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

Diagnosis: Anoxic Encephalopathy

Treatment long-term acute care hospital (LTACH)

The insurer denied coverage for long-term acute care hospital (LTACH)

The denial is overturned

The patient was hospitalized after a fall. The patient had sustained a SDH (subdural hematoma) and underwent surgical evacuation. Magnetic resonance imaging (MRI) also revealed bilateral acute pontine ischemic strokes. The patient remained with anoxic encephalopathy and was deeply unconscious. The patient underwent tracheostomy and percutaneous endoscopic gastrostomy (PEG) for ventilator-dependent respiratory failure (VDRF). The patient's course in the hospital was complicated by autonomic neuropathy and storming. The patient was managed with Morphine and Gabapentin. The patient's hospital stay was also complicated by Klebsiella urinary tract infection (UTI). She was treated with intravenous (IV) Zosyn.

The patient had a prolonged stay on Ventilator and was deeply unconscious and had other autonomic complications in addition to neuromuscular weakness. She would have to undergo prolonged and specialized weaning trials due to all these underlying issues.

The patient was transferred to long-term acute care hospital (LTACH) facility for weaning. At admission, patient was on Pressure-regulated volume control (PRVC) 450/12 fraction of inspired oxygen (FiO2) 30% (percent) with Positive end-expiratory pressure (PEEP) 5.

The patient was placed on active weaning trials. Her autonomic storming was managed carefully as weaning progressed. The patient was placed on pressure support (PS),
subsequently to T-Piece and eventual liberation from mechanical ventilation (MV).

The patient subsequently was discharged to a skilled nursing facility (SNF) once she was weaned off the ventilator.

This patient had a complicated and prolonged acute hospitalization and had severe anoxic encephalopathy. Weaning these patient's is very difficult and needs a specialized unit such as the one in LTACH. Long-term weaning outcomes are better in a specialized unit such as an LTACH. Admission to LTACH was appropriate.

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 long-term acute care hospital (LTACH) admission is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection (UTI).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female. She was admitted through the ER (emergency room) with a diagnosis of acute pyelonephritis.  She had renal calculi treated with a percutaneous nephrostolithotomy.  She had been managed at home with Cipro and Bactrim.  CT (computed tomography) imaging had left renal calculi up to 14 mm (millimeters). Vitals were Tmax (maximum temperature) 101.4 Fahrenheit, pulse 88 per minute, blood pressure 118/64 mmHg (millimeters of mercury).  IV (intravenous) Levaquin was started.

Day two, she was treated with IV (intravenous) antibiotics.  The urine culture grew streptococcus species.

Day three, the patient was discharged home.

Yes, the Inpatient admission was medically necessary.
The patient had previous urologic surgery (e.g., stent placement). She had renal calculi treated with a percutaneous nephrostolithotomy.

Admission is indicated for 1 or more of the following: Hemodynamic instability, Altered mental status that is severe or persistent, Persistence or worsening of clinical findings (eg, fever, pain, dehydration, vomiting) despite observation care treatment (ie, remain too severe to allow treatment at lower level of care), Parenteral antibiotics needed beyond observation care treatment (eg, patient cannot take oral medication, known or suspected pathogen resistance to oral agents), Pregnancy of 24 weeks' gestation or beyond (if pyelonephritis) Immunocompromised state (eg, AIDS [acquired immune deficiency syndrome], chronic systemic corticosteroid use), Urinary system finding that requires invasive procedure, or places  patient at increased risk for systemic illness (eg, hypotension), or delayed recovery as indicated by 1 or more of the following:Ureteral obstruction (eg, stone), Bladder emptying significantly impaired (eg, neurogenic bladder, bladder outlet obstruction), Renal or perinephric abscess Emphysematous pyelonephritis, Granulomatous pyelonephritis, Pyelitis Pyonephrosis, Previous urologic surgery (eg, stent placement), Anatomical abnormality (eg, of collection system, ureters, reflux), Transplanted kidney, Acute renal failure Need for IV (intravenous) hydration support (eg, inability to maintain oral hydration) despite observation care treatment.

As the patient had previous urologic surgery, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: small cell lung cancer

Treatment: proton beam radiation therapy (RT)

The insurer is denied coverage for proton beam radiation therapy
The denial is overturned. 

This female patient has a history of small cell lung cancer.

Proton beam therapy has been used for treatment of tumor which requires highly conformal radiation therapy due to the location of tumor in close proximity to critical structures and in cases of re-irradiation treatment, such as in this member's case. Multiple peer reviewed publications have demonstrated that proton beam RT with its superior ability to precisely conform radiation dose distribution around irregularly shaped target can deliver of high dose of radiation to tumor precisely with maximum sparing of these normal tissues, which is critical for cases of re-irradiation as in this patient. Due to prior RT to the lung, re-irradiation of recurrent lung cancer will carry high risks of normal tissue complications such as radiation pneumonitis, radiation induced fracture of clavicle and ribs, and spinal cord myelitis leading to paralysis. Proton beam has advantage of being able to deposit high dose of radiation to tumor with sharp dose fall off from normal tissues can enable delivery of higher dose to tumor without exceeding normal tissue tolerance and can improve local control and reduce risks of radiation complications.      

