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

Diagnosis: Class I malocclusion
Treatment: D8080 Braces and D8670 Monthly Visits x12
The insurer denied: D8080 Braces and D8670 Monthly Visits x12
The denial is overturned.

This patient is a teenage female. The request is for orthodontic benefits and monthly visits. The patient has a skeletal Class I malocclusion with moderate upper and lower arch crowding. 
She has a deep bite and is missing her lower left first permanent molar. The prior denial was due to a handicapping index score of 18 points.

The requested health service is medically necessary.

The patient has an ectopically erupting lower second premolar. This means that it is erupting outside of its normal position. This will be a food trap and will eventually cause dental decay in that area due to it being harder to keep clean. Also, the patient's upper left and right permanent canines are "blocked out", meaning there is not enough room for them in the dental arch. Without the canines being properly positioned, there can be no "canine guidance". This is when the lower canines glide along the insides of the upper canines during the chewing cycle. Without canine guidance, the posterior teeth will bang into each other in a traumatic way and eventually lead to fracturing and/or loosening of several teeth. Orthodontic treatment is needed to correct these problems. This case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Mounjaro
The insurer denied: Mounjaro
The denial is upheld.

The patient is an adult male with a history of obesity. Mounjaro (tirzepatide) is being requested for management of weight loss. The patient does not have a known history of diabetes mellitus type 2. The patient's current weight is 212 pounds with a body mass index (BMI) of 32.2.

The request for Mounjaro is not considered medically necessary.

The appeal letter, medical records including lab work, and denial letters were reviewed. This is an adult male with a history of obesity. The documentation shows the patient's father is a 
type 2 diabetic, and both maternal and paternal grandparents are diabetic. His paternal grandmother had complications from diabetes status post leg amputation. The patient's mother, 
father, brother, and sister all had hypertension. His father and siblings are all morbidly obese. His sister underwent gastric bypass surgery, and his brother was recently started on glucagon-like peptide-1 (GLP-1) to help him lose weight. He had a myocardial infarction in his early thirties. The patient reports leading a healthier lifestyle, using Victoza, metformin, and Contrave with no success. He also reports being on Rybelsus, but insurance approval was discontinued due to the patient not being a diabetic. The patient began Mounjaro last yer, with a weight of 289 pounds and BMI (body mass index) 43.9. After being on Mounjaro, he lost 27% of body weight. His current weight is now 212 pounds, with BMI (body mass index) of 32.2. His blood pressure has normalized, and anti-hypertensives have been discontinued, as his hypertension is now well controlled, with a recent blood pressure of 119/79. The patient also states that he had been struggling with trigger finger in his left index finger; however, since he began Mounjaro, the swelling and functioning of his finger has continued to improve and is almost completely gone currently. Appeal notes indicate patient reports that in the year since he began Mounjaro, his blood pressure and gout have improved. The FDA (United States Food and Drug Administration) approved Mounjaro injection to improve blood sugar control in adults with type 2 diabetes as an addition to diet and exercise. The patient is not a diabetic, and there is no documentation that he has hemoglobin A1c (glycated hemoglobin) greater than or equal to 6.5%, fasting blood glucose greater than or equal to 126mg/dL (milligrams per deciliter), or a 2-hour plasma glucose greater than or equal to 200mg/dL (milligrams per deciliter) during oral glucose tolerance test. Therefore, the request for Mounjaro is not considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonary Emboli

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.		

The denial is overturned.

This is a patient with a history of multiple pulmonary emboli (PE's).  The patient was maintained on Xarelto.  The patient presented to the emergency department (ED) with complaints of chest pain and shortness of breath (SOB).  The patient had seen an Ear, Nose and Throat (ENT) doctor the previous day and was giving oral antibiotics and oral steroids for a sinus infection.  The patient was generally compliant with Xarelto but had missed two days a few days prior while on a camping trip.

On presentation to the ED, the patient's vital signs were as follows: Temperature 99.5 degrees Fahrenheit (F), heart rate (HR) 93 to 110, blood pressure (BP) 130-140/70-80, and oxygen (O2) saturations 93-97% (percent) on room air (RA).  The patient's white blood cell count (WBC) was 21 and D-dimer was elevated.  The patient's electrocardiogram (ECG) revealed sinus tachycardia with an S1, Q3, T3 pattern. 

