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

Diagnosis: Substance Abuse/Addiction - active withdrawal symptoms.
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was overturned. 

This patient is a female with a history of anxiety, depression, and hypertension, who presented to the hospital with 6 months of feeling lethargic, having shakes, and loss of appetite. She reported being stressed and drinking alcohol at night. Per the admission history and physical the patient had a Clinical Institute Withdrawal Assessment (CIWA) scale calculated at 12.

From a psychiatric standpoint, the patient appeared disheveled, with withdrawn behavior, and depressed.

The alcohol level was elevated. The patient was admitted for active withdrawal symptoms and placed on a CIWA protocol with Librium taper and Ativan as needed. Normal saline was started for hyponatremia, along with thiamine folate and multivitamin. 

The psychiatrist cleared the patient for discharge to home, with Lexapro 20 milligrams (mg) daily and outpatient psychotherapy.

At issue is the medical necessity of the inpatient stay.

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

The requested health service/treatment of inpatient stay is medically necessary for this patient.

This patient presented to the hospital with signs of moderate alcohol withdrawal, as evidenced by a CIWA scale of 12, along with multiple electrolyte derangements and abnormality of LFTs (liver function tests). Concurrently, the patient had thrombocytopenia and evidence of hepatic fatty infiltration likely related to chronic alcohol consumption. The patient was placed on alcohol withdrawal protocol with Librium and Ativan to prevent seizures. Despite appropriate treatment, over the next 48 hours, the patient continued to have tremors. 

Alcohol withdrawal is a life-threatening condition with high mortality and morbidity. Typically, this patient population is managed under an Intensive Care Unit (ICU), depending on the severity of the symptoms. The patient in this situation had a CIWA score of 12 on admission. The inpatient hospitalization was medically necessary for this situation.

Furthermore, the patient had hyponatremia, which requires frequent assessment. Combining both factors contributes to the inability to care for this patient under a lower level of care.

Therefore, the inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Idiopathic Constipation. 
Treatment: Amitiza (Lubiprostone) 8 mcg Capsule, Pre-service. 

The insurer denied the Amitiza (Lubiprostone) 8 mcg Capsule, Pre-service. 
The denial is overturned. 

This patient is a male. He has had chronic constipation and fecal incontinence. He did not respond to other medications. His doctor requested Amitiza. 

Yes, the treatment with Amitiza is medically necessary. 

Systemic review and meta-Analysis of randomized clinical trials showed that "Lubiprostone is a safe and efficacious drug for the treatment of chronic idiopathic constipation and irritable bowel syndrome with constipation, with limited adverse effects in 3 months of follow-up" (Li, et al). 

Hyman, et al published a study and evaluated the safety and effectiveness of lubiprostone in children and adolescents with constipation. Mean spontaneous bowel movement (SBM) frequency significantly increased compared with baseline at week one (3.1 vs 1.5 spontaneous bowel movements/week). Spontaneous bowel movement frequency was improved significantly from baseline overall and for individual dose groups during weeks two, three, and four. They concluded that "Lubiprostone was efficacious and well tolerated in children and adolescents with functional constipation." The doses of Amitiza used in this study were 12 micrograms once daily (QD), 12 micrograms twice daily (BID), or 24 micrograms twice daily based on age and weight. 

In summary, Lubiprostone (Amitiza) has been shown to be effective and well-tolerated in children with chronic idiopathic constipation. This patient has had chronic idiopathic constipation and did not respond to all other available medications. In clinical practice, Amitiza would be the next treatment option. The proposed treatment is medically necessary. 

The plan covers Amitiza for adult patients 18 years or older. Current peer-reviewed literature supports that Amitiza is effective and well-tolerated in children with chronic idiopathic constipation. In clinical practice, Amitiza has been widely used in children with chronic constipation who did not respond to other available medications.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Possible Stroke

