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

Diagnosis: Chronic obstructive pulmonary disease

Treatment: Inpatient admission	

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient is an adult who was a resident of a group home who was brought to the emergency department (ED) with complaints of shortness of breath (SOB), frequent falls, and decreased appetite. She denied chest pain. She has a past medical history of hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), dementia, anorexia, and polysubstance abuse.

At presentation to the ED (emergency department): the Temperature was 97.8 degrees F (Fahrenheit), Respirations 22, Pulse 82, and the Blood Pressure was 127/72. Her Body mass index was 18.6. She was in no acute distress, lungs were clear, speaking in full sentences and there was no use of accessory muscles. The patient was alert and oriented x 3, had normal heart sounds, and a soft abdomen.

The White blood cell count (WBC) was 5.6, Hemoglobin 12.2, Potassium 3.0, and the Blood urea nitrogen (BUN) and creatinine were normal. The chest x-ray had no acute infiltrates, pneumothorax, or pleural effusion. The admitting diagnoses were SOB (shortness of breath) and failure to thrive.

The patient remained stable after admission, was afebrile, hemodynamically stable and without hypoxia. The Wells' score was 0. The patient had potassium (K+) replaced by mouth (PO) and was treated with maintenance inhalers - Stiolto and Albuterol as needed (PRN).

Her symptoms improved after coming to the ED. This patient did not need acute inpatient hospitalization. She could have been in observation while diagnostic testing and treatment were initiated. She was treated with oral medications. She was stable for discharge after a period under observation without need for an acute inpatient hospitalization.

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 inpatient hospital is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Facial droop. 
Treatment: Inpatient Hospital Admission. 

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

The patient is an adult female who presented to the emergency room with right-sided facial droop with improvement of symptoms. There was some associated tingling as well as a headache that was considered mild although was severe the day prior. Neurology was consulted and neurological examination was significant for mild left ptosis and mild left sided facial weakness. Computed tomography of the head, computed tomography angiogram and computed tomography neuroperfusion were unremarkable. The patient was admitted for telemetry and neurological workup including blood work and magnetic resonance image of the brain. The patient was started on dual anti-platelets. The following day, numbness had improved, and other symptoms had resolved. The patient only had a slight headache. The inpatient admission was denied by the plan as not meeting level of care for inpatient admission. 

The inpatient admission was not considered medically necessary. 

According to the Milliman Care Guidelines (MCG) 26th Edition for Neurology, inpatient admission is indicated when a patient has severe neurologic deficits or progressive neurological symptoms. This patient had mild neurologic deficits. In addition, symptoms were improving rather than progressing. All of the workup and monitoring could have been done at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Clavicle fracture.
Treatment:  Full hospital admission.

The insurer denied coverage for full hospital admission.  The denial is upheld.

This is an adult with a history of chronic lymphocytic lymphoma (CLL) and a bicycle accident. The patient presented to the hospital for a scheduled repair nonunion clavicle, removal of deep hardware clavicle, iliac crest bone graft, and debridement of the bone. The procedure was performed, and the patient was transferred to the post anesthesia care unit (PACU). The patient was given prophylactic antibiotics. Ambulation was encouraged. The patient tolerated physical therapy (PT) and achieved all necessary goals for discharge. Pain was adequately controlled on oral (PO) Dilaudid.

The medical record showed an episode of feeling faint after physical therapy (PT). The patient needed Dilaudid. There were no changes to vital signs to require specific treatment. The physician records make no report of post-surgical complications. There was no reason for hospitalization based upon an ongoing medical problem or inadequate pain relief. 

This opinion takes into consideration the type of surgery with the associated iliac crest bone graft. There were no reports of hip pain or inability to walk. 

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 full hospital admission is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied coverage for Wegovy.
The denial is overturned.

The patient has a history of morbid obesity. She reports that for many years she has tried to lose weight and has been doing exercise. A recent glycated hemoglobin (HbA1c) is 5.7. Her physician has recommended Wegovy. The insurance company has offered several alternatives but they are not semaglutides. 

Up To Date has an article titled "Obesity in Adults: Drug Therapy." The article states that a number of medications are approved by the FDA (United States Food and Drug Administration) for the treatment of obesity in conjunction with healthy eating, physical activity, and behavior modification. Candidates for drug therapy include those with a Body Mass Index (BMI) over 30 or a BMI over 27 with related comorbidities. Semaglutide is a glucagon-like peptide-1 (GLP-1) agonist that is approved for the treatment of obesity. It has demonstrated efficacy in weight reduction, as well as improvement in glycemia and lipids. It has also demonstrated cardiovascular benefits. The article also states that phentermine, benzphetamine, phendimetrazine, and diethylpropion are only approved for short term use, have more side effects, and have potential for abuse. 

This patient requires treatment for weight loss. According to the Up To Date article, semaglutide is a better treatment for obesity than the alternatives that the insurance company has offered. 

The formulary drugs may not cause an adverse reaction, but would likely be less effective. 