A computed tomography angiogram (CTA) was done to rule out PE and was positive for PE's of the left upper lobe, left lower lobe, and possible infarction.  Hematology was consulted and it was their opinion that the patient had developed PE's from Xarelto failure.  Hematology recommended placing the patient on intravenous (IV) Heparin for their multi-lobar PE.  The plan was to achieve therapeutic anticoagulation and subsequently switch to oral (PO) Coumadin or Pradaxa.  The patient achieved therapeutic anticoagulation and was started on Pradaxa.  However, the patient's insurance company would not approve Pradaxa and the patient was not keen on taking Coumadin, so the patient was started on Lovenox and was discharged home on Lovenox. 

Given the fact that this patient had a history of multiple PE's in the past and now presented with multi-lobar PE despite being compliant with their Xarelto regimen, it was appropriate to admit the patient to the hospital for IV Heparin as recommended by Hematology.

This could not have been achieved in any other setting besides an acute inpatient hospital stay.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Substance abuse inpatient rehabilitation
The insurer denied substance abuse inpatient rehabilitation.
The determination is upheld.

The patient is an adult male who was admitted on to inpatient rehabilitation substance use disorder treatment of alcohol and cannabis (marijuana) use disorders.  He had a longstanding history of substance use disorders with past substance use disorder treatment episodes without sustained abstinence and relapse. He had attempted detoxification but left before the treatment had started.

There was a report of co-occurring psychiatric disorders in this case including bipolar depression. The patient was taking no psychotropic medications.

The inpatient level substance-related rehabilitation treatment included the opportunity to participate in groups, individual counseling, educational sessions, and recovery groups. He was prescribed comfort medications and Valium taper without complication.
Discharge planning occurred that included recommendations for continued residential treatment. The patient was cooperative and engaged throughout his inpatient stay with reasonable motivation and participation in therapeutic activities. There were no psychiatric or biomedical complications during his stay.
At issue is the medical necessity of substance abuse inpatient rehabilitation.
The requested health service/treatment of substance abuse inpatient rehabilitation treatment was not medically necessary for this patient.
The patient was motivated and was capable of effectively receiving substance use disorder treatment in a less restrictive treatment setting with clinically appropriate structure, monitoring, and sober supports. The patient did not need the structure of an inpatient setting to effectively participate in rehabilitation substance abuse treatment. The structure and intensity of services necessary for the rehabilitation/substance use disorder treatment could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports. There is no evidence that the inpatient level structure and 24-hour nursing monitoring was medically necessary for a successful outcome in this case. There were no biomedical, psychiatric, or general medical issues complicated withdrawal that warranted the requested inpatient level services.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizoaffective disorder and syncopal episode

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is an adult female with a history of schizoaffective disorder and hypertension. The patient was admitted in the inpatient psychiatric unit for suicidal ideation and syncopal episode. She had a small laceration in her left elbow. Computerized Tomography (CT) of the head was negative. Troponin work up was negative for cardiac incident.  

During the inpatient stay the patient required psychiatry consultation, continuous cardiac monitoring, serial troponins, electrocardiogram (EKG), and transthoracic echocardiogram (TTE). Chest X-ray (CXR) revealed subsegmental atelectasis in the right lung base. EKG showed sinus rhythm with a first-degree anterior-ventricular (AV) block. Echo showed ejection fraction (EF) 65 percent (%) with dilated right ventricle, thickened, and calcified aortic valve leaflets, aortic root dilation, small pericardial effusion, and impaired left ventricle relaxation. The psychiatrist ordered 1:1 monitoring and increased her Bupropion XL. The patient was diagnosed with orthostatic hypotension secondary to dehydration and hypertensive medication. She was discharged back to inpatient Psychiatry.      

Per Milliman Care Guidelines, inpatient admission is indicated for Hemodynamically instability as indicated by 1 of the following: vital sign abnormality not readily corrected by appropriate treatment; Hypotension as indicated by ALL of the following: Not patient baseline (e.g., healthy adult with low SBP) or intentional therapeutic goal, Low blood pressure, SBP (systolic blood pressure) less than 90 mmHg (millimeters of mercury) in adult, MAP less than 70 mmHg in adult, Decrease in baseline MAP (mean arterial pressure) of 25% or more, with significant signs or symptoms due to lower blood pressure (e.g., near syncope, syncope, chest pain).

Literature indicates improving access to cardiology consultations with multidisciplinary, in-hospital and patient care pathways improve survival.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left arm parasthesia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female who presented to the emergency ward with left arm paresthesia. At presentation, a computed tomography (CT) of the brain did not demonstrate acute pathology. The patient's blood pressure was 232/125. The patient was admitted to the acute inpatient hospital setting. Magnetic resonance imaging (MRI) of the brain the next day showed acute thalamic stroke.

