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

Diagnosis: Alcohol Use Disorder, Vomiting, Tremor.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a history of alcohol use disorder who initially presented to the emergency department with concerns about nausea, vomiting, and tremors. The initial examination documented the patient as alert and oriented with bilateral upper extremity tremors. The Clinical Institute Withdrawal Assessment (CIWA) was 15. Intravenous fluids, lorazepam, and ondansetron were administered with clinical improvement. The patient was admitted to the hospital with concerns about alcohol withdrawal syndrome and vomiting. The treatment plan included CIWA with lorazepam as needed, vitamin supplementation, intravenous fluids, and consultations. Per the Medication Administration Record (MAR), the last dose of lorazepam was given just after midnight following hospitalization. The treatment included continued vitamin support, gabapentin, and monitoring. No benzodiazepines were administered per the CIWA thereafter. The patient was discharged to home. At issue is the medical necessity of an inpatient hospital admission.
Based on the clinical documentation provided, evidence-based literature, and standards of care, the acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.
The patient presented with vomiting in the setting of recent alcohol abuse. Initial examination documented the patient as alert, oriented, tachycardic, hypertensive, and with bilateral upper extremity tremors. Initial evaluation revealed laboratory abnormalities in line with alcohol abuse, but no other significant abnormalities. The treatment plan included CIWA with lorazepam as needed, intravenous fluids, and vitamin supplementation. Following observation care, tremors had resolved, vomiting had resolved, hemodynamics were stable, and no further benzodiazepines were required per CIWA. No other issues or complications were documented, and the patient was discharged to home.
The clinical indications for admission to inpatient care were not met. The patient did not have alcohol or sedative withdrawal signs plus high-risk indicators (e.g., history of delirium due to alcohol or sedative withdrawal, history of repetitive seizures due to alcohol or sedative withdrawal, Intrinsic seizure disorder (epilepsy), pregnancy, or another significant medical history (e.g., severe cardiac disease) that is assessed to be at risk for destabilization due to withdrawal). The patient also did not have severe alcohol or sedative withdrawal that is not manageable at a lower level of care such as marked signs of withdrawal plus inadequate response to pharmacotherapy in the emergency department or other appropriate lower level of care, lower level of care not feasible or appropriate (e.g., unavailable or inappropriate to patient condition or treatment history). Lastly, the patient did not have severe dysfunction in daily living, imminent danger to self, or imminent danger to others.[2]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute kidney injury. 
Treatment: Inpatient hospital admission. 
The insurer denied the inpatient hospital admission. 
The determination is upheld. 

This is a male patient with a history of type II diabetes mellitus (DM), chronic kidney disease (CKD), hyperlipidemia, hypertension (HTN) and a left 5th toe amputation who presented to the hospital with worsening bilateral lower extremity edema for several months. He reported shortness of breath but no dyspnea on exertion or decreased exercise tolerance. He requires help from his wife for perform of his activities of daily living (ADLs). He has noticed less urinary frequency over the past two months. A duplex ultrasound (US) of the lower extremities did not show any evidence of deep or superficial vein thrombosis. An echocardiogram showed normal left ventricular (LV) size and function, no LV regional wall motion abnormalities, and no significant valvular findings. He was started on intravenous (IV) lactated ringers at 75/hour (hr) and given intravenous (IV) dextrose (D) 50. Nephrology was consulted for acute kidney injury on chronic kidney disease. He was admitted for further work up and management of an acute kidney injury. He was started on furosemide for his edema. Further urine studies demonstrated a microalbumin to creatinine ratio of 4084 consistent with nephrotic range proteinuria. He continued on IV furosemide. His lisinopril was held. At issue is the medical necessity of an inpatient stay. 

