literature also indicated that the ideal candidates for uterine artery embolization would include patients with heavy menstrual bleeding, ones who are premenopausal and when the patient has no desire for future pregnancy.

The literature supported the performance of the uterine artery embolization for this patient with uterine leiomyomas and excessive bleeding.  The healthcare plan did not act reasonably, and with sound medical judgment, and in the best interest of the patient.  The requested outpatient procedures, for the specified date of service are considered medically necessary for this patient.

Based on the above, the medical necessity for outpatient procedures 37243, 36247, 75736, 75774, and 76937 for date of service specified is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Hernia
Inpatient Hospital

This patient is a man who presented to the hospital with the complaint of left inguinal pain in the setting of a known left inguinal hernia. He was imaged with computed tomography (CT) scan that showed the sigmoid colon within the left inguinal hernia. The patient was admitted for observation to the hospital. The hernia was able to be reduced manually. Subsequent to the reduction, the patient tolerated a diet and was discharged from the hospital with instructions for short-term follow up with the surgeon. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient level of care was not medically necessary. This patient presented with inguinal pain due to a left inguinal hernia. The hernia was able to be reduced with resolution of symptoms and the patient was discharged from the hospital in stable condition. He did not require emergent surgery. He was clinically stable throughout the period of monitoring. This patient did not require inpatient admission as provision of IV fluid, pain medications, imaging and arrangements for follow up could have been appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Malpositioned Teeth
Dental/Orthodontic Procedure

The patient is a female with a Class I occlusion with appropriate overjet and a slightly deep bite. The maxillary arch has some spacing, and the mandibular arch has some crowding. She is treatment planned for 24 months of orthodontics to correct her malocclusion. The braces were denied by the health plan and this determination is being appealed.

The health plan's determination is upheld. The Braces and Monthly Visit [D8080, D8670] are not medically necessary for this patient.
There is no medical reason to correct her mild crowding with braces. The patient does have a mild deep bite, however, that alone is not a medical necessity to treat. There are many ways to correct patients with a deep bite and retroclined incisors, and there is strong evidence that one treatment is not better than another. Furthermore, deep bites may be corrected in adulthood, so it is not as if she will lose the ability to correct her malocclusion should she choose to do so as an adult.
Appeal type: Medical necessity
Decision: Upheld

Malpositioned Teeth
Dental/Orthodontic Procedure

The patient is a female with a skeletal Class I molar occlusion and class II cuspid malocclusion, mild maxillary spacing, moderate mandibular spacing, mild overbite and mild overjet. The proposed treatment is braces for 18-24 months. This is under review.

The health plan's determination is upheld. The Braces, monthly visits, orthodontic retention are not medically necessary for this patient.
Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 9 with no auto qualifiers. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 mm or greater and underbite 3.5mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces and the monthly visits are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Overturned

Endocrine/Metabolic/Nutritional - Diabetes
Pharmacy/Prescription Drugs

The patient is a male with type 1 diabetes with history of diabetic macular edema. The patient has been receiving Eylea injections with improvement. The medication was denied by the health plan and Avastin and Mvasi were recommended. The subject under review is the medical necessity of the requested Eylea.

The health plan's determination is overturned.

No, the health plan has not acted reasonably in its determination of medical necessity.
Eylea has been demonstrated to have been effective in the treatment of diabetic macular edema and is approved by the Food and Drug Administration (FDA) for this. The patient has been receiving Eylea injections with positive results. A change in current therapy may result in results that are not as ideal for the patient. The frequency of Eylea injections after loading treatments are done is less frequent which puts less treatment burden on the patient and physician.

Yes, Eylea is medically necessary for this patient. Diabetic macular edema (DME) is the most frequent cause of vision loss in patients with diabetes and is an important public health problem. Recent randomized clinical trials have shown anti-vascular endothelial growth factor (VEGF) therapy improved visual acuity and macular swelling, and currently it has become the first line of the treatment of DME. Eylea outperforms Avastin for diabetic macular edema with moderate or worse vision loss. All anti-VEGF drugs (Eylea, Avastin, and Lucentis) reduced macular edema, but Eylea and Lucentis reduced the swelling more than Avastin.
Eylea has been demonstrated to have been effective in the treatment of diabetic macular edema and is approved by the FDA for this. The patient has been receiving Eylea injections with positive results. Overall, there was a better vision outcome in those patients who were taking Eylea over Avastin or Lucentis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol abuse
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

