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

Diagnosis: Possible secondary syphilis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is an immunosuppressed male patient with a past medical history significant for diabetes mellitus, chronic obstructive pulmonary disease (COPD), obesity, and substance abuse who presented to the Emergency Department with complaints of high blood sugar, rash, and malaise. 

Vital signs on presentation included: Temperature - 97.8, Blood Pressure - 135/75, Pulse - 96, Respiratory Rate - 18, oxygen (O2) saturation - 97% on room air. Laboratory results included the following; white blood cell (WBC) count - 8.3, hemoglobin (HGB) - 11.6, hematocrit (HCT) - 37.4, creatinine - 0.7, glucose - 219, lactate - 1.2.

The patient was admitted with a possible secondary syphilis. He was empirically started on intravenous antibiotics (doxycycline). Abdominal ultrasound showed no evidence of cholelithiasis or biliary ductal dilatation. The patient remained afebrile, and hemodynamically stable. He was discharged to continue oral doxycycline as outpatient.

According to documentation, the patient presented with a rash. He was afebrile, hemodynamically stable, with unremarkable laboratory findings including a normal WBC count. The patient was able tolerate oral intake and there was no evidence of a disseminated infection requiring acute hospitalization. Presumptive secondary syphilis is generally outpatient management. Documentation does not support the need for an inpatient stay. 

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

Diagnosis: Lumbar disc herniation

Treatment: Inpatient hospitalization

The insurer denied coverage for inpatient hospital admission

The denial is reversed.

This male patient has no prior medical history and presented to the emergency department (ED) with complaints of right lower extremity pain following a fall at home. The patient reported slipping on a dustpan and falling, causing his right leg to jet out in front of him and he fell to the ground. The patient presented with pain in his right hip, right medial thigh of his groin to his knee. He reported the pain worsened with movement and palpation. The patient's physical exam was remarkable for hip tenderness to palpation and range of motion. A computed tomography (CT) scan of the pelvis and lumbar spine showed no fracture or acute findings. The patient received pain management with morphine and acetaminophen with no improvement. The patient was admitted for further evaluation and management of right hip/lower extremity/ lumbar sprain versus fracture/ lumbar herniated disc. Magnetic resonance imaging (MRI) of the lumbar spine showed L3-4 right subarticular-foraminal protrusion with mild mass effect upon the right L3 nerve root, mild spinal stenosis and mild spondylosis change at L4-5 and L5-S1 without significant nerve root impingement. The final impression was lumbar disc herniation.  Physical therapy (PT) was started. Continuation of PT was recommended with over the counter medications for pain management, and weight-bearing right lower extremity with assistive device. He was medically cleared for discharge to home with instructions for follow up with orthopedic surgery. 

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. The medical record demonstrated that the patient had intractable pain and required several dosages of intravenous (IV) morphine. A practitioner reported that this patient's pain was unimproved from medication provided in the ED. The physician reported intractable pain and unable to ambulate. The patient was evaluated by PT services. The records documented the patent was unable to place foot on ground because of pain and had difficulty lowering self into a chair. Subspecialty consultations recommended additional imaging and other specialist evaluation. 

Due to complexity of this patient's clinical condition, ongoing need for IV analgesia and inability to be mobilized, this patient's inpatient admission and length of stay was medically necessary. This patient's care would not have been appropriate at the observation level as no clinical improvement was reported. 

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

The medical necessity is substantiated. The denial of coverage for the inpatient hospital admission is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia. 
Treatment: Inpatient Level of Care. 

The insurer denied coverage for the inpatient level of care. 

The denial is overturned. 

This is a female patient with cirrhosis, varices who was sent to the hospital by her Primary Care Provider (PCP) for a blood transfusion. On arrival to the hospital, the patient had a hemoglobin level of 6.7 with a systolic blood pressure (SBP) of 90. The patient was admitted to the hospital, transfused, and was discharged the following day. 
As per the Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 24th Edition Gastrointestinal Bleeding, Upper, the clinical indications for admission to inpatient care are: hemoglobin less than 12 grams per deciliter (g/dL) (120 gram per liter (g/L)) if male, or less than 10 g/dL (100 g/L) if female; systolic blood pressure less than 100; liver disease. 