The formulary drugs have not been tried. However, Wegovy would likely be more effective than the formulary drugs as per the discussion in the Up To Date article "Obesity in Adults: Drug Therapy." 

The denial is overturned.

The carrier's denial of a request for a formulary exception for Wegovy to treat obesity is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Malocclusion.
Treatment:  D8080 braces, and D8670 monthly visit x 12.

The insurer denied coverage for D8080 braces, and D8670 monthly visit x 12.  The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss, among other clinical findings. 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 (right lateral incisor # [number] 7) 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 as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 19 points on review 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 Handicappi.ug 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 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 insurer and plan criteria to justify orthodontic care.

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 visit x 12 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Osteolysis.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.
 
Patient is an adult with a past medical history significant for gastric stress ulcer who presented to the emergency department with complaints of pain, swelling and erythema of the right hand following a cat scratch two months prior.

Vitals on presentation were within normal limits. Oxygen saturation was 99% (percent) on room air. Laboratory values were notable for the following: White blood cells (WBC)-8.0, Hemoglobin (Hgb)-13.8, Hematocrit (Hct) 40.9, glucose-86, creatinine-0.79, lactic acid-0.51.

Patient was empirically started on intravenous antibiotics (vancomycin and Zosyn) for possible osteomyelitis. X-ray of the hand showed soft tissue prominence dorsal to the distal first phalanx with extensive osteolysis of the shaft and base of the distal first phalanx. Patient underwent a bedside incision and drainage. She had peripherally inserted central catheter (PICC) line placement for planned 6-week course of intravenous antibiotics. Patient remained afebrile, hemodynamically stable, and clinically improved. She was discharged to continue intravenous antibiotics as an outpatient. 

According to documentation, patient presented with a right hand infection/cellulitis following a cat scratch. She was afebrile, stable hemodynamically, and laboratory results were unremarkable. Imaging studies were suspicious for osteomyelitis. Patient complained of 10 out 10 pain, despite oral antibiotics as an outpatient. Based on documented failure of outpatient intervention, need for incision and drainage procedure and intravenous antibiotics, hospital admission was medically necessary. 

Prior determination of denial of coverage for inpatient hospital admission is overturned.

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 full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a past medical history (PMH) of diabetes mellitus type 2 (DM2) who was admitted with complaints of (c/o) abdominal pain associated with nausea, vomiting, and constipation. His vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD). Lab work was notable for leukocytosis, glucose 414, no anion gap, urinalysis (UA) without (w/o) ketones. Imaging studies included a chest x-ray (CXR) which showed no acute pathology, a computed tomography (CT) scan of the abdomen/pelvis (A/P) showed no acute pathology. An electrocardiogram (EKG) showed sinus tachycardia with left ventricular hypertrophy (LVH). The patient was diagnosed with hyperglycemia and nausea/vomiting and treated with intravenous fluids (IVF), anti-emetics, radiological/biochemical work-up, bowel regimen, and subcutaneous (SQ) insulin. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) hyperglycemia greater than 400. The patient was hemodynamically stable, responded to insulin therapy, and there was no DKA (diabetic ketoacidosis), acute mental status change, end-stage renal disease (ESRD), sepsis, acute cerebrovascular accident (CVA), acute myocardial infarction (MI) or significant complications, and he did not have any evidence of acidosis as the patient had a normal serum bicarbonate without a significant increase in anion gap, and did not require an insulin drip. Hyperglycemic patients presenting to the emergency department (ED) with a blood glucose less than (<) 600 can be appropriately managed at a lower level of care. Overall, this patient did not have complicated hyperglycemia and could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Upper abdominal and throat pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld. 

The patient had ingested bleach and was complaining of upper abdominal and throat pain. He was hemodynamically stable. The abdominal exam was benign. proton pump inhibitor therapy was started. An endoscopy was performed and showed that the esophagus was overall normal with mild erythema immediately distal to the upper esophageal sphincter. There was no mucosal damage noted to the stomach. 

Medical necessity was determined using Milliman Care Guideline (MCG), guideline MG-GAS for Gastroenterology. Severe dysphagia associated with a caustic ingestion is an indication for admission. This patient did not have severe dysphagia and the endoscopy revealed only a small area of mild inflammation. Milliman Care Guideline (MCG) guideline A-0203 lists indications for endoscopy. However, endoscopy is listed as ambulatory care.

This patient accidentally swallowed some bleach and required an urgent endoscopy to evaluate damage to the Upper Gastro-intestinal (GI) tract. In this case, there was no evidence of severe damage or severe dysphagia. The endoscopy could have been performed as an ambulatory procedure with observation care. Therapy could also have been given as an outpatient. 

