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

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

This male patient with no past medical history presented to the Emergency Department (ED). He was 35-days sober from alcohol, Xanax, and cocaine abuse.  The patient reported that he was running and woke up on the ground.  The patient reported that a bystander told him that the patient looked like he was having a seizure. The patient denied a history of seizures. The patient reported that he hit his head.  The patient denied alcohol or illicit drug use or marijuana.  On exam, the patient's neurovascular exam was intact. The patient was alert, and oriented with clear speech. The patient had no facial asymmetry, and had full range of motion and equal strength in all extremities. The patient's pupils were equal and reactive to light. The patient reported dizziness with positional changes, and nausea but denied vomiting.  The patient's urine drug screen was positive for benzodiazepines. It was negative for phencyclidine (PCP), tetrahydrocannabinol (THC), opiates, cocaine, barbiturates, acetaminophen, and ethanol. The patient's creatinine kinase was 678. The patient's computed tomography (CT) scan of the head revealed no evidence of an acute intracranial hemorrhage or territorial infarction. The patient was admitted to the medical surgical floor for diagnoses of new onset seizure and mild rhabdomyolysis. The neurologist was consulted and the impression was partial complex seizure with generalization. The patient was recommended to undergo an electroencephalogram (EEG) and magnetic resonance imaging (MRI) of the brain. The patient was administered 500 mg of Keppra twice a day. The patient's EEG was normal. The patient refused MRI. The patient was discharged in stable condition, and was instructed to follow-up with a neurologist for a 48-hour EEG.  

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. At the time of admission, the patient was neurologically intact, alert, and oriented with clear speech. The patient had facial asymmetry, full range of motion and equal strength in all extremities. The patient had no further episodes of seizures in the ED and was not post-ictal. The patient could have been observed and the testing could have been performed at an observational level of care. 

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

Based on the above, the medical necessity for inpatient hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fall with resultant pain in right side
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This is a male who fell onto his right side in elevator. He had severe pain to the right side and was bought to the hospital. He was evaluated and found to have pubic rami fractures. He was also found to have a sacral fracture. He was unable to walk.  He was evaluated by orthopedic surgery who recommended non operative treatment. He received pain medication and rehabilitative services.  The patient was admitted to the hospital.

Yes, the proposed inpatient admission was medically necessary.

This patient has a complex medical condition to substantiate the treatments provided. He had significant underlying orthopedic comorbidities of status post hemiarthroplasty, open reduction internal fixation (ORIF) tibial plateau and open reduction internal fixation (ORIF) humerus. His recent injury was not isolated to the pubic rami. He was also found to have a sacral fracture. This should be taken into consideration as his ambulatory ability would be severely compromised. He would be extremely hard to mobilize. The records reported he could not stand or move his right lower extremity.   In addition, there is the risk of bleeding (albeit low) due to multiple sites of fracture. 

As per Interqual Criteria, the patient sustained a fracture to more than one location (in addition to pubic rami) which would substantiate the admission and level of care provided.  It would be important to monitor status more than at an observational level.  The literature reports need for ongoing treatment secondary to complexity of fracture patterns.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Chiropractic Services. 
The insurer denied chiropractic services for medical necessity. The denial was upheld.

The patient is a female who began chiropractic treatment for idiopathic neck, back, right arm and thigh pain. Her Visual Analog Scale (VAS) score was a 10/10. The initial examination indicated positive compression and Soto Hall, and negative shoulder depressor, with spasm and subluxation. Neurological findings were normal.
Notes indicate a cervical magnetic resonance imaging (MRI) scan reported cervical (C)5-7-disc protrusions. All visits noted spasm and subluxation, and VAS was 2-9/10, 3-6/10, 5-7/10 and 2-6/10 on various dates of service. Notes reported "no real change since initial visit" with mild reduced ranges of motion in the cervical spine. The initial consultation and examination were broken into three different dates of service. Treatment included spinal manipulation, low level laser therapy, manual therapy, and spinal decompression therapy.

At issue is Chiropractic services for medical necessity.

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

No, the requested health service/treatment of Chiropractic services was not medically necessary for this patient.

Generally accepted standards of chiropractic treatment recommend a therapeutic trial of 12 visits within 4 weeks, with an assessment for improvement at the midpoint of the trial (6 visits). If there is no improvement after the initial 6 visits, the provider should modify the treatment method and continue the trial, perform additional diagnostic procedures, or refer the patient for alternative treatment. [4] The notes lacked details regarding the actual content of therapeutic exercise and did not indicate a rationale for either a three-part initial examination and intake, nor a re-evaluation. There was no re-examination. There was no clear medical necessity reported for performing a cervical MRI scan. The examination was not an actual re-examination, but part of the initial examination, with no clear rationale for its purpose, and with no differential diagnosis or proper history indicated.