The requested health service was medically necessary.

The patient had an acute stroke with hypertensive emergency. She repeatedly required parenteral medications to manage her blood pressure for more than 24 hours. Clinical trials have demonstrated that people with ischemic stroke and systolic blood pressure ranging from 161-180 millimeters of mercury (mmHg) have the best outcome after stroke (1). The continued elevated blood pressure warranted acute inpatient level of care for monitoring and treatment (2) to achieve the target range. Therefore, the requested health service was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vitiligo
Treatment: Opzelura 1.4% Cream
The insurer denied: Opzelura 1.4% Cream
The denial is overturned.

The patient is an adult female with vitiligo, treated with topical steroids and topical calcineurin inhibitors. The provider is requesting Opzelura cream. The health plan does not provide coverage for vitiligo as it is considered cosmetic.

The requested health service is medically necessary.

Vitiligo is a disorder of pigmentation, in which patients experience a loss of functional melanocytes. Therefore, patients lack pigment protection in vitiliginous areas of the skin. Patients are at increased risk of sunburns and skin cancer. The aims of vitiligo treatments are repigmentation and stabilization of the depigmentation process. The importance of treating vitiligo was reviewed in the 2009 study cited below. It is not simply a cosmetic condition. Opzelura is the first and only Food and Drug Administration (FDA) approved medication for vitiligo. In the randomized controlled trial (Rosmarin et al), the primary endpoint at week 24 was reached by significantly more patients given ruxolitinib cream at 15% twice daily (15 [45%] of 33) and 15% once daily (15 [50%] of 30) than were treated with vehicle. Therefore, Opzelura is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class I malocclusion
Treatment: D8080 Braces and D8670 Monthly Visit x12
The insurer denied: D8080 Braces and D8670 Monthly Visit x12
The denial is overturned.

The patient is a teenage female. The request is for orthodontic benefits with monthly visits (x12). The patient has a skeletal Class I malocclusion with moderate upper and mild lower spacing. She has a severe overjet. The prior denial was due to the patient's score being 16 on the handicapping index scale.

The requested health service is medically necessary.

The patient has a deep impinging overbite with soft tissue damage on her palate. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this, and the monthly visits (x12) are needed to follow treatment progress. This case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: fever and abnormal movements

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

At time of admission, this is a young, otherwise healthy male, who presented to the emergency department (ED) with abnormal movements. These movements were described as short-lived episodes of whole-body jerking over the last two days, in the setting of fever, diarrhea, cough, and congestion for five days.  Physical examination on presentation showed that the patient was nonfebrile, alert, and "appeared well...tolerating by mouth (po)", though with "ongoing jerks while in the ED".  Neurology was consulted and recommended inpatient admission for a video electroencephalogram (vEEG).  Per medical records, no anti-seizure medications were given during admission.  Abnormal movements were not seen after admission. The vEEG was completed and was interpreted as 'normal baseline electroencephalogram (EEG)' with 'no clinical or electrographic seizures reported or detected.'  The patient was stable for discharge home. 

The patient had possible seizure activity, though did not require any anti-seizure medications. In addition, the patient appeared well with stable vital signs, normal laboratory work-up, and a reassuring physical examination. A video electroencephalogram (vEEG) was performed which was normal, though a routine electroencephalogram (EEG) could have been performed with close clinical follow-up as an outpatient given the patient's reassuring physical examination, stable vital signs, and normal laboratory workup. There was no evidence of ongoing infection, encephalitis, or status epilepticus. The patient's vital signs were stable without fevers, abnormal heart rate, abnormal oxygen saturations, or blood pressure indicating any signs of infection, respiratory distress or cardiac compromise. The patient's labs, including blood counts, electrolytes, and glucose, did not indicate any abnormal results requiring intervention or increased lab draws or monitoring. The patient did not exhibit any signs/symptoms of increased or continued seizure activity, require a change in seizure medication regimen or increased neurological checks.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cystic fibrosis
Treatment: Elexacaftor-Tezacaftor-Ivacaftor (Trikafta)
The insurer denied Elexacaftor-Tezacaftor-Ivacaftor (Trikafta)
The health plan's determination is overturned. 

The patient is a young girl with cystic fibrosis (CF). She has classic CF with both gastrointestinal and pulmonary manifestations. Her genotype is diagnostic of cystic fibrosis per the CF Foundation Guidelines. Coverage for Elexacaftor-Tezacaftor-Ivacaftor (Trikafta) has been requested and denied as not meeting medical necessity criteria.  