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

The carrier's denial of coverage for the proton beam radiation therapy is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld.

This is a patient with no significant past medical history that presented to the hospital complaining of chest and shoulder pain for a 1-2 week period.  On presentation, vital signs were stable: blood pressure (BP) 169/73, pulse 86.  Physical examination revealed reproducible pain with arm and body movement.  12 lead electrocardiogram (ECG) demonstrated sinus rhythm with non-specific T (interval on ECG) wave inversions in the inferior leads and no ST (interval on ECG) segment abnormalities. Serum blood testing revealed renal insufficiency with a creatinine of 2.7 and anemia with a hemoglobin of 10.  Serial serum troponin was not elevated (0.03).  Exercise stress testing was performed and demonstrated "borderline ischemia."  The patient was discharged on medical therapy.

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

This patient presented with reproducible chest pain that was of new onset over the preceding weeks.  She was noted to be hypertensive on examination. No other abnormalities or findings consistent with an acute coronary syndrome were noted.  Based on history and presentation alone, this patient had a low short term risk of death and nonfatal cardiac ischemia.(Reference1)  She underwent exercise stress testing and had a Duke treadmill score of + (positive)3.  No evidence of ischemia was noted on myocardial imaging. These findings are consistent with a low one year mortality and a low probability of significant coronary artery disease. (Reference 2) Utilizing the HEART [history, ECG, age, risk factors, troponin ] score she is considered low risk (3 points). (Reference 3)  Utilizing the thrombolysis in myocardial infarction (TIMI) risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 4) Risk assessment of patients presenting with chest pain and no significant ST (interval on ECG) changes on ECG was reviewed by Hedayati et al. (Reference 4).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. Ultimately this patient was deemed to have atypical chest pain and discharged on medical therapy. 	

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 migraines

Treatment: Nurtec

The insurer is denied coverage for Nurtec

The denial is upheld. 

This male patient has a history of chronic migraines

Nurtec is a calcitonin gene-related peptide receptor antagonist Food and Drug Administration (FDA) approved for the acute treatment of migraine with or without aura in adults. The patient is noted to have a diagnosis of chronic migraines and had previously tried multiple medications to include Depakote, amitriptyline, propranolol, verapamil, Botox, candesartan, Emgality, Ajovy, Aimovig, Namenda, gabapentin, and sumatriptan. It was reported he had been on Nurtec for the last six months; however, the most recent note indicated that Nurtec did not add much benefit. There was a letter that the patient had tried Ubrelvy, but the submitted clinical notes provide no records of this to include dates of service and efficacy.

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

The carrier's denial of coverage for the Nurtec is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep Impinging Overbite

Treatment: insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit)

The insurer denied coverage for insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit)

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 deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 16 and 18 points on review by 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, 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 an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care.  In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 18 points (5 points overjet, 6 points overbite, 5 points anterior crowding and 2 points labiolingual spread).

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

Based on the above, the medical necessity for the insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite. 
Treatment: D8080 Braces And D8670 Monthly Visit x12. 

The insurer denied the D8080 Braces And D8670 Monthly Visit x12. 
The denial is overturned. 

The patient is a male. The request is for braces and monthly visits. He has Skeletal Class I, and Class II canines. His upper left first premolar is in complete buccal crossbite. 

Yes, the braces and monthly visits are medically necessary. 

The patient has an upper left first premolar in complete buccal crossbite. This means that it is totally outside of the lower premolar and does not touch it. This will lead to over eruption (super-eruption) of this tooth, with it hanging down more that the adjacent teeth. This will cause increased cavities in the area (food trap) as well as trauma to that tooth when the patient goes through the chewing cycle and that tooth is hit by the lower teeth. This can cause loosening and/or fracturing of multiple teeth in the area. Orthodontic treatment is needed to correct this problem. This case has medical necessity.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: multiple sclerosis (MS).

Treatment: Vumerity

The insurer is denied coverage for Vumerity

The denial is upheld. 

This female patient has a history of multiple sclerosis (MS).

The patient does not meet the insurer's criteria for Vumerity since she has only tried a single MS medication. While the reason for requesting Vumerity over Tecfidera are clear (less GI side effects) the reasons for requesting Vumerity over all the other available MS medications, many of which are on the insurer's formulary, are not clear. It is possible that Tecfidera/Vumerity are being requested because they are considered lower risk and more tolerable for this patient who seems to be mostly asymptomatic and to have a radiologically isolated syndrome. However, this has not been made explicit, and therefore there is no reason to approve Vumerity when there are so many other alternative medications recommended as initial disease modifying therapies (DMTs) (Pardo, et al) this patient has not tried.