Overall, in this case there was a lack of clinical detail. The treatment lacked an ongoing clinical improvement, a non-supervised home rehabilitation program, there was no rationale for the three-part initial intake, and there was a lack of actual treatment, or proper documentation of the treatments involved at each date of service. Therefore, the requested health treatment of Chiropractic services is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Edarbi. 
The denial is upheld.

The patient is a female with past medical history of hypertension who was prescribed Edarbi (azlisartan) 80 mg daily. The patient had been treated with benazepril with no response per the patient's primary care physician (PCP). The patient has been on Edarbi once daily for several years with good response. The patient's PCP noted in appeal that "it is unsafe to change medication and poses a risk to her health".
The subject under review is whether the formulary drug would be or has been ineffective or would be not as effective as the requested non-formulary Edarbi.

The health plan's determination is upheld.

Candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide would not be ineffective, not as effective as Edarbi, or would have adverse effects. Although the patient is well controlled on the current medication there is minimal risk to worsening elevated blood pressure or hypotension with changing to a formulary alternative. The formula alternatives are appropriate for treatment of the patient's hypertension. Because she has been well treated on current angiotensin II receptor blocker (ARB) she would be well treated on at least one of the formulary alternatives without intolerance. There is not a clinical reason, such as adverse reaction or contraindication that prevents the patient from trying a formulary alternative.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autonomic Dysfunction
Treatment: Autonomic Testing
The health plan denied the requested autonomic testing. 
The health plan's determination is overturned.

The patient is a male who has been referred for diagnostic testing for autonomic dysfunction. A letter by a clinical geneticist at the facility describes that planned testing will include muscle biopsy, fasting test, metabolic testing and various imaging studies as a diagnostic evaluation to clarify the patient's diagnosis and establish an appropriate treatment plan.
A letter from another physician describes that the patient has a complex medical history. He was noted to have right sided weakness (right hemiplegia) in infancy, enlarged liver and spleen (hepatosplenomegaly) demonstrated on abdominal ultrasound, and had a stroke-like episode when he was younger. An extensive genetic workup has not revealed a clear diagnosis. This physician notes that an in-patient fasting study and the additional metabolic/functional testing required to clarify the patient's diagnosis cannot be performed at the requested health care facility. Letters by two additional physicians also request approval for testing. A letter describes that the patient has developmental delay, with episodes of regression related to illness. He has hypoglycemia, pallor, weakness, puffiness of the face, abdominal pain, rashes and intermittent fevers.

A physician recommended additional workup at the health care facility to include spinal tap, functional test to full out McArdle's disease (PYGM gene), and a fasting test.
Whether this diagnostic workup is medically necessary for the patient is the issue at question in this review.

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

The patient has an extremely complex medical history, with concerning recurrent episodes of unexplained, documented hypoglycemia, episodes of unresponsiveness, hepatosplenomegaly, stroke-like episodes and early right sided hemiparesis. An extensive genetic evaluation has not elucidated the cause of his recurrent, potentially life-threatening symptoms. His history is highly suggestive of an underlying, complex metabolic disorder which has already resulted in neurological deficit. Additional diagnostic work up is imperative to clarify the cause of his recurrent episodes of hypoglycemia, weakness and altered consciousness, and to prevent further neurological damage or death. The diagnostic workup is highly specialized, and numerous physicians who have explained that such testing cannot be performed at the local facility.
The autonomic testing requested is medically necessary for the patient. He has had an extensive workup which has not revealed a definitive diagnosis. Clarification of the underlying cause of his symptoms is vital to prevent further neurological deterioration or death. Testing also offers the probability of therapeutic intervention.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Atrial Fibrillation
Treatment: Closure of left atrial appendage
The insurer denied the Closure of left atrial appendage.
The denial is overturned. 

The patient is a male with a history of hypertension, obesity, sleep apnea and atrial fibrillation. He has been treated with Eliquis and metoprolol since the diagnosis. The patient underwent a catheter ablation of the atrial fibrillation with restoration of normal sinus rhythm. He was continued on Eliquis.  

As per attached letter from the provider, the patient has become intolerant of anticoagulation with development of skin ecchymosis and lower gastrointestinal (GI) bleeding.  Transesophageal echocardiogram (TEE) revealed no evidence of thrombus. Placement of left atrial appendage occlusion device (Watchman) was requested due to development of intolerance to anticoagulation.

Yes, the requested 33340 (closure of left atrial appendage) is likely to be more beneficial than any standard treatment(s) for the insured's condition or disease.

The patient has a history of atrial fibrillation, status post (s/p) radiofrequency (RF) ablation and is currently on chronic anticoagulation with Eliquis.  The patient had used the Eliquis for over two years; however, as per a letter from the treating provider, the patient developed intolerance to Eliquis with bleeding complications. His HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score is calculated at 2. WATCHMAN left atrial appendage (LAA) occlusion device has been shown to be non-inferior to Warfarin in clinical trials in terms of ischemic cerebral vascular disease (CVA) prevention and is considered a reasonable alternative in patients with non-valvular atrial fibrillation, who are not candidates for anticoagulation.  Therefore, the patient would be a candidate for the device due to intolerance of anticoagulation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative colitis. 