Tricafta is medically necessary for the patient.
The patient's extremely rare mutations are unlikely ever to be studied or approved individually by the Food and Drug Administration (FDA). Nasal cell based pre-clinical studies of the N1303K CFTR function conducted at Cincinnati children's Hospital Medical Center suggest that patience with this mutation will benefit from a CFTR modulator. Similar increases in CFTR function in cells homozygous for the N1303K mutation have been documented in several small clinical case reports.

Although Trikafta does not fulfill the specific published criteria for medical necessity, there is enough data to suggest that the patient may nevertheless experience significant from it. Since CF is a fatal disease and Trikafta may drastically change its outcome, a trial of Trikafta would be indicated for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental Disorder.
Treatment:  Braces.

The insurer denied Braces.  The determination is overturned.

The patient has a Class II Division 1 malocclusion with maxillary and mandibular crowding. He has a 9-millimeter (mm) overjet and 8mm overbite. He is treatment planned for orthodontics to correct his malocclusion. At issue is the medical necessity of braces.

This patient, like fifteen percent of the population, exhibits an Angle's Class II bite. (1) Patients with a Class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible. There is strong medical evidence that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. (2) Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6 plus (+) mm overjet, which this patient has. (3) For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: decreased mobility
Treatment: home health care
The insurer denied Home Care / Personal Care Consumer Directed Personal Care Assistance Services (CDPAS) 60 Hours per Week 
The health plan's determination is overturned. 

This is a female patient with a history of primary generalized osteoarthritis, atherosclerotic heart disease, hypertension, hyperlipidemia, history of falls, diabetes mellitus type 2, urge incontinence, and polyneuropathy. She lives with her son and his family in a private home. The patient and her care team requested Home Care / Personal Care Consumer Directed Personal Care Assistance Services (CDPAS) 60 Hours per Week.

Home Care / Personal Care Consumer Directed Personal Care Assistance Services (CDPAS) 60 Hours per Week is medically necessary.
There is documentation in the Uniform Assessment System (UAS) of the patient requiring maximal assistance with tasks of walking, locomotion, transfer toilet, and toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the Plan failed to document a plan to meet these unscheduled and unpredictable care needs. The Plan should not have utilized a tasking tool to calculate hours given that the patient has unscheduled and unpredictable care needs. The UAS demonstrates decline in function and increased assistance needs as compared to the previous UAS performed. The patient lives with her son and therefore has informal support. However, it cannot be assumed that the informal support person can provide all needed care outside of the approved CDPAS hours as informal supports must be voluntary. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in CDPAS services is not solely for safety and supervision but to assist the patient with activities of daily living (ADL).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain, Wounds on Hands and Lower Limbs.
Treatment: Inpatient Hospital Admission.

The insurer denied: Inpatient Hospital Admission.  The denial is upheld.

This patient is an adult male with Crohn's disease, who presented with severe lower abdominal pain. He was seen at the hospital a few days previously, at which time admission was advised. In the emergency department, the patient had tenderness in the bilateral lower quadrants. There were multiple ulcerations of skin on the left lower extremity. The wounds were foul smelling. Computed tomography (CT) of the abdomen / pelvis showed thickening and inflammation in the terminal ileum and proximal ascending colon. The patient refused skin checks and was noted to be uncooperative. The patient received morphine 2 milligrams (mg) intravenously and signed out against medical advice.

The requested health service was not medically necessary.

The patient did not have hemodynamic instability, severe pain requiring acute inpatient management, or peritoneal signs. The patient did not require identification of etiology or finding or evaluation requiring the patient to not eat or drink for extended period (e.g., more than 24 hours). The patient did not have inability to maintain oral hydration (e.g., needs intravenous fluid support) that persists after observation care and did not have suspected toxic megacolon. The patient did not have bacteremia. The patient did not require a procedure that could not have been performed on ambulatory basis. The patient did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, and did not have any complications such as intra-abdominal abscess or a surgical abdomen. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism
Treatment: Physical therapy
The insurer denied the physical therapy.
The health plan's determination is overturned. 

The patient is a young male with autism spectrum disorder, overactivity and sensory integration disorder. 

The requested physical therapy services are medically necessary for the patient. The literature supports that physical and occupational therapy are medically necessary interventions in children with autism, overactivity and sensory disorder. The documentation for this patient documents deficits, goals and progress toward those goals. Therefore, the physical therapy in question was medically necessary.