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

The carrier's denial of coverage for the Vumerity is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Desaturation, cyanosis, vomiting and choking

Treatment: Inpatient level of care

The insurer is denied coverage for inpatient level of care.

The denial is overturned. 

This female patient has a history of desaturation, cyanosis, vomiting and choking.

According to a Neonatology Attending Progress note: "infant was noted to have cyanosis with desaturations to 46% that recovered by placing the baby upright. Saturations improved to 93% at around 6 minutes. Infant per report had a choking episode (milk curds). Mother also reports the infant was hard to burp".   Accordingly, the infant was admitted to the NICU where the physical assessment was normal, other than slightly cool (97.7F).  A complete blood count (CBC) was unremarkable. The infant was placed on cardiorespiratory monitoring and continuous pulse oximetry. There was no further episode of cyanosis or respiratory distress.  There was physiologic jaundice that did not require treatment. The infant was discharged home with her mother. 

According to Milliman Care Guidelines (MCG): P-595, Newborn care, Term, with Severe Illness or Abnormality: 

Higher-level neonatal care (ie, other than Level I nursery) for neonate whose gestational age is 37 0/7 weeks or greater is indicated by 1 or more of the following:
Respiratory distress in neonate, as indicated by 1 or more of the following):

- Cyanosis  

Continuing Care: Intensity of Care Criteria 2 provided, as indicated by 1 or more of the following: 

Other clinical situation (eg, needed treatment or intervention, postoperative state, acuity of illness, diagnosis) such that a ratio of 3 or 4 neonates per registered nurse is clinically necessary and appropriate.

According to InterQual, Acute Pediatric Care, Nursery:
Special Care Level II:

This level of care is for stable or moderately ill neonates who have problems that, while potentially serious, are expected to resolve rapidly and not require subspecialty level services urgently. These newborns have conditions such as apnea of prematurity, the inability to maintain body temperature, or the inability to take oral feedings. Level II care also includes neonates who have transferred from a higher level of care.

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

The carrier's denial of coverage for the inpatient level of care is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated blood pressure
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The decision is upheld. 

The patient is a male with obesity and hypothyroidism hypertension who had recently been hospitalized with hypertensive urgency suspected related to medication noncompliance.  The patient was sent from an urgent care facility due to elevated blood pressures.

The patient's blood pressure on presentation was between 179/106 and 225/155.  Oral labetalol and nifedipine were administered prior to admission.  On admission, the patient's blood pressure was 185/104.  Labs were notable for a bicarbonate 31, BUN (blood urea nitrogen) 32 and creatinine 2.2.  The troponin was 0.05 and brain natriuretic peptide was 1350.  The chest x-ray showed no acute process.  The electrocardiogram demonstrated sinus rhythm with no acute ischemic changes.  Losartan and metoprolol were resumed.  Intravenous fluids were provided.  Levothyroxine was reinitiated.  The creatinine dropped to 1.7.  The patient left the hospital against medical advice the day after admission.

No, the inpatient admission was not medically necessary.

The patient's elevated blood pressures were asymptomatic and there was no evidence of hypertensive emergency.  The acute kidney injury was likely due to pressure related diuresis and was not documented to be due to hypertensive emergency.  Although the brain natriuretic peptide was elevated, there was no examination or clinical evidence of acute heart failure.  There was no evidence of acute myocardial infarction, aortic dissection, hypertensive encephalopathy, cerebral infarction, intracranial hemorrhage, papilledema, seizure activity or microangiopathic hemolytic anemia.  Intravenous antihypertensive agents were not required for frequent administration or infusion.  The patient's blood pressure improved with only oral agents.  The patient remained asymptomatic.  Renal function improved promptly with hydration.  The patient did not have uremia, volume overload, acidosis or hyperkalemia.

In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Radius and Ulna Fracture

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

This patient presented to the emergency department (ED) following a fall from a skateboard. The patient was found to have a right radius and ulna fracture. Orthopedics was consulted and the patient was admitted for pain management and neurovascular checks following open reduction internal fixation. The patient was discharged.

The records show the young man sustained an open fracture to his forearm. A puncture wound was present. His fractures were unstable and required operative management. The records show a non-complicated post-surgical course. His vital signs were stable. There was no evidence of bleeding or fever. 
 
He did not require treatment for other conditions. There were no problems with his surgical site. The discharge summary noted post-operative pain was managed with oral Acetominophen. His neurologic status was stable. 

These findings do not substantiate necessity for the inpatient 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.