The inpatient admission was not medically necessary based on the documentation provided. The patient presented with worsening lower extremity edema. He was found to have an elevated creatinine and was admitted for further work up. He was hemodynamically stable. There was no documentation of a greater than 3-fold rise in his serum creatinine from baseline or anuria. He did not have severe electrolyte or metabolic abnormalities. He did not have respiratory distress. He did not have cardiac arrhythmias of immediate concern. He did not have a worsening clinical status. He did not have uremic pericarditis, encephalopathy or bleeding. He did not have severe or persistent changes in mental status, nausea or vomiting. He did not have severe hypertension or other manifestation of acute kidney injury that required inpatient management. He could have been managed at a lower level of care with subsequent transition to outpatient follow up.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

This is a male patient who was admitted with complaints of (c/o) gluteal cleft cellulitis. His vital signs were notable for pulse 114, and temperature (T) 100.5 degrees Fahrenheit. The physical exam was notable for cellulitis with induration to gluteal cleft without discharge. Lab work was unremarkable. Imaging studies, a computed tomography (CT) scan showed an abscess in the left medial gluteal fold with superimposed cellulitis. The patient was diagnosed with cellulitis and abscess in the left medial gluteal fold and treated with intravenous (IV) antibiotics. Surgery was consulted and performed a peri-anal incision and drainage (I&D). The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

This patient presented to the ED with c/o gluteal cleft cellulitis associated with severe pain, tachycardia, and fever. Given the patient's presentation, this patient met sepsis criteria, met the Infectious Diseases Society of America (IDSA) definition of severe cellulitis, and the expected length of stay was greater than 48 hours. In addition, the presence of an infection in the gluteal cleft location further indicates that the patient had a severe enough infection, especially given the need for surgical intervention, to justify an inpatient stay, rather than a lower level of care. Overall, this patient presented with sepsis related to cellulitis and an abscess suggesting that the patient required immediate treatment for infection with intravenous antibiotics and surgical intervention and that an inpatient level of care was required for safe medical evaluation and treatment.
Regarding the provided Milliman criteria, the patient met the following - admission is indicated for 1 or more of the following - clinical presentation is judged to require intensity of patient monitoring that cannot be provided at other than inpatient level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Calcipotriene-Betamethasone Diprop Suspension
The insurer denied Calcipotriene-Betamethasone Diprop Suspension.
The determination is upheld.

The patient is a male with psoriasis. He has failed halobetasol. He has also failed Locoid lotion. The medication under review is Calcipotriene-Betamethasone Diprop Suspension.

The formulary drugs will not be ineffective, have not been ineffective, and would be as effective as the non-formulary drug. The formulary drugs would not have adverse effects.
Clinical guidelines for the management of psoriasis recommend the use of calcipotriene solution/ointment in combination with betamethasone. According to the American Academy of Dermatology Psoriasis Guidelines and current evidence-based dermatology literature, the preferred medicines calcipotriene solution/ointment used in combination with betamethasone, which is covered by the patient's insurance plan, are effective treatments for the management of psoriasis (1-4). The evidence-based literature is consistent and in line with the patient's medical policy. The preferred agents are appropriate agents for the treatment of the patient's psoriasis.
There are no comparative, controlled studies showing that Calcipotriene-Betamethasone Diprop Suspension has a superior efficacy or safety profile to all of the formulary alternatives. The formulary medications should be tried and failed before initiating Calcipotriene-Betamethasone Diprop Suspension. It is noted that the patient has tried and failed clobetasol for his psoriasis. However, after a review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Calcipotriene-Betamethasone Diprop Suspension before the formulary alternatives such as calcipotriene solution/ointment used in combination with betamethasone. There is no documentation provided that he has tried and failed, has a contraindication to, or intolerance to the preferred medications, which are effective for psoriasis according to the current dermatology literature and psoriasis guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Dupixent
The insurer denied: Dupixent
The denial is upheld.

The patient is an adult female with atopic dermatitis to the hands, treated with topical steroids and Opzelura. She has been well controlled on Dupixent (received her loading dose 2 months ago) for roughly one month. The provider is requesting continuation of Dupixent. The health plan requires use of preferred agents topical calcineurin inhibitors or Eucrisa, and phototherapy.

The requested health service is not medically necessary.

