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

Diagnosis: plaque psoriasis

Treatment: Otezla 30 milligrams (mg)

The insurer is denied coverage for Otezla 30 milligrams (mg).

The denial is overturned. 

This male patient has a history of plaque psoriasis

The requested service is medically necessary based on the provided medical records and the medical literature.  The patient has failed topical therapy and requires systemic therapy for control and management of his psoriasis diagnosis.  The patient was previously noted to have improvement with Otezla without significant documented adverse reactions.  

Although treatment with light therapy or methotrexate are alternative medical options, this patient has noted improvement of psoriasis with Otezla.  The request to re-initiate Otezla therapy is thus medically necessary.  

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 Otezla 30 milligrams (mg)  is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: psoriatic arthropathy

Treatment: Humira 40 milligrams

The insurer is denied coverage for Humira 40 milligrams

The denial is overturned. 

This female patient has a history of psoriatic arthropathy, inflammatory polyarthropathy, psoriasis, bilateral primary osteoarthritis of the knees, pain in the knees and hypothyroidism.

The insurer stated the current standard Humira plan criteria only allows coverage for Humira if the requested drug will not be used in combination with another biologic or targeted synthetic disease modifying anti-rheumatic drug.  The patient has a great response to the Humira medication. She will not be taking Humira medication in combination with any other biologics or Otezla. Otezla was previously used by the patient, but it is not the current treatment. Documentation was submitted with the appeal. The Humira is being used for psoriatic arthritis (PsA) and psoriasis, both FDA-approved indications. Documentation has been provided that Otezla is not being given, and that Humira is monotherapy.   

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 Humira 40 milligrams is overturned.  The medical necessity is 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 female. She presented with two days of right lower quadrant abdominal pain. 

The patient was diagnosed with appendicitis with a CT (computed tomography) scan of the abdomen and pelvis, and she was admitted. She did not develop complications. She had no fevers, vomiting, or vital sign abnormalities. It was documented that she did not want to eat prior to being discharged. She did not undergo an appendectomy. She did have intravenous medications administered. She was discharged home the following day. 

No, the inpatient admission was not medically necessary. 

The patient could have been treated at a lower level of care. Given the patient's presentation and findings, treating the patient at a lower level of care would have been consistent with the standard of care in the medical and surgical community. A lower level of care would not have compromised the patient's health, safety, or treatment provided. 

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient in regards to this hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Sided Numbness Weakness and Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female. She presented to the ED (emergency department) with complaints of right arm numbness "s/p [status post] smoking crack last night." Her history included HTN (hypertension), DM (diabetes mellitus), and polysubstance abuse disorder.

On exam in the ED (emergency department), the patient reported numbness to light touch on her right side. Her NIHSS (National Institutes of Health Stroke Scale) score was 3. CTH (computed tomography of head) and CTA (Computed Tomographic Angiography) were negative. The patient's labs were said to have been unremarkable. A decision was made to take her to the floor for further evaluation for possible stroke.

Subsequent MRI (magnetic resonance imaging) of the patient's brain was negative for acute stroke. The patient complaints of right sided weakness, but there was not an imaging correlate.  The patient was started on ASA (aspirin) and a statin. She continued to take her home/outpatient medications.  The patient's final diagnosis was one of a TIA (transient ischemic attack) secondary to crack use.

No, the Inpatient admission was not medically necessary.
The patient presented to the hospital with subjective complaints of right sided numbness. An evaluation for a possible stroke, particularly in the setting of substance abuse, was warranted. However, it was not necessary for the patient to be treated at/in the inpatient level of care.

The evaluation of a suspected stroke is generally done in the observation setting/level of care. The patient in this case had subjective complaints, but no sustained neurological impairments. Initial vitals and labs were both said to have been unremarkable. There was no degree of clinical worsening on either area either. The patient was not noted to have had any sort of infection. No stroke was identified on imaging. There was otherwise no evidence of neurologic deterioration.

As such, the provision of care in the inpatient setting would have otherwise exceeded the patient's clinical needs at the time services were provided. The inpatient admission was not necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
The health plan followed evidence-based standards of care in making their determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overjet, Open Bite, Class I Malocclusion, Anterior Crowding

Treatment: Braces and monthly visits

The insurer denied coverage for braces and monthly visits.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, copies of peer reviewed literature as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, open bite, Class I malocclusion, anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index, attaining 20 total points to support orthodontic care. 

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 does not claim an automatic qualifying condition and completes the second portion of the index, arriving at 20 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining at total of 20 points on the HLD index (5 overjet, 8 open bite, 5 anterior crowding, 2 labiolingual spread), which is below the threshold of 26 points to support orthodontic care. Of note in this case, the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.
 