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient is a female with a past medical history of diabetes mellitus, and hyperlipidemia.  The patient came to the Emergency Room (ER) due to facial and left upper extremity numbness that started a few hours ago.  The patient called her primary care physician, who advised her to come to the ER.  The patient still had numbness of the left upper extremity in the ER.  The physical examination revealed a sensory deficit.  There was no cranial nerve deficit.  The patient was oriented to person, place, and time.  The patient had normal range of motion.  The patient's blood pressure was 134/78.  The assessment and plan included ruling out transient ischemic attack, and to obtain an immediate computed tomography (CT) scan of the head.  When the stroke team arrived, the patient denied motor weakness, paralysis, slurred speech, or facial droop.  The patient denied smoking, alcohol use, or drugs.  On examination, there was no facial droop, tongue deviation, gaze preference, slurred speech, arm drift bilaterally, leg drift bilaterally, ataxia, or muscle weakness bilaterally in the upper or lower extremities.  The patient's CT scan of the head without contrast revealed no focal acute intracerebral abnormalities.  The stroke team noted that if the patient's symptoms persisted, a non-emergent outpatient magnetic resonance imaging (MRI) may be performed.  The patient was not a candidate for a tissue plasminogen activator (tPA) intervention because of her minimal neurologic deficits.  The patient was admitted for further work-up.  The patient was to undergo an MRI of the brain and a transthoracic echocardiogram, and if negative, the patient was to be discharged home and follow-up with neurology.  The patient was treated with aspirin, atorvastatin, and intravenous fluids.  The patient's MRI of the brain and carotid Doppler were normal.  The patient was discharged.

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient.  The patient presented with symptoms concerning for stroke. Thus, close inpatient monitoring was medically necessary for this patient. 

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

The insurer's denial of coverage for the inpatient admission should be reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis.
Treatment: Inpatient Hospital Admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

The patient is an immune compromised male with a past medical history significant for recurrent cellulitis/abscess, asthma, bipolar disorder, and depression who presented to the Emergency Department with complaints of right foot swelling and erythema. Vitals on presentation included: Temperature- 36.8 Celsius, Blood Pressure- 125/67, Pulse- 87, Respiratory Rate- 18, Oxygen saturation- 98% on Room Air. Laboratory results included the following: White blood cell count- 4.7, hemoglobin - 13.1, hematocrit 39.3, creatinine- 1.03, glucose- 118.  The patient was empirically started on intravenous antibiotics (vancomycin and Unasyn) for possible cellulitis of the right foot. Infectious Diseases consulted and recommended adjustment in antibiotic coverage. X-ray of the foot showed soft tissue swelling, otherwise no acute fracture or injury. Cultures remained negative. The patient remained afebrile and hemodynamically stable. The patient was discharged on oral antibiotics (doxycycline and Augmentin).
 
According to documentation, the patient presented with a possible right foot cellulitis. Otherwise, he was afebrile, hemodynamically stable, with unremarkable laboratory results including normal white blood cell. The patient did not have any evidence for a disseminated infection and no surgical intervention was required. Based on these findings, patient did not meet criteria for acute hospital admission.   

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep bite with palatal impingement
Treatment: Braces
The insurer denied the braces.
The denial is overturned. 

The patient is a male.  The request is for orthodontic benefits.

Yes, the proposed treatment with Braces is medically necessary.

The patient has a very deep bite with palatal impingement causing trauma to the upper gums behind his front teeth.  This is an automatic qualifier according to the handicapping index scale. This condition is seen in the photos, on the x-ray and mentioned in the clinical notes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Decay Interproximal of Tooth #19

Treatment: D2751 for a white glass with metal crown for tooth 19

The insurer denied coverage for D2751 for a white glass with metal crown for tooth 19

The denial is overturned 

According to the medical records, the patient is a male who is under the care of his dentist for crown #19.  The initial request was denied as not medically necessary.

As per Park (2010), "This clinical case describes a treatment approach that combines, in a single appointment, a crown lengthening procedure and the final crown preparation for the restoration of a severely decayed tooth.  This approach allows for a more accurate placement of the crown margin in relation to the bone crest while reducing treatment time."

"Porcelain-fused-to-metal (PFM) crowns have been considered the gold standard for the repair of damaged teeth.  PFM crowns have good mechanical properties, satisfactory esthetic results, and an acceptable biological quality needed for periodontal health." (Porcelain-Fused-to-Metal Crowns versus All-ceramic Crowns, 2015)

As per Makhija et al. (2016), "Network dentists use a broad range of materials for single-unit crowns for anterior and posterior teeth, adopting newer materials into their practices as they become available.  Material choices are significantly associated with dentist's and practice's characteristics."

"Practical Implications Recommendations for crowns may be influenced by factors unrelated to tooth and patient variables.  A concern for tooth fracture -- whether from endodontic treatment, fractured teeth, or large restorations -- prompted many clinicians to recommend crowns." (McCracken et al., 2016) 

Based on the radiographs provided, there appears to be significant dental decay on the interproximal of this tooth.  The crown needs to be removed and the decay be removed and then a new crown be placed.  This follows best practices and the standard of care.      

