Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines.
Treatment: Formulary exception for Zembrace Sym Touch 3mg/0.5ml SC SOAJ.
The insurer denied the Formulary exception for Zembrace Sym Touch 3mg/0.5ml SC SOAJ.
The denial is upheld.

The patient is a male with migraine headache disorder. The provider is requesting Zembrace. Previous treatments are not noted other than he has tried triptans and has nausea and vomiting with migraines. The record includes note of gabapentin, which is a preventive rather than abortive agent. The requested medication was denied coverage as he has not tried and failed and does not have a contraindication to the use of three preferred agents.

No, the health plan should not cover the requested Formulary exception for Zembrace.
There is no documented reason as to why the patient cannot be treated with the preferred triptan medications for his condition. All of the preferred agents are FDA (United States Food and Drug Administration) approved for the acute treatment of migraine headaches and are considered first line, standard of care, abortive agents (Thorlund et al.). There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Zembrace relative to the preferred agents.

The record note that the patient has failed multiple oral medications including triptan class is non-specific and does not address the health plan's formulary. Of note, there are sublingual formulations and formulary injectable triptans.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II malocclusion with mandibular retrusion, a deep impinging overbite

Treatment D8080 braces and D8670 monthly visit x (times) 12

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12

The denial is overturned

This patient presented for evaluation for orthodontic care.  The orthodontist identified a Class II malocclusion with mandibular retrusion, a deep impinging overbite with severe soft tissue damage, and mild lower crowding.  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 and the patient's Handicapping Labio-Lingual Deviation (HLD) index was determined to be 21.

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, a Handicapping Labiolingual Deviation Index is utilized. 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 a palatally impinging overbite with soft tissue damage that classifies as an automatic qualifying condition.  This reviewer has determined from the records the patient has a greater than 100% (percent) overbite with palatal impingement, lower crowding, a Class II div 2 malocclusion, low mandibular plane angle and retroinclined incisors which qualifies him for coverage.

The clinical circumstances as presented do meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval.

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

Based on the above, the medical necessity for the D8080 braces and D8670 monthly visit x 12 is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Hip Pain

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

This patient with no significant medical history transferred from one hospital to another Emergency Department (ED) where she initially presented with severe right hip pain radiating to the knee, unsteady gait and inability to walk. Venous duplex studies of the lower extremities were negative for deep vein thrombosis.

A hip x-ray showed a questionable fracture. A computerized tomography (CT) scan ruled out a fracture but was remarkable for severe right hip chondromalacia. The patient was admitted for further management.  Consultations with Orthopedic and Physical Medicine and Rehabilitation (Rehab) Services were ordered to evaluate the patient.  The patient's pain improved significantly with non-steroidal anti-inflammatory medication (NSAID).  Magnetic resonance imaging (MRI) results indicated lumbar-sacral disc bulging, a displaced right femoral neck fracture, bone marrow edema, and a small to moderate right hip joint effusion. Neurosurgery evaluated the patient's lumbar sacral disc bulges and determined that intervention was not needed. Rehab discussed using a walker versus a cane and suggested a steroid injection which the patient declined as she was improving on NSAIDs. The Orthopedic Service recommended physical therapy on discharge along with continued NSAID use for pain. Later, the patient was stable and cleared for discharge. Instructions were given for medications and follow up appointments with her Primary Medical Doctor, Neurosurgery and the Neurology Clinic.

The records show there was no evidence of a traumatic condition. The patient reported several days of pain and received several subspecialty consultations and imaging studies. A non-displaced fracture was identified on magnetic resonance imaging (MRI). Her hospital course was non complicated with stable vital signs (no evidence of fever). She was able to tolerate oral pain medications. She was able to tolerate physical therapy (PT). The records showed a walker was recommended which she declined. The diagnostic studies all could have been completed as outpatient. Timely consultations also could have been completed. She did not require treatment for an underlying medical condition.

Criteria supports admission for fracture when operative intervention is required. No surgery nor invasive procedures were completed. There were no extenuating circumstances to substantiate the admission and length of stay. Services could have been provided at a lower level of care. 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: Upheld

Diagnosis: Chronic Pancreatitis

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient had a history of chronic pancreatitis and pancreatic insufficiency. He had a drainage of a pancreatic pseudocyst. He now presented with vomiting and abdominal pain. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The amylase was 248 (normal to 300). A computed tomography axial (CAT) scan was read as chronic pancreatitis with no change. Intravenous (IV) hydration, proton pump inhibitor therapy (PPI) therapy and pain medications were given.

Milliman care guideline (MCG) guideline M-250 lists indications for admission for Pancreatitis. This patient did not have acute pancreatitis but had chronic pancreatitis. Indications for admission for chronic pancreatitis include evidence of infection, hemodynamic instability, hypoxemia, acute renal failure, and severe electrolyte abnormalities. The patient did not have these conditions.