As per the MCG Health Inpatient & Surgical Care 24th Edition Anemia, Iron Deficiency or Unspecified, the clinical indication for admission to inpatient care include 1 or more of the following: (1) Hemodynamic instability indicated by vital sign abnormality not readily corrected by appropriate treatment as indicated by 1 or more of the following: Tachycardia that persists despite appropriate treatment (e.g., volume repletion, treatment of pain, treatment of underlying cause); Hypotension that persists despite appropriate treatment (e.g., volume repletion, treatment of underlying cause); (2) Clinically significant signs or symptoms that are severe or persist despite emergency department and observation care treatment (e.g., transfusion, volume replacement), such as severe sign or symptom secondary to anemia (i.e., in this case, the patient exhibited weakness and lightheadedness). 

Based on the review of the medical record and literature, the inpatient level of care was considered medically necessary for this patient. This patient presented with symptomatic anemia with hemoglobin less than 12 g/dL (her hemoglobin was 6.7) and systolic blood pressure less than 100 (her systolic blood pressure was 90). The patient had hemodynamic instability. As per the MCG clinical guidelines, acute level hospitalization was warranted for management of this patient's anemia. 

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 inpatient level of care is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral legal blindness, arthritis, and mobility abnormalities

Treatment: 37.5 hours per week of Consumer Directed Personal Assistance Services (CDPAS)

The insurer denied coverage for 37.5 hours per week of Consumer Directed Personal Assistance Services (CDPAS)

The denial is upheld.

This male patient has a medical history of legal blindness in bilateral eyes, arthritis and unspecified abnormalities of gait and mobility.  A Uniform Assessment System (UAS)  New York assessment was done. It was noted that the patient requires maximum assistance with meal preparation, ordinary housework and shopping. The patient needs extensive assistance with managing finances, managing medications, bathing, personal hygiene, dressing his upper and lower body, walking, locomotion, toilet transfer, toilet use, bed mobility and eating. The patient walks using an assistive device. The patient stated he needs some assistance to accomplish tasks at home. A total of 37.5 hours per week of Consumer Directed Personal Assistance Services (CDPAS) is being requested.

The insurer has partially denied the request for 37.5 hours per week of CDPAS. The insurer states that the patient is unable to complete tasks necessary to care for his children because of arthritic pain in his wrists and shoulders. However, the patient did not meet the requirements for all of the additional hours that were requested. The insurer clarifies that personal care services benefits help the patient care for his needs, and it does not cover general safety supervision outside of specific daily activities. The personal care services benefits do not provide care for the patient's young children. The insurer states that the patient was approved to receive 31.5 hours per week of CDPAS.

Based on the review of the medical record and literature, the documentation provided for this case does not indicate a change in the patient's need for assistance in meeting his needs warranting an increase in hours of CDPAS. The patient's provider does not specify any particular services that need to be increased. As per New York Codes Rules and Regulations and insurer's criteria, CDPAS do not cover child-care needs. There is no indication that the patient's ability to meet his needs have changed. There is no support in the available information for an increase in hours from 31.5 to 37.5 hours per week. Thus, the request for 37.5 hours per week of CDPAS is not considered medically necessary for this patient.

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

The carrier's partial denial of coverage for the requested 37.5 hours per week of Consumer Directed Personal Assistance Services (CDPAS) should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Anterior crossbite with gingival attachment loss.
Treatment:  Orthodontic treatment - Braces (D8080) and Monthly Visit x12 (D8670).

The insurer denied the Orthodontic treatment - Braces (D8080) and Monthly Visit x12 (D8670).  The denial is upheld. 

The patient is a female.  The request is for dental benefits for orthodontic treatment and monthly visits.  The patient's assessment revealed skeletal class I, Cl II canines, moderate maxillary and mandibular spacing and missing maxillary lateral incisor.  The patient has an anterior crossbite with gingival attachment loss (mandibular left canine).