This patient with a history of polysubstance use was admitted on 02/28/2019 after presenting with request for detox.  Evaluation showed the patient to be hemodynamically stable with mild tachycardia.  Her CIWA score was 6.  The patient was found to have a mild hand tremor.  The patient remained clinically stable throughout hospital stay and was noted to have mild alcohol withdrawal managed with benzodiazepine as needed.  Inpatient admission was not medically necessary for this patient, because she did not have several alcohol withdrawals.  The patient did not fail to respond to treatment at a lesser level of care, and she did not have signs of withdrawal that required an inpatient level of care.  Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a past medical history significant for hypertension and tobacco and cocaine abuse who presented to the emergency department with complaints of a cough, fever, and worsening shortness of breath. Her symptoms started 3 days before the day of admission and became progressively worse. The cough was associated with green sputum. The patient also complained of chest discomfort associated with the cough. Her last use of cocaine was on the day of admission. At the time of initial evaluation, the patient denied headaches, substernal chest pain, palpitations, abdominal pain, nausea, vomiting, and leg swelling.

When seen by the admitting physician, the patient's temperature was 102.8 degrees Fahrenheit (F), blood pressure 117/82, pulse rate 126, respiratory rate 18, and oxygen saturation 94% on room air. The patient was not in acute distress. The lung exam revealed rales. The rest of the physical exam was unremarkable.

A chest x-ray revealed air space opacities in the left upper lobe, lingula and right lower lobe consistent with bilateral infiltrates compatible with pneumonia. The patient was admitted to the hospital with a diagnosis of community-acquired pneumonia. Blood cultures were obtained. The patient received treatment with 2 antibiotics including Ceftriaxone and Azithromycin. Some additional studies, including Legionella antigen and strep antigen, were ordered.

The health plan's determination is overturned.

A review of the medical records demonstrated that this patient developed sepsis syndrome as a result of community-acquired pneumonia. The diagnosis of sepsis syndrome was evident because the patient met systemic inflammatory response syndrome (SIRS) criteria. The patient's temperature was greater than 100.4 F, heart rate was greater than 90 beats per minute (bpm), white blood cell count was greater than 12,000/cubic millimeters (mm3). Also, the patient had pneumonia based on the results of the chest x-ray. Sepsis is a serious clinical condition with a high mortality rate, especially if not treated promptly.

According to the Merck Manual Professional Version,
"Overall mortality in patients with septic shock is decreasing and now averages 30 to 40% (range 10 to 90%, depending on patient characteristics). Poor outcomes often follow failure to institute early aggressive therapy (eg, within 6 h of suspected diagnosis)."

The treatment of sepsis includes:
1) Perfusion restored with intravenous (IV) fluids and sometimes vasopressors 2) Oxygen support 3) Broad-spectrum antibiotics 4) Source control 5) Sometimes other supportive measures

Treatment of sepsis is usually provided at the inpatient level of care, often in the intensive care unit. Therefore, this patient required admission at the inpatient level of care, based on the severity of the clinical condition and the complexity of services provided. According to the standard of care, the treatment of sepsis requires admission at the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Schizophrenia 
Mental Health - Inpatient

The patient is a  male with a diagnosis of schizophrenia (SCZ). The question is whether continued inpatient stay (CIS) is medically necessary.  Case notes document that the patient suffer from chronic SCZ.  The admission of the patient to inpatient care was necessitated by worsening suicidal ideation (SI) for about two weeks, associated with intense auditory hallucinations (AH) including command hallucinations. Additionally, the patient experienced severe anxiety, depression, and paranoia.  He experienced insomnia and was amotivational.  He had been receiving clozapine as an outpatient but adherence to this medication is unknown.  He had been evaluated several times in the emergency room prior to the admission under review.  He suffered from loss of his job and was housebound with his mother.  After admission, the patient was treated with venlafaxine, trazodone, clonazepam and Clozaril.  The Clozaril was gradually increased.  A progress note indicates the patient no longer experienced auditory hallucinations and that his anxiety was decreased, and he had decreased beliefs that others were reading his mind.   With this lessening of psychosis, he had no suicidal ideation, from the available progress notes.  The day prior to discharge was he sleeping well, "feeling fine," without perceptual abnormalities. He was rational and participated in aftercare planning. 

The health plan's determination is overturned, in part. 

The requested treatment of CIS was medically necessary for this patient, in part.  On the proposed last date approved by the health plan, the patient, if discharged, would have had  a high probability of requiring readmission or of self-harm.  The patient continued with auditory hallucinations, anxiety and paranoia.  While this represented a partial improvement, the patient would be at substantial risk if discharged.  He was chronically ill, and his illness represented a severe worsening of his chronic condition.  Progress notes document that he continued to experience thought broadcasting, paranoia, and delusions of reference.  A progress note indicates the patient no longer experienced auditory hallucinations beginning two days prior to discharge and that his anxiety was decreased, and he had decreased beliefs that others were reading his mind.  With this lessening of psychosis, he had no suicidal ideation, from the available progress notes.  The day prior to discharge he was sleeping well, "feeling fine," without perceptual abnormalities.  He was rational and participated in aftercare planning. Therefore, the patient could have been discharged one day prior to the actual discharge date.
Appeal type: Medical necessity
Decision: Overturned