This patient had chronic pancreatitis. IV hydration, antiemetics, and pain control could have been given with Observation status. He did not meet MCG criteria for admission for Pancreatitis. The health care plan acted reasonably and with sound medical judgement. An inpatient admission was not medically necessary.

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

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

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male who had presented to the medical facility filing the appeal for the complaints of abdominal pain. In the Emergency Department, the patient reported nausea, emesis, diarrhea and abdominal pain. The patient had a prior medical history of hypertension, peptic ulcer disease, diverticulitis, hiatal hernia, Clostridium (C.) difficile colitis and intussusception. The patient had undergone surgical treatment for the intussusception. The patient evidenced hypertension on presentation with otherwise normal vital signs. A recent esophagogastroduodenoscopy (EGD) showed gastric torsion, a Schatzki's ring, and a hiatal hernia. The patient evidenced an alcohol level on testing. A computed tomography (CT) scan showed no acute intra-abdominal processes. The patient received supportive care and intravenous (IV) morphine for the pain. The patient was admitted and received intravenous (IV) fluids, pain medication, and conservative therapy. Once improved, the patient was discharged home.

No, the proposed inpatient hospital admission was not medically necessary.
While the care as provided was medically appropriate, the level at which the care was provided was not medically necessary. Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level. The patient had abdominal pain; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level.

While the care as provided was medically appropriate, the level at which the care was provided was not medically necessary. Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level. The patient had abdominal pain; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervical Radiculopathy

Treatment Procedure code 72141 - Magnetic Resonance Imaging (MRI) Cervical Spine without Contrast, a special picture study of the neck portion of the spine without injected dye

The insurer denied coverage for Procedure code 72141 - Magnetic Resonance Imaging (MRI) Cervical Spine without Contrast, a special picture study of the neck portion of the spine without injected dye

The denial is overturned

The patient reported a two-week history of right arm pain that felt heavy with numbness and tingling in digits 3-5 and pain was localized to the right elbow. Splinting has helped somewhat. She had neck stiffness. She has a known history of degenerative joint disease of the cervical spine with last MRI years ago. Meloxicam was not providing relief. Her exam notes pain and heaviness to neck with prolonged flexion, palpable trapezius spasm bilaterally, bilateral hand grip weakness right greater than left with swelling to fingers of the right hand. Numbness to lateral 3 digits right hand. The plan was for a referral to pain management, an x-ray of the cervical spine, an MRI of the cervical spine and a sed rate. She was given a Medrol dosepak.

The healthcare plan did not take into account bilateral grip weakness with neck pain and stiffness with known spondylosis.

The cervical MRI is medically necessary as there is noted bilateral hand weakness right greater than left which is new. Guidelines are not specific to grading of the weakness and any new onset is significant to allow for imaging. Therefore, the MRI cervical spine is medically necessary to rule out pathology for treatment. 

Magnetic resonance imaging (MRI) is the imaging method of choice for evaluating radiculopathies. MRI provides excellent visualization of soft tissue abnormalities including disc herniations and nerve compressions. There is a risk of falsely positive MRI studies as disc herniations and foraminal narrowing, while strongly correlated with radicular symptoms, may not be causative in any individual case. (2)

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

The insurer's denial of coverage for Procedure code 72141 - Magnetic Resonance Imaging (MRI) Cervical Spine without Contrast, a special picture study of the neck portion of the spine without injected dye is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.
Treatment:  Braces and Monthly Visits.
The insurer denied the  Braces and Monthly Visits.
The denial is overturned.

The patient is a male with Class II malocclusion. He has anterior open bite, excessive overjet and a left side posterior crossbite.

Yes, the braces and monthly visits are medically necessary.
The patient has a severe overjet, meaning his upper front teeth stick out very far in front of his lower anterior teeth. He also has an anterior open bite, meaning his front upper teeth do not overlap his lower front teeth like they are supposed to. This means that during the chewing cycle, his teeth will bang into each other because there is no "anterior guidance." Anterior guidance is when a person's lower front teeth glide along the backs of the upper front teeth. This patient cannot do that so his posterior teeth with bang into each other in a traumatic fashion, which will over time cause fracturing and/or loosening of teeth. Also, with his upper front teeth sticking out so far, they will be prone to trauma. Orthodontic treatment is needed to correct these problems. This case has medical necessity.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior Crossbite with Gingival Attachment Loss (mandibular right canine).

Treatment braces and monthly visits.

The insurer denied coverage for braces and monthly visits.

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, 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 (mandibular right canine) in addition to 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 when clinical attachment loss and recession of the gingival margin are present. 

Upon review of the submitted documentation, 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, an HLD index is utilized. 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 met and does support comprehensive orthodontic care. In this case, the clinical circumstance does 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. This is confirmed by the studies listed in the references.

Each of the 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.

The healthcare plan did not act reasonably and with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for braces and monthly visits is overturned.  Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crowding; overbite
Treatment:  D8080 Braces
The insurer denied the  D8080 Braces.
The denial is upheld.