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: Formulary Exception
Decision: Overturned

Diagnosis: Lupus

Treatment: Oxycontin (oxycodone extended release (ER))

The insurer denied coverage for Oxycontin (oxycodone extended release (ER))

The denial is overturned

 
This woman has Lupus, Fibromyalgia, and endometriosis. She has tried transcutaneous electrical nerve stimulation (TENS), acupuncture, Physical therapy and bed rest. The Health Plan is requiring that the patient try at least 3 Formulary alternatives before approving Oxycontin.  According to the records (Medication List Update) the patient has tried Morphine, Hydromorphone, Fentanyl patches. She is currently on Nucynta. The patient has documentation that is required by clinical practice guidelines (1,2). The patient meets the plan's criteria, and the request is approved for a formulary exception.

The patient has tried several of these medications already and is stable on oxycontin.

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were tried, and the patient did have an adverse reaction or contraindication to Xtampza and other formulary medications did not relieve her pain.

The formulary drug(s) is expected to be ineffective based on her past medication usage.

The non- formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Oxycontin (oxycodone ER) is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Teeth Spacing Problem
Treatment: Braces, retainer, and monthly visits
The health plan denied: Braces, retainer, and monthly visits
The determination is: Upheld

The patient is a female with a Class I occlusion with 3-millimeter (mm) overbite and 4 mm overjet. She has maxillary and mandibular spacing. She has treatment planned for orthodontics to correct her malocclusion.
At issue is the medical necessity of the requested health service/treatment of braces, monthly visits, and retainer.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of Braces, monthly visits and retainer is not medically necessary for this patient. The patient has spacing. Her overbite is appropriate, and there is no indication of damage to the incisors in the photographs. Her cephalometric radiograph shows she does not have a traumatic deep bite. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) on this patient. There is no indication from the photographs provided that there is a severe overjet auto qualifier present.
There is no medical reason to correct her malocclusion with braces. While the patient has maxillary spaces, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.[1] This patient presents with none of those conditions. This patient has a Class I occlusion, and masticatory efficiency is highest in patients with a Class I occlusion.[2] If her teeth were aligned, it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons, treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems/Other/Periodontitis
Treatment: Service/treatment of dental services (D4341 UR (upper right)/LR (lower right)/UL(upper left)/LL(lower left)
The health plan denied service/treatment of dental services (D4341 UR (upper right)/LR (lower right)/UL(upper left)/LL(lower left) 
The health plan's determination is overturned.

The patient is a male who presented to the office for the treatment of scaling and root planning in the UR, UL, LL, and LR. Provided for review are letters of appeal and denial, health plan language, periodontal indices, full mouth radiographic images, multiple pages of American Dental Association claim forms, and explanation of benefits.
In question is the medical necessity for the requested service/treatment of (D4341 UR/LR/UL/LL for all four quadrants.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, the requested health service/treatment of dental services (D4341 UR (upper right)/LR (lower right)/UL(upper left)/LL(lower left)) is medically necessary for this patient. Previous denials have been on the basis that there is not enough information provided to support the requested treatment. The information provided in this review shows evidence of radiographic angular bone defects throughout all four quadrants as well as deep periodontal pockets with bleeding on probing; all supporting the presence of active periodontal disease necessitating scaling and root planing. Hence, the treatment of 4341 for all four quadrants is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: White glass with metal crown for tooth # (number) 7
The insurer denied the white glass with metal crown for tooth #7.
The determination is overturned.

This is a female patient who presented for evaluation and treatment of tooth number (#) 7. Provided for review are letters of appeal and denial, a single radiographic image of the tooth #7, and a single page of American Dental Association (ADA) claim forms. Previous denials have been on the basis that there was not an amount of affected tooth structure due to decay or fracture such that the tooth could not be restored with a direct restoration. At issue is the medical necessity of the planned treatment of white glass with metal crown for tooth #7.

The requested health service/treatment of white glass with metal crown for tooth #7 is medically necessary for this patient. Upon review of the documentation, there is involvement of 2/3 of the tooth with either a previous restoration and/or access removal for root canal therapy. This necessitates replacement with an indirect restoration as a direct restoration such as a filling is not appropriate and would allow for tooth fractures. Hence, the requested crown #7 is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Gynecological
Inpatient hospital

Diagnosis: hysteroscopy with laparoscopic myomectomy and salpingectomy
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The inpatient hospital admission was not medically necessary. 
The laparoscopic procedure was reported to have been performed as planned without intraoperative complication. That procedure has generally been considered to be an outpatient procedure. The operation report states the estimated blood loss was only 750cc - not a profound hemorrhage. The report also fails to mention any uncontrolled bleeding, complication, or other unexpected events during the procedure. After the transfusion, her hematocrit is shown to settle at 35 the next day, which suggests there was never significant anemia (the hematocrit is only expected to rise about 3 points for each unit of blood). The patient's vitals were normal the day after surgery.
The American Congress of Obstetricians and Gynecologists (ACOG) outlines criteria for discharge after outpatient procedures, and states vitals need to only be within 20% of baseline. The physician notes on postoperative day 1 suggest a routine postoperative course other than the pain. The management described in the record on the day after surgery included oral pain medication, spontaneous voiding, and tolerating oral diet - these are traditional targets for discharge that appear to have been reached. Again, there is no reference to an unanticipated event. The patient could have been cared for at a lower level of care.