Schizophrenia
Mental Health: Inpatient

The case involves an adult male with schizophrenia and co-occurring substance use disorder with opioid, cannabis and sedative-hypnotic-anxiolytic class substances of abuse. He was admitted to acute inpatient level services with severe symptoms of psychosis with paranoid thought content, disorganized and erratic behavior, and, severe symptoms of motor agitation representing a danger to self and others. Additionally, the patient has a history of non-compliance with treatment and had been non-adherence with medications in the context of use of heroin, Vicodin, benzodiazepines and marijuana.

The health plan's determination is overturned. The Inpatient Services are medically necessary for this patient. The patient's acute symptoms of psychosis and exacerbation of schizophrenia together with continued risk of impulsive behavior, as well as non-compliance with treatment and the co-occurring substance use disorders did warrant the continued acute inpatient level structure and monitoring through discharge. The case is complicated by active substance use disorders; and non-compliance with treatment and medication adherence problems in the context of substance use with opioid, anxiolytic and cannabis class substances of abuse. The residual symptoms of psychosis; risk for relapse, co-occurring substance use disorders, and treatment issues related to non-compliance/non-adherence with medications and the need for arranging a safe and clinically appropriate discharge plan warranted the continued services at an acute inpatient level of care to include safety monitoring and maintaining abstinence from substances of abuse. The continued inpatient stay thru discharge was therefore clinically appropriate and medical necessary in order to provide the necessary active treatment and monitoring and the continued inpatient level structure through the day of discharge when the patient had reached a level of stability that he could return to the community with clinically appropriate level services and aftercare.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for chronic obstructive pulmonary disease (COPD), asthma, and hypertension who presented to the hospital after he sustained a syncopal episode at home.  This episode apparently lasted for approximately 10 minutes and was accompanied by shaking movements in his body.  Prior to that, the patient had been feeling short of breath and was unable to locate his Albuterol inhaler. Reportedly, at that time the patient turned blue in the face.  Otherwise, the review of systems was negative for chest pain, palpitations, dizziness, lightheadedness, leg swelling. The patient denied any previous history of blood clots or recent travel, hemoptysis, or seizure.  Emergency Medical Services (EMS) arrived and the patient received treatment with epinephrine, dexamethasone, and Albuterol with improvement in his symptoms.  The patient was admitted to the hospital with a diagnosis of syncope versus seizure.  Other medical problems included alcohol abuse, cocaine abuse, elevated liver enzymes, and COPD exacerbation.
The health plan's determination is upheld.
Neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care, mainly because the patient remained in absolutely stable clinical condition and did not require any procedures or diagnostic tests necessitating admission at the acute inpatient level of care.
Utilizing the San Francisco Syncope Rule, which is a risk stratification tool that predicts risk for serious outcomes at 7 days in patients presenting with syncope or near-syncope this patient did not belong to the low-risk group for serious outcome.  Therefore, the patient should have been admitted to the hospital from the ER.  During the entire admission, the patient was hemodynamically stable, had unremarkable results of the physical exam except for some rhonchi, unremarkable results of the diagnostic tests (electrocardiogram (EKG), CT scan of head), the inpatient level of care was not warranted.  This patient had elevated liver enzymes, which could have been related to his history of alcoholism and obesity.  Regardless, the workup of this problem could have been performed as an outpatient.  The patient most likely had a mild COPD exacerbation but was not in respiratory distress at any time, and did not require invasive or noninvasive mechanical ventilation.  His respiratory rate and oxygen saturation remained within normal limits all the time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic migraines
Treatment: Aimovig

The Aimovig is medically necessary. 

The patient is a male with chronic migraines who failed treatment in the past with amitriptyline, Topamax, Depakote, rizatriptan, sumatriptan, zolmitriptan, and gabapentin.  For the past four years, his migraine medication was propranolol without any significant relief from his migraines.  Per the physician, the patient has 15 to 16 migraine days per month. Headaches lasted for more than four hours per day and were associated with sensitivity to light and sound, nausea, and dizziness. Over-the-counter analgesics were no longer helpful for him. The patient was provided a sample Aimovig injection after which he only had three headaches in the following month. 

The patient has chronic migraines refractory to multiple preventative medications. The medicine requested, Aimovig, is approved by FDA, 140 milligrams (mg) once a day, for migraine prevention. The attending physician letter indicates that there is no evidence of medication overuse headaches. Therefore, the proposed treatment is medically necessary.

The request is for an FDA approved indication in a patient who has failed multiple treatment options.