The patient is a male. The request is for dental benefits for Orthodontic treatment (Braces).

Per the Provider's clinical summary, the patient presents with a class II skeletal relationship, mild crowding in the upper and lower arches, deep impinging overbite (lower teeth biting into palate).

The health plan denied the claim because the patient did not score a 26 on the HLD (Handicapping Labio-Lingual Deviation) index Report, the score needed for orthodontic treatment approval.

The provider appealed because of the patient's deep impinging overbite with soft tissue damage.

No, the requested braces are not medically necessary.
The information submitted does not show tissue damage to the soft palate as a result  of the patient's overbite. The photos of this area do not show any redness, swelling or ulceration of the palate. Therefore, the braces are not medically necessary.

Per the HLD (Handicapping Labio-Lingual Deviation) index Report, an impinging overbite with tissue damage to the soft palate is an automatic qualifier for orthodontic treatment. Unfortunately, this is not demonstrated in the information supplied. Therefore the requested orthodontic therapy is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Partially obstructing mass in the mid transverse
colon
Treatment: Continued inpatient admission
The insurer denied the Continued inpatient admission
The denial is upheld

The patient is a female with a partially obstructing mass in the mid transverse colon. Comorbidities noted in the record include thrombocytopenia, HTN (hypertension), HLD (hyperlipidemia), GERD (gastroesophageal reflux disease) and hypothyroidism. The lesion was initially stented and the patient subsequently admitted. On the day of admission, she underwent an elective right colon resection. Following surgery she developed an anastamotic leak with an associated fluid collection confirmed by CT (computed tomography) scan.  IV (intravenous) antibiotic therapy was initiated and a drain placed by Interventional Radiology. TPN (Total Parenteral Nutrition) was initiated. A midline wound infection was identified and drained and topical wound care initiated.

Upon Initial Review dates of service were not authorized as not medically necessary. This was subsequently revised and in their final adverse determination letter the health plan partially revised their determination and authorized the stay for a specific period of time.

The treating facility is appealing this determination stating that these days were necessary to optimizing the patient's condition prior to discharge into the community.

No, the Continued inpatient admission was not medically necessary.

From a review of the medical records submitted reflect that the patient's condition (post-operative anastamotic leak and associated intra-abdominal collection) and the services required to manage these issues rise to the level of acute inpatient care. The record documents ongoing issues with open incisional infections, continued feculent catheter drainage, diminished nutritional status, and pain management concerns. These required interventions including intravenous antibiotics, analgesics and nutritional support as well as management of both her wound infection and drainage catheter care both of which required frequent attention.

The patient had been successfully converted to oral medications and was able to resume satisfactory oral intake by the dates of service in question. Her wound care needs had diminished to a level that could be managed on an alternative level of care.

This reviewer concurs with the plan's decision as outlined in their final determination letter.

By reviewing the medical care received by the patient and determining when she needed acute inpatient care and when she could be safely transitioned to a lower level of care, the plan was acting in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension as well as diabetes, chronic kidney disease, atrial fibrillation, heart failure, major depressive disorder, bilateral primary osteoarthritis of the knee. 

Treatment: Personal Care Worker (PCW) services of 10 hours per day for 4 days, and 9 hours per day for 1 day, a week, totaling 49 hours per week. 

The insurer denied coverage for Personal Care Worker (PCW) services of 10 hours per day for 4 days, and 9 hours per day for 1 day, a week, totaling 49 hours per week. 

The denial is overturned. 

This case involves an elderly female who has a past medical history that includes hypertension as well as diabetes, chronic kidney disease, atrial fibrillation, heart failure, major depressive disorder, bilateral primary osteoarthritis of the knee. The documentation indicated she has been recommended to receive home care services 12 hours a day for 7 days a week due to the above diagnoses.  The documentation indicated she has the inability to independently perform activities of daily living.  She has been receiving personal care assistant services 5 days a week for 10 hours.  She is alert and oriented to time and place however forgetful due to age-related cognitive decline.  Her daughter does assist with decision-making as needed.  She does reside with her grandson and has a history of stroke with right-sided hemiparesis and generalized weakness.  She is able to ambulate with a walker and assistance however she is unable to stand for prolonged periods of time.  She does have difficulty bending and needs maximal assistance getting in and out of the bathtub as well as with bathing/dressing of her lower body.  She needs extensive assistance with personal hygiene and dressing. The recommendation was made to continue with personal care services. 

The patient has issues with forgetfulness and cognition as well as significant issues with activities of daily living (ADL).  It is appropriate to provide the requested coverage to assist in activities of daily living. Therefore, the health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for the Personal Care Worker (PCW) services of 10 hours per day for 4 days, and 9 hours per day for 1 day, a week, totaling 49 hours per week is substantiated. The insurer's denial is overturned.