This patient has not demonstrated an adequate trial and failure to all other standard of care measures for atopic dermatitis. The documentation does not support aggressive topical measures with emollients, topical calcineurin inhibitors, and phototherapy, which are considered first and second line therapies for eczema. Patch testing should be performed as well. Therefore, Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, DM2 (diabetes mellitus type 2), and CKD (chronic kidney disease) stage 3. 
Treatment: Increase Personal Care Aide (PCA) Services, Level 2: 12 Hours per Day - 7 Days per Week - for a Total Amount of 84 Hours per Week. 
The insurer denied: Increase Personal Care Aide (PCA) Services, Level 2: 12 Hours per Day - 7 Days per Week - for a Total Amount of 84 Hours per Week. 
The denial is overturned. 

The requested health service is medically necessary. 

Per the appeal letter, the patient has limited mobility, weakness and limited endurance which makes assistance necessary for basic tasks and personal needs. The patient also has bladder incontinence and needs assistance with transfers to the toilet and clean up. The patient requires frequent diaper changes to prevent urinary tract infections (UTIs). He also needs reminders to use his assistive device and assistance with transfers and ambulation to alleviate pain. Per the appeal letter, the patient is unable to prepare meals as it is too complex and labor intensive and so the patient needs assistance with meal prep and grocery shopping. The patient also needs assistance with washing and grooming due to mobility limitations. His wife is severely disabled and unable to assist in any way. The current plan approved 5.5 hours per day - 7 days per week - for a total 38.5 hours per week is not sufficient to achieve these tasks. An increase in Personal 
Care Aide (PCA) Services, Level 2 to 12 Hours per Day - 7 Days per Week - for a Total Amount of 84 Hours per Week is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Obesity. 
Treatment: Mounjaro (tirzepatide). 
The insurer denied Mounjaro (tirzepatide). 
The health plan's determination is upheld. 

This is a case review for a female patient being prescribed Mounjaro for the diagnosis of obesity. Coverage for this medication was denied by the health plan. The plan's preferred medications are Ozempic, Rybelsus, Trulicity, and Victoza. 

A formulary exception is not indicated in this case. 
The patient is being prescribed Mounjaro for the diagnosis of obesity. The plan did not provide coverage because the patient has not tried and failed the plan's formulary drugs. The Formulary alternatives are: Ozempic, Rybelsus, Trulicity, and Victoza. 
According to the FDA (Food and Drug Administration) guidelines, Mounjaro is approved to treat type 2 diabetes mellitus. The patient does not have this diagnosis. Although there is data which demonstrates that Mounjaro does promote weight loss, there is not yet FDA approval for the medication for this purpose. Formulary alternatives include Ozempic, Rybelsus, Trulicity, and Victoza. These medications are also only FDA approved to treat type 2 diabetes mellitus. These medications would also not be expected to be inferior to the requested medication, Mounjaro.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Traumatic Brain Injury

Treatment: 21 Meals/Week, 3 Meals x 7 days; Home Delivered Meals

The insurer denied coverage for 21 Meals/Week, 3 Meals x 7 days; Home Delivered Meals.

The denial is modified.

 
This case involves an adult female who lives with her caregiver who provides emotional support and care with a subject of review for the coverage of 21 Meals/Week, 3 Meals x 7 days; Home Delivered Meals. She has a history of intervertebral disc displacement of the lumbar spine, bipolar disorder, anxiety, depression, hypertension, post-traumatic stress disorder (PTSD), pain, and limited range of motion. 

In the Letter of Medical Necessity, the patient is reported to have suffered from a traumatic brain injury from vehicular accident that resulted in hospital stay with fractures to her cervical and thoracic spine, sustained laceration to her liver and spleen and had resection of her colon. She is unable to prepare meals herself due to safety reasons. She does have a home health aide at her home until 1:00 pm. Due to her condition she is not always able to eat while the aide is present. 