Treatment: Outpatient hospital facility based intravenous Remicade (Infliximab) infusion; code J1745. 

The insurer denied coverage for the outpatient hospital facility based intravenous Remicade (Infliximab) infusion; code J1745. 

The denial is overturned. 

This is a female patient with a medical history of ulcerative colitis. The patient was felt to be having active symptoms including joint inflammation. The patient had been started on Remicade infusions and her symptoms improved. It was advised to continue the Remicade infusion. The patient required steroid therapy for a previous ulcerative colitis flare. The patient's colonoscopy showed a significant worsening of her colitis in the left colon. The inflammation was described as severe. 

The American College of Gastroenterology (ACG) has published a clinical guideline: ulcerative colitis in adults. There are recommendations for management of moderately to severe active ulcerative colitis. A recommendation that is listed is to give anti-tumor necrosis factor (TNF) therapy such as infliximab. This is a strong recommendation with a high quality of evidence. 

Based on the review of the medical record and literature, intravenous Remicade (infliximab) is considered medically necessary for this patient. This patient has active ulcerative colitis. The patient had required steroids and had a colonoscopy that showed worsening severe inflammation. According to the ACG guideline, treatment with Infliximab is highly recommended for this patient's case. Since infliximab is given as an intravenous fusion, it is often given in an outpatient hospital facility. 

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

The medical necessity for outpatient hospital facility based intravenous Remicade (Infliximab) infusion; code J1745 is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class I, vertical growth pattern, Class II canines, maxillary and mandibular spacing, 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 patient is a female child who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to skeletal Class I, vertical growth pattern, Class II canines, maxillary and mandibular spacing, 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 10 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, New York State requires the use of an orthodontic index.  The HLD 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 10 points (5 overjet, 3 overbite, and 2 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: Wisdom Teeth. 
Treatment: Dental Services (D0367). 

The insurer denied the Dental Services (D0367). 
The denial is upheld. 

The patient is a female requesting dental benefits for a CT (computed tomography) scan of the right wisdom tooth due to the proximity of the root to the inferior alveolar nerve.  Panoramic x-ray was taken. 

The records are standard and ordinary as it pertains to dental clinical consultations and the dental claim appeals process. 

No, the proposed treatment of a dental CT (computed tomography) scan is not medically necessary. 

A dental CT (computed tomography) scan is a specialized x-ray that provides a three dimensional image of dental structures, soft tissues, nerve pathways, and bone in a single scan. 

While one of the indications for such an x-ray is the surgical planning of impacted wisdom teeth, the records do not indicate why the panoramic film that was taken was not sufficient. 

The records do not specify or support the need for a CT (computed tomography) scan. 

Although the CT (computed tomography) scan is more accurate than traditional dental x-rays, it also produces higher levels of radiation exposure; therefore if it is not deemed to be absolutely necessary and a traditional x-ray could provide the same diagnostic information, then the risk would not outweigh the benefit.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System
Home Health Care

Diagnosis: Parkinson's
Treatment: Personal Care Aide (PCA) Level 2 Services
The insurer denied Personal Care Aide (PCA) Level 2 Services: Requested Increase to 16 Hours per Day, 7 Days per Week - Total of 112 Hours per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of Parkinson's disease, dementia, urinary incontinence, neuropathy, recurrent falls, gastroesophageal reflux disease (GERD), gastroparesis, orthostatic hypotension, insomnia, constipation, anxiety, and depression who had been assigned PCA (personal care assistant) services. The patient (Pt) is at risk for falls and skin breakdown if left unattended for extended periods of time. Turning and position is necessary as well as safety supervision. The patient is confused and not able to press life alert system if fall occurs.

The Personal Care Aide (PCA) Level 2 Services: Requested Increase to 16 Hours per Day, 7 Days per Week - Total of 112 Hours per Week are medically necessary for this patient. 

The patient has documented progressive medical diagnosis of Parkinson's disease. There is also documentation of the patient's worsening functional status and mental status. The patient lives alone and is bed bound. The patient requires assistance with all ADLs (activities of daily living)/IADLs (instrumental activities of daily living). The patient has unscheduled and unpredictable care needs for which the insurer failed to document a care plan. The patient's bed mobility, transfer toilet, toilet use, personal hygiene and locomotion needs occur at unscheduled and unpredictable times. Because the patient has 24 hour care needs, the assessment tool was inappropriately utilized to calculate PCA hours. The patient does not have informal care outside of the allotted PCA hours. The increase in PCA hours is not solely for safety and supervision, but to assist the patient with safe completion of ADLs/IADLs. The patient's medical providers have documented medical necessity for an increase in PCA hours. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 16 hours/day, 7days/week, to total 112 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.