The dental code D2751 for a white glass with metal crown for tooth 19 is considered medically necessary for this patient.  The replacement of the crown is medically necessary.  There is recurrent decay and this needs to be removed and a new crown made. 

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

Based on the above, the medical necessity for the dental code D2751 for a white glass with metal crown for tooth 19 is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ovarian torsion. 

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

The patient is a female who presented to the emergency room (ER) due to complaints of left lower quadrant abdominal pain and nausea. Ultrasound findings were concerning for a left ovarian torsion. The patient underwent a diagnostic laparoscopy, detorsion of the left ovary and left ovariopexy. The procedure was uncomplicated with minimal blood loss (5cc). The patient tolerated the procedure, and she was transferred to the post anesthesia care unit in stable condition.  The patient was voiding, tolerating a diet and ambulating without difficulty. She was discharged from the post anesthesia care unit in stable condition with outpatient instructions to follow up with Gynecology in 2 weeks.

This patient underwent a laparoscopy. A laparoscopy is an ambulatory procedure.
According to Milliman Care Guidelines, Inpatient and Surgical Care, Laparoscopic Gynecologic surgery, including myomectomy, oophorectomy, and salpingectomy, laparoscopic procedures are ambulatory procedures. Inpatient stay may be needed for:
Older patients (> 65)
Conversion to abdominal procedures
Surgical complications
Comorbidities.

This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. She was tolerating oral intake and voiding adequately. Her incisional pain was minimal.
 
A laparoscopic procedure is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required. The patient could have been observed up to 24 hours after surgery and if stable she could have been sent home. More complicated procedures like hysterectomies are all ambulatory procedures.

Based on the above, the inpatient admission was not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical Chest Pain

Treatment: Myocardial perfusion imaging (CPT Code 78452), a special test to check the blood flow to the heart and how well the heart is pumping

The insurer denied coverage for myocardial perfusion imaging

The denial is upheld

This is the case of a female with a history of gastroesophageal reflux disease, non-obstructive coronary artery disease noted on computed tomography angiography and hyperlipidemia. She presented to the hospital with chest pain that occurred at rest and resolved after several minutes on consecutive evenings. Work up revealed normal electrocardiogram and no elevation in troponin level. She was discharged from the Emergency Department. She underwent myocardial perfusion testing that was unremarkable.  Of note, stress testing within the prior six months was also performed and found to be without abnormality.

This patient presented with atypical chest pain and had a low pretest probability of significant coronary artery obstruction. (1) Stress test performed within the past six months was normal. Appropriate use criteria for stress testing in patients with atypical chest pain and low risk profiles label myocardial perfusion testing as rarely appropriate. (2) In conclusion, myocardial perfusion testing was not medically necessary in this case.

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

The insurer's denial of coverage for 78452, myocardial perfusion imaging (MPI), a special test to check the blood flow to the heart and how well the heart is pumping is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic obstructive pulmonary disorder

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This female patient has a history of hypertension, hyperlipidemia, asthma, anxiety, and depression who presented to the Emergency Department (ED) with a chief complaint of cough/ bronchitis. The patient reported productive cough, shortness of breath (SOB) and chest tightness x 2 months.  In the ED, the patient's oxygen saturation was 97% on room air.  Physical examination was significant for positive diffuse wheezing in bronchi and mild tachypnea.  Chest X-ray revealed mild congestive changes.  Treatment in the ED included nebulizers and intravenous (IV) Solumedrol.  Upon reassessment, the patient had increased work of breathing and persistent bronchospasms.  The patient received treatment with bilevel positive airway pressure (BiPAP), Terbutaline, and IV Magnesium.  The patient was eventually weaned to oxygen via nasal cannula.  She was admitted to Inpatient care on for further management of chronic obstructive pulmonary disorder (COPD) exacerbation.  The patient was treated with IV steroid and nebulizers and her condition improved.  She was discharged home on with primary care provider (PCP) and pulmonary follow up advised.  The discharge diagnosis was asthma exacerbation.