The medical records provided for review do support the service being requested. It would be proper and reasonable for her to receive home delivered meals to cover at least two meals each day, in order to guarantee that there are always cooked meals when her aide leaves at 1:00 PM. As a result, the assessment does support the request for home delivery of 2 meals a day seven days a week.

Based on the above, the insurer's denial must be modified. 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 21 Meals/Week, 3 Meals x 7 days; Home Delivered Meals services is not substantiated. However, the assessment does support the request for home delivery of 2 meals a day seven days a week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: braces, monthly visits and retainer
The insurer denied braces, monthly visits and retainer
The determination is overturned.

The patient is a female with a Class II Division 2 malocclusion with maxillary and mandibular crowding. She has a 7-millimeter (mm) overjet and 8 mm overbite. Tooth 28 is in crossbite. She is treatment planned for 24-30 months of orthodontics to correct her malocclusion. At issue is the medical necessity of braces, monthly visits and retainer.
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 costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with a 6 plus (+) mm overjet, which this patient has. (3) For these reasons, the orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Cardiac
Inpatient hospital

Diagnosis: Angina
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a female with past medical history (PMHx) significant for hypertension (HTN), HLD (hyperlipidemia), pre-DM (pre-diabetes mellitus), multiple sclerosis (MS), and previous tobacco abuse. The patient was admitted for unstable angina. She had a cardiac cath and received a stent to her right coronary artery (RCA).

The inpatient hospital admission was not medically necessary. Cardiac catheterization is normally an outpatient ambulatory procedure. The patient comes in, has the procedure, and is discharged later in the day. If the patient has a complication such as bleeding from the access site or has bleeding around the heart or a hole in the artery that is being fixed, then this ambulatory stay would convert into an inpatient stay. In this case, the patient was admitted through the Emergency Department; however, she was stable. She had stable vital signs. She was not taken emergently to the cathlab as in a ST-Elevation Myocardial Infarction (STEMI) (also an inpatient admission). She was taken to the cath lab on an urgent basis and had an uncomplicated stenting procedure performed. She did not have any post procedures complications necessitating an inpatient stay. She was observed post procedure and was able to the discharged. In this patient, a lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Bbraces, monthly visits and retainer are medically necessary.
The insurer denied braces, monthly visits and retainer are medically necessary.
The determination is upheld.

This is a female patient with a Class I skeletal pattern with Class II cuspids, mild maxillary crowding and mild mandibular spacing, moderate overjet and moderate overbite with a lingually positioned maxillary left cuspid and retained maxillary primary left cuspid. At issue is if the requested health service/treatment of braces, monthly visits and retainer are medically necessary.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 16 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, deeping impinging overbite with severe soft tissue damage, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm 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, according to the standard of care, the requested health service/treatment for braces, monthly visits and retainer are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep impinging overbite
Treatment: Orthodontic treatment: D8080 braces and D8670 monthly visits
The insurer denied coverage for: Orthodontic treatment: D8080 braces and D8670 monthly visits.
The denial is: Upheld
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 22 points by internal reviewers. 

Upon review of the submitted documentation, (study models were not provided for review), 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, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six 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 deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

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 D8080 braces and D8670 monthly visits is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: cancer
Treatment: genetic testing
The insurer denied ClonoSEQ B-Cell Clonality Test 
The health plan's determination is upheld. 

The patient is a female with a neoplasm of uncertain behavior on the left anterior proximal upper arm. The pathology reveals primary cutaneous marginal zone B-cell lymphoma.

Genetic Testing: ClonoSEQ B-Cell Clonality Test is not medically necessary for this patient.
The patient's histological diagnosis confirms the B-Cell lymphoma type, and any staging or concerns of any generalized spread of this lymphoma is based on body-wide imaging studies. While this test might have some diagnostic (and therefore therapeutic) benefit for this patient if the diagnosis was of unlikely certainty, such is not the case for this patient. The differential diagnosis of a more aggressive and/or generalized lymphoma does not appear to exist for this patient, and the actions needed to confirm staging and/or extent of this tumor will not be impacted by the requested test.