Regarding the validity of the Handicapping Labio-Lingual Deviation 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 several studies.

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 clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care, as it does not meet the accepted criteria for approval. The health care plan did act reasonably, with sound medical judgement, and in the best interest of the patient.

The insurer's denial of coverage for the braces and monthly visits is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class II malocclusion, posterior crossbite, overjet, overbite, anterior crowding

Treatment: D8080 braces

The insurer denied coverage for D8080 braces.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph and tracings, panoramic radiograph, montage of extraoral and intraoral clinical images, and insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The Orthodontist identified several clinical findings including Class II malocclusion, posterior crossbite, overjet, overbite, anterior crowding, and has recommended orthodontics. The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index twice, arriving at two results (12 points and 19 total points) to justify orthodontic care. 

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 does not claim an automatic qualifying condition
and completes the second portion of the index twice, arriving at two results (12 points and 19 total points) to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist that attained a total of 19 points on the HLD index (5 points overjet, 4 points overbite, 10 points anterior crowding), which is below the threshold of 26 points to support orthodontic care. Of note in this case, is that the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.
 
The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the D8080 braces is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle Cell Disease.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a female who was admitted to the hospital for back pain. She has a past history of sickle cell anemia, asthma, and obstructive sleep apnea (OSA). On presentation, her pain was 10/10 and vitals were unremarkable. Labs noted a white blood cell count (WBC) 21.1 and hemoglobin 6.2. Total bilirubin was 5.9 and lactate dehydrogenase (LDH) was 2233. She was started on intravenous (IV) fluids in the emergency department (ED). She has a history of persistent low back pain. She was started on Morphine. There was concern on admission of a pain crisis from sickle cell. Hydroxyurea was given in addition to Folic acid, IV fluids, and Symbicort. Her pain was refractory to treatment. She did require 2 units packed red blood cells (PRBC). Her condition improved and she was stable at discharge.
The question at hand is whether the patient met medical necessity for the acute inpatient level of care.

The inpatient admission was medically necessary.
The patient did meet medical necessity for the acute inpatient level of care per current literature and standard of care. According to Smith et al., Alexander et al., and Dampier et al., , the patient's case was consistent with a sickle cell pain crisis with worsening anemia. She required multiple doses of pain medications and transfusions due to anemia. The patient had refractory symptoms and elevated WBC count with concern of underlying infection. She required constant electrolyte replacement. The severity and complexity of care would not have been appropriate for a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems.
Treatment: Inpatient hospital Stay.
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient presented to the emergency department (ED) via Emergency Medical Services complaining of dyspnea, cough, and wheezing. His medical history was remarkable for heart failure with reduced ejection fraction, asthma, diabetes, and polysubstance abuse. He was treated with albuterol en route to the ED. His blood pressure was 106/99 millimeters of mercury with a heart rate of 102 beats per minute. His respiratory rate was 20 per minute. His arterial oxygen saturation, by report, was "in the 80's". On physical examination the patient appeared to be in respiratory distress with use of accessory muscles of respiration. His pulmonary examination was remarkable for bibasilar rales and diffusely decreased breath sounds. He had bilateral lower extremity edema. Arterial blood gas showed a respiratory acidosis with a potential hydrogen (pH) of 7.33. His partial pressure of oxygen (pO2) of 49.2 mmHg with a partial pressure of carbon dioxide (pCO2) of 51 mmHg. Chest X-ray showed pulmonary edema. His N-terminal pro brain natriuretic peptide (proBNP) level was 605 picograms per milliliter (pg/ml). Urine toxicology screen was positive for cocaine. The patient was treated with intravenous furosemide, steroids, bronchodilators, and bi-level positive airway pressure (BiPAP) and admitted to the hospital for management of acute decompensated heart failure. Treatment with furosemide, bronchodilators, and steroids was continued. BiPAP was continued until his oxygen saturation could be maintained and was then kept on standby. 

An inpatient level of care was medically necessary. This patient presented to the hospital with acute decompensated heart failure. He was tachycardic, tachypneic, hypoxic, and in respiratory distress, with use of accessory muscles of respiration. Arterial blood gas showed respiratory acidosis. He required BiPAP for ventilatory support. The patient was at high risk for adverse outcomes, including serious arrhythmias and the need for intubation and mechanical ventilation. He required careful and continuous monitoring, with the ability to intervene emergently, if needed. This required an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health/Anxiety.
Treatment: Mental Health: Residential.
The health plan denied the requested mental health residential stay. 
The health plan's determination is overturned.

The patient is an emerging adult female who was admitted for residential treatment of co-occurring anxiety and depressive disorder best characterized as recurrent and severe major depressive disorder with suicidal