This patient did not need acute inpatient hospitalization.  She could have been placed in observation status while diagnostic testing and treatment were initiated.  The patient was afebrile and hemodynamically stable.  She was not hypoxic.  No use of accessory muscles is described.  She was not retaining carbon dioxide (CO2); pH 7.38, partial pressure of carbon dioxide (PCO2) 44, and lactate levels were normal.  There was no Pneumonia, Pleural effusion or Pneumothorax (PTX) on chest x-ray.  The patient improved with treatment and short time on BIPAP.  WBC was normal.  The patient was ambulatory.  She was tolerating orally.  She was stable for discharge after a period in observation status (Observation could be for up to 48 hours).  The patient could have been placed on oral steroid taper, bronchodilator and followed up closely in an outpatient setting after discharge.  

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

Diagnosis: Spinal cord injury. 
Treatment: MyoCycle Home Functional Electrical Stimulation Therapy. 

The insurer is denied coverage for  MyoCycle Home Functional Electrical Stimulation Therapy. 

The denial is upheld. 

This male patient has a history of a spinal cord injury and resultant paraplegia.  The patient was seen by his internal medicine primary care physician, for symptoms consistent with acute sinusitis and treated with oral antibiotics.  The treating physician also requested a MyoCycle Home Functional Electrical Stimulation (FES) Therapy for the treatment and prevention of chronic disease. Under review is the medical necessity of the requested MyoCycle Home Functional Electrical Stimulation Therapy. 

The MyoCycle Home Functional Electrical Stimulation Therapy system is a Food and Drug Administration (FDA) cleared class 2 medical device.  This device is intended for patients with spinal cord injury with minimal to no voluntary arm or leg movement.  

The requested durable medical equipment (DME) is not merely a type of exercise device.  Proposed beneficial effects are improving cardiopulmonary function, increase muscle mass, decrease spasticity and increase bone density.   The accumulated peer reviewed medical literature supports a result of improvement in health outcome.  The long term beneficial effects of this device evaluated in the peer reviewed (randomized controlled) published medical literature are also promising.  

There is no evidence from the clinical information specifically regarding the patient that supports the requested device as particularly useful for the treatment and prevention of this patient's chronic disease.  In this case, the requested device is best described as investigational/experimental. From a physical medicine and rehabilitation/pain management perspective as well as within a reasonable degree of medical certainty, the requested MyoCycle Home Functional Electrical Stimulation Therapy is not medically necessary in this particular case. 

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 MyoCycle Home Functional Electrical Stimulation Therapy is upheld.  The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Ocular hypertension
Treatment: Vyzulta
The insurer denied Vyzulta.
The determination is upheld.

The patient has a history of ocular hypertension (OHT) or glaucoma who has previously been treated with a prostaglandin, possibly latanoprost. Per the handwritten note from her doctor, this did not control her intraocular pressure (IOP) adequately. Therefore, he recommended Vyzulta (latanoprostene bunod) for therapy. At issue is whether the formulary drug(s) will be or has been ineffective, would not be as effective as the non-formulary drug, Vyzulta 0.024% drops, or would have adverse effects.

The formulary drugs travoprost, and bimatoprost may well be as effective as Vyzulta and are unlikely to have adverse effects compared to Vyzulta. Vyzulta is a prostaglandin analog that is metabolized into 2 moieties and regulates intraocular pressure (IOP) through both the trabecular outflow and uveoscleral outflow pathways. The first component is latanoprost, considered the most efficacious first-line agent for glaucoma, which has been on the market for more than 2 decades. This is the medication it appears the patient has tried with unsatisfactory results. No information is provided about the goal IOP or whether any effects were seen with the latanoprost. The second component is butanediol mononitrate, which releases nitric oxide induces (NO). NO causes cell relaxation in the trabecular meshwork which is thought to lead to an increase in the conventional outflow pathways. In the VOYAGER study, which compared Vyzulta to latanoprost alone, Vyzulta was associated on average with 1.2 millimeters of mercury (mmHg) of additional IOP lowering compared to latanoprost. However, Vyzulta is not currently used as a first line therapy by many physicians. Bimatoprost has also been shown to lower IOP beyond what can be achieved with latanoprost and that has not been tried in this patient. Studies have shown up to 1.5 mmHg reduction in IOP with bimatoprost over latanoprost in up to 92% of patients. Travoprost may also offer superior IOP lowering and has not been tried per the submitted materials.  It appears that the patient has tried one formulary medication with insufficient control of her disease. It is reasonable to try travoprost or bimatoprost prior to using the newer nonformulary medication.