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

Diagnosis: Osteoarthritis (chronic knee pain)
Treatment: J7323 hyaluronan or derivative, Euflexxa, for intraarticular injection, per dose, 3 units
The insurer denied coverage for J7323 hyaluronan or derivative, Euflexxa, for intraarticular injection, per dose, 3 units.
The denial is upheld.

This patient has chronic right knee pain. She has tried physical therapy. Her magnetic resonance imaging (MRI) shows a flap tear and osteoarthritis of her knee. The request is for viscosupplementation with Euflexxa.

Pererira, et al conducted a systematic review of viscosupplementation for knee arthritis and concluded:

"Strong conclusive evidence indicates that viscosupplementation leads to a small reduction in knee osteoarthritis pain compared with placebo, but the difference is less than the minimal clinically important between group difference. Strong conclusive evidence indicates that viscosupplementation is also associated with an increased risk of serious adverse events compared with placebo. The findings do not support broad use of viscosupplementation for the treatment of knee osteoarthritis." [1]

Rutjes, et al similarly found overall no clinically important benefit for pain intensity or frequency of osteoarthritis flares in 89 trials involving 12,667 patients, but high-molecular-weight and cross-linked preparations had greater effects. [2]

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for J7323 hyaluronan or derivative, Euflexxa, for intraarticular injection, per dose, 3 units is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Multiple Sclerosis. 
Treatment: Consumer directed personal assistance services (CDPAS) 56 hours per week. 
The insurer denied coverage for CDPAS 56 hours per week. 
 The denial is modified. 

This patient is an adult with a diagnosis of multiple sclerosis. She lives alone in a 2-bedroom apartment. She is currently approved by the insurer for CDPAS 31.5 hours/week and is requesting an increase to 56 hours/week. 

According to the most recent Uniform Assessment System (UAS) report, the patient cognitive skills are described as "modified independent." She requires extensive assistance for bathing and lower body dressing. Limited assistance is needed for upper body dressing and toilet use. She only requires supervision for bed mobility, ambulation, and toilet transfer. The patient is infrequently incontinent of bladder and continent of bowel. She is independent with personal hygiene and bed mobility. She is "able to warm foods in the microwave and get drinks from the refrigerator" and "make a simple meal." She uses a walker for ambulation and taken by her caregivers to go shopping. The patient's functional status has declined compared to the UAS report from the prior year; particularly for lower body dressing and mobility (transfers/ambulation). However, the decline has been modest, and her functional ability does not support the medical necessity of increasing CDPAS to 56 hours/week. A modest increase in CDPAS is warranted. Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by increasing CDPAS to 42 hours/week. 

From a physical medicine and rehabilitation perspective, the requested increase CDPAS 56 hours per week is not medically necessary. However, increasing CDPAS to 42 hours/week is medically necessary.  

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

The insurer's denial of coverage for the consumer directed personal assistance services (CDPAS) 56 hours per week is modified. Medical necessity is substantiated for CDPAS of 42 hours/week.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ovarian torsion
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission 
The denial is upheld

The patient presented with severe abdominal pain, and findings suggestive of torsion. She underwent an uncomplicated laparoscopic left oophorectomy.

According to Milliman Care Guidelines, Inpatient and Surgical Care, Laparoscopic Gynecologic surgery, including myomectomy, oophorectomy, and salpingectomy, laparoscopic procedures are ambulatory procedures. Inpatient stay may be needed for: Older patients (>[greater then] 65), Conversion to abdominal procedures, Surgical complications, or Comorbidities. The patient did not meet any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. She was tolerating oral intake and voiding adequately. Her incisional pain was minimal.

The laparoscopic procedure is an outpatient procedure and includes appropriate postoperative monitoring.

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

Diagnosis: Acute Coronary Syndrome, Acute Ischemic Heart Disease.
Treatment: Inpatient Hospital Admission.
The health plan denied the requested acute hospital admission as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a history of congestive heart failure (CHF), pacemaker, myocardial infarction, hyperlipidemia, hypertension, and diabetes who presented with intermittent left-sided chest pain with exertion. He was in no acute distress. The electrocardiogram demonstrated a ventricular paced rhythm. Troponins were negative. The brain natriuretic peptide (BNP) was 55. Vital signs and the oxygen saturation were normal. The creatinine was mildly elevated. A chest x-ray was negative. Echocardiography demonstrated a normal left ventricular ejection fraction (LVEF) and mild mitral regurgitation. Defibrillator interrogation demonstrated an isolated episode of ventricular tachycardia. A myocardial perfusion imaging exercise test demonstrated no ischemia. He remained stable and was discharged.

An inpatient level hospitalization is under review for medical necessity.

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

This patient presented with chest pain and remained stable. There was no CHF, respiratory distress, ongoing symptoms suggestive of treatment refractory angina or angina equivalent, severe arrhythmia, hemodynamic instability, another serious cause for chest pain, such as a pulmonary embolism (PE) or aortic dissection, need for prolonged intravenous (IV) medications or oxygen support, need for invasive hemodynamic monitoring, need for vasopressor or mechanical cardiac support, introduction of high risk medications requiring ongoing in-hospital monitoring, or supporting evidence for an acute coronary syndrome/myocardial infarction such as elevated cardiac biomarkers.