No, the proposed treatment of orthodontic therapy and monthly visits is not medically necessary.

The severity of the conditions stated in the attending physician's clinical summary is not supported by the records submitted.  More specifically, the attending physician's clinical summary and the Handicapping Labio-Lingual Deviation (HLD) index scoring is contradictory because the summary states that the patient has moderate maxillary and mandibular spacing, but on the index it scores for crowding.  Both the photos and the x-rays do not support either extreme.

The severity of the diagnoses are not substantiated, and therefore orthodontic treatment and monthly visits are not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class I, vertical growth pattern, maxillary and mandibular crowding, and anterior crossbite).
Treatment: Orthodontic braces (D8080) and monthly visits (D8670).
The insurer denied coverage for orthodontic braces (D8080) and monthly visits (D8670).
The denial is upheld. 

This is a male patient who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to skeletal Class I, vertical growth pattern, maxillary and mandibular crowding, and anterior crossbite.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present to support orthodontic necessity.  The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 14 points on review by their internal reviewers.  

It is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, the HLD index is utilized.  This index provides 6 specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore, does not support comprehensive orthodontic care using this criterion.  In this case, the clinical circumstance does not meet the insurer and the plan criteria to justify orthodontic care.  This reviewer concurs with the HLD index of the insurer attaining 14 points (3 overjet, 3 overbite, 5 anterior crowding and 3 labiolingual spread).

Orthodontic braces (D8080) and monthly visits (D8670) are not considered medically necessary for this patient.

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

The carrier's denial of coverage for orthodontic braces (D8080) and monthly visits (D8670) should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neuropathy and Atypical chest/abdominal pain.  
Treatment: Inpatient hospital admission.  

The insurer denied coverage for the inpatient hospital admission.  

The denial is upheld.  

This is a male patient who was seen in the emergency department (ED) for burning and itching with rib pain/injury on the right side for 1 month. He had been seen 5 days prior.  He had an extensive work up including sonogram and computed tomography (CT) and all were normal.  He had no fever, chills, visual changes, headache, numbness/tingling, shortness of breath (SOB), cough, chest pain (CP), palpitations, leg swelling, syncope, nausea/vomiting/diarrhea (n/v/d), dysuria, or rashes.  The diagnosis was neuropathy.  He had possible neuropathy vs psychological pain syndrome.  The plan was for labs, Benadryl and admission.  He complained of burning/itching/headache.  The history and physical (H&P) states he was admitted for atypical chest/abdominal pain.  Diagnostic workup done 5 days prior to this admission was normal.  Symptoms had been present for 1 month.  Exam showed hyperpigmented vesicular lesions.  

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

The inpatient admission was not medically necessary.  The patient complained of pain in abdomen and chest for 1 month.  He had undergone extensive diagnostic testing that was normal 5 days prior.  The records did not indicate that he had experienced a change in his condition; there was no change in symptoms or signs.  He showed no signs of a neurologically unstable condition that required further work up or admission.  

"Neuropathic pain, as outlined here, is defined as pain arising as a direct consequence of a lesion or disease affecting the somatosensory system.  We have here presented an overview of pharmacotherapy for neuropathic pain.  Neuropathic pain is generally intractable and does not quickly respond to evidence supported medications in many cases.  However, therapeutic options have expanded in the past few years, due to approval and expansion of the indications for various drugs.  In addition, recently approved drugs generally have a wider therapeutic dose range than in the past, given the increasing opportunities for global studies.  These situations enable adequate therapy, depending on the extent of the symptoms and interindividual differences, but also require careful observation for determining the optimal dose while considering therapeutic efficacy and safety in individual patients" (Nishikawa et al 2017).  

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

Diagnosis:  Gender dysphoria.
Treatment:  57292 - Construction, Artificial Vagina; with graft; 54125 - Amputation Penis, Complete; 14301 - Adjacent tissue transfer or rearrangement, any area, defect 301.1 square cm (centimeters) to 60.0 square cm, and other surgical procedures.

The insurer denied the  57292 - Construction, Artificial Vagina; with graft; 54125 - Amputation Penis, Complete; 14301 - Adjacent tissue transfer or rearrangement, any area, defect 301.1 square cm (centimeters) to 60.0 square cm, and other surgical procedures.

The denial is upheld. 

No, the proposed treatment is not medically necessary at this time for the clinical scenario presented.

Based on review of the clinical information provided, the patient has been diagnosed with gender dysphoria and there has been sufficient information demonstrating that the patient has been evaluated and treated for this diagnosis; however, the patient is under the age of 18. The clinical efficacy for gender confirmation and transformation surgeries in patients under the age of 18 is still considered to be unproven, and it has not been established as standard of care. Clinical evidence has not demonstrated that gender confirmation procedures are safe and effective treatments for gender dysphoria under the age of 18.  Therefore, the requested service is not medically necessary for this patient at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Medical Injectable Service(s) - Sodium Hyaluronate (Monovisc)
The insurer denied the Medical Injectable Service(s) - Sodium Hyaluronate (Monovisc).
The denial is overturned. 

This patient is a female with knee pain. Her physician has diagnosed osteoarthritis. The patient had received courses of conservative treatment which did not provide benefit. She received an initial hyaluronate injection which did not help. Her physician then provided a series of Monovisc over several years which were beneficial. Most recently, the physician has requested additional injections to both knees. Her symptoms had returned.

Yes, the proposed treatment with sodium hyaluronate (Monovisc) is medically necessary.

The records show the patient has osteoarthritis to her knees. She had received conservative treatment in the past which was not beneficial. Her physician reported previous injection of Euflexxa was provided which was not beneficial. He reported the records were not available to confirm the fact. He reported ongoing treatments of Monovisc over the following years that were successful.  

The records show the criteria had been met (previous injection with formulary agent which failed).  At this time, as the letter of appeal documents, the injection of Monovisc would be necessary and should be continued.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Multiple Sclerosis. 
Treatment: Formulary exception for Mavenclad. 

The insurer denied the Formulary exception for Mavenclad. 
The denial is upheld. 

The patient is a female with multiple sclerosis (MS). She has been treated with Avonex. Her provider is requesting Mavenclad. 

No, the health plan should not cover the Formulary exception for Mavenclad. 

There is no documented reason provided as to why the patient cannot be treated with preferred formulary agents for her condition. Anticipatory side effects do not preclude a trial of the preferred agents. The risk of PML (progressive multifocal leukoencephalopathy) in a person who has not been treated with natalizumab or a chemotherapeutic agent is extremely low and does not preclude the use of any of the preferred agents. All of the preferred agents are FDA (Food and Drug Administration)-approved for her condition based on high quality clinical trials published in the peer reviewed medical literature (Rae-Grant et al.). There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Mavenclad relative to the preferred agents. There is no evidence that switching to a preferred agents would jeopardize the patient's clinical stability.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Paroxysmal atrial fibrillation
Treatment: Cardiac Ablation Procedure
The insurer denied the Treatment: Cardiac Ablation Procedure.
The denial is overturned. 

The patient is a male. He has history of paroxysmal atrial fibrillation with episodes of rapid ventricular response, symptoms of palpitations. The patient's echo revealed normal LV (left ventricle) function. CHADS-VASC (congestive heart failure, hypertension, age, diabetes, stroke, vascular disease, age, sex category) score was calculated to be 0.

The patient was started on metoprolol, and subsequently his dose was increased. The patient continued to have breakthrough episodes of atrial fibrillation despite b-blocker (beta blocker) therapy, and atrial fibrillation ablation procedure was recommended.

Yes, the Cardiac Ablation Procedure is medically necessary.

The patient has a known diagnosis of paroxysmal atrial fibrillation, managed with b-blockers (beta blockers) with recent titration of the dose. He is still symptomatic, with episodes of atrial fibrillation with rapid ventricular response. Given persistent arrhythmia with uncontrolled heart rate, despite titration of b-blocker (beta blocker), proceeding with catheter based ablation procedure would be a reasonable therapeutic choice, which is consistent with the current standard of care.