In the setting of this case, an acute inpatient level hospitalization, compared to for example observation, has not been established as standard of care towards improved cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

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

The patient presented with right upper quadrant (RUQ) abdominal pain. She was previously found to have cholelithiasis and elevated liver enzymes. A magnetic resonance cholangiopancreatography (MRCP) did not show common bile duct (CBD) stones. By the time of admission her pain had resolved. She was afebrile and the vital signs were stable. The abdominal exam was benign. There was no leukocytosis. An abdominal ultrasound showed gallstones but not acute cholecystitis. A hepatobiliary scintigraphy (HIDA) scan was negative. An Endoscopic ultrasound (EUS) was negative for bile duct obstruction. There was a plan to do an outpatient cholecystectomy. 

Clinical indications for admission for Gallbladder or Bile Duct Stone or Inflammation (Milliman Care Guidelines (MCG) M-555) include having acute cholecystitis or acute cholangitis if certain indications are met. In this case, the patient did not have either acute cholecystitis or acute cholangitis. Other indications for admission for gallbladder calculus include hemodynamic instability, severe vomiting, severe dehydration, bacteremia, or CBD obstruction. She did not have these conditions. 

This patient had gallbladder disease but did not have either acute cholecystitis or acute cholangitis. No emergency surgical interventions were required. Intravenous (IV) hydration and monitoring of the liver enzymes could have been done with observation status. She did not meet MCG criteria for admission for Gallbladder or Bile Duct Inflammation or Stone. 

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

Diagnosis: Ischemic cardiomyopathy and heart failure with preserved ejection fraction, remote coronary artery bypass grafting (CABG), hypertension, diabetes, obstructive sleep apnea, atrial fibrillation and atrial flutter.
Treatment: Cardiac Monitoring Service: Special Heart Monitor.
The insurer denied: Cardiac Monitoring Service: Special Heart Monitor.
The denial is upheld.

The patient is an adult female with a history of ischemic cardiomyopathy and heart failure with preserved ejection fraction, remote coronary artery bypass grafting (CABG), hypertension, diabetes, obstructive sleep apnea, atrial fibrillation and atrial flutter. Left atrial appendage occlusion was performed following an episode of bleeding while on oral anticoagulant therapy. An implantable loop recorder was implanted to monitor heart rhythm. The patient was noted to have frequent episodes of atrial fibrillation and atrial flutter on implanted loop recorder (ILR) and ultimately underwent ablation of cavotricuspid isthmus dependent flutter. Review of implanted loop recorder report from six months ago demonstrates a low burden of atrial arrhythmia 
(0.2%[percent]) and good battery status. A request was submitted to the patient's health care plan to remove the old implantable loop recorder and implant a new device.

The proposed treatment is not medically necessary.

This patient has a history of atrial fibrillation and atrial flutter. Arrhythmia was documented by implantable loop recorder and heart rhythm has been monitored for a period of years. Current arrhythmia burden is extremely low at 0.2%. Moreover, the patient has a left atrial appendage occlusion device in place and is effectively treating for the possibility of thromboembolism due to atrial fibrillation. Current guidelines do not recommend perpetual monitoring of patients with implantable recorders that already have a documented history of atrial fibrillation and atrial flutter. (Reference 1).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurrent Gluteal Abscesses

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient is an adult with a past medical history of recurrent gluteal abscesses who presented to the emergency room with complaints of perianal pain and a gluteal abscess.
Vitals on presentation included: Temperature. 98.3 Fahrenheit, Blood Pressure-119/73, Pulse-81, Respiratory Rate-20, oxygen saturation 98% (percent) on room air. Laboratory values were notable for the following: White Blood Cells (WBC)-13.5, Hemoglobin-13.6, Hematocrit-40.9, creatinine-0.68, glucose-93.  The patient was empirically started on intravenous antibiotics (Unasyn). Ultrasound showed complex fluid filled collection in the left gluteus maximus muscle. In the emergency department, a drainage attempt was unsuccessful. The patient underwent an incision and drainage procedure under general anesthesia. Post-operative course was unremarkable. The patient remained afebrile, hemodynamically stable and clinically improved. The patient was discharged to continue oral antibiotics as an outpatient.  

According to documentation, the patient presented with a recurrence of left gluteal abscess. The patient was afebrile and hemodynamically stable. Laboratory results were notable for elevated WBC (13.5).   Bedside incision & drainage procedure was unsuccessful because it was "too large."  Based on above findings, hospital admission was medically necessary for administration of intravenous antibiotics and surgical incision and drainage under general anesthesia in a high-risk patient with recurrence of infection.  

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 the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: braces (comprehensive orthodontic treatment)

The insurer denied coverage for braces (comprehensive orthodontic treatment)

The denial is overturned

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, open bite, anterior crowding and posterior crossbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 27 total points. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, 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 completed the second portion of the index arriving at 27 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support 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. 

Based on the above, the insurer's denial must be overturned. 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 braces (comprehensive orthodontic treatment) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive sleep apnea.
Treatment: E0562 heated humidifier with positive airway pressure (PAP) and E0601 PAP device.

The insurer denied coverage for E0562 heated humidifier with PAP and E0601 PAP device.  The denial is overturned.
 
The patient is an adult with a history of (H/O) chronic obstructive pulmonary disease (COPD), obesity, hypertension (HTN), coronary artery disease (CAD) and obstructive sleep apnea (OSA). The patient was diagnosed with OSA based on a sleep study done many years ago. The patient has been on continuous positive airway pressure (CPAP) 13 centimeters (cm) for many years. The patient had a repeat sleep study done more recently and was noted to have severe OSA with an apnea - hypopnea index (AHI) of 51. The patient was prescribed a new CPAP machine and supplies, as he has been using his old machine for many years.

The patient had a visit with his sleep doctor and CPAP Compliance reports indicate that this patient is compliant with the CPAP.

The insurance company's response stated that a request for similar equipment was already approved. It was unclear if the patient had already received the supplies or not.

This patient needs the supplies requested. If they have not already been sent to the patient this patient should be provided these supplies.

Based on the above, the insurer's denial must be overturned. 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 E0562 heated humidifier with positive airway pressure device (PAP) and E0601 PAP device is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

This adult male was hospitalized for pneumonia. He presented to the emergency department for evaluation of elevated blood pressure at home. His past medical history is remarkable for hypertension, hyperlipidemia and benign prostatic hyperplasia (BPH). The patient's vitals were remarkable for fever of 101.7, heart rate 137 respiratory rate 20, oxygen (O2) saturation 95% on room air, blood pressure 146/92 and he was in no acute distress. Electrocardiogram (EKG) showed sinus tachycardia. There was mild leukocytosis. Creatinine was 1.5. Troponins were mildly elevated and considered 2/2 demand ischemia. Chest x-ray and chest computed tomography angiogram (CTA) suggested pneumonia. Treatment included antibiotics. The patient remained hemodynamically stable, tachycardia resolved, there was no hypoxia, and he was deemed stable for discharge to home. 

The request for inpatient hospitalization has been denied and the patient is appealing the decision.

The proposed treatment was not medically necessary.

Based on the peer reviewed medical literature, there was not a medical need for acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, hypoxia, altered mental status that is severe or persistent, dehydration that is severe or persistent, bacteremia, cardiac arrhythmia of immediate concern, pulmonary edema, pulmonary embolism, aortic dissection, acute myocardial infarction, elevated troponin that cannot be explained by reduced renal clearance from acute dehydration, complicated pneumonia, hypertension requiring inpatient hospitalization, septic shock or any other medical condition, symptom or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital stay. The care the patient received for uncomplicated community acquired pneumonia (CAP) like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Back Pain.
Treatment:  Inpatient Stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld.

The patient is a male with a history of low back pain, who was admitted to the hospital via the emergency room (ER). He had the sudden onset of low back and bilateral leg pain with weakness since the morning of admission. He had no bowel or bladder changes. His examination showed no deficits. A lumbar magnetic resonance imaging (MRI) was obtained that showed mild disc bulging without spinal stenosis.

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

The inpatient stay was not medically necessary. The patient had low back pain. The patient had a normal examination. The computed tomography (CT) scan showed no spinal stenosis. The CT scan showed a small lumbar vertebrae (L)4-5 disc bulge. He was admitted for pain control and he was evaluated by neurology and neurosurgery. There were no immediate interventions recommended for the patient.

The patient could have been admitted to an alternate level of care for pain control, to be evaluated by neurosurgery and to obtain a lumbar MRI. This was done the day after admission, and no interventions were recommended. The patient could have been discharged after the MRI and the evaluations were completed.
Appeal type: Medical necessity
Decision: Upheld

Endocrine
growth hormone

Diagnosis: growth hormone deficiency
Treatment: growth hormone
The insurer denied Skytrofa. The health plan's determination is upheld. 

The patient is female who has been diagnosed with growth hormone deficiency (GHD) and seeking growth hormone (GH) treatment under that indication. She developed pubertal changes for which her evaluation showed luteinizing hormone (LH) 1.4 and Estradiol 23.2 both of which were pubertal. Other evaluation including follicle-stimulating hormone (FSH), dehydroepiandrosterone (DHEAS), prolactin, T4 and thyroid stimulating hormone (TSH) was unremarkable. 

Skytrofa is not medically necessary for this patient.
This patient is not short for her age and in the last year she has grown 5.3 centimeter (cm) in a year which is a normal growth velocity considering the fact that she was on GnRH analog to suppress puberty. Treatment with growth hormone is not medically necessary.
Based on her bone age, this patient's adult height prediction +/- 1 standard deviation (SD) was 61.3+/-2 inches which may be less than her genetics; however, early puberty is known to compromise adult height which is not due to growth hormone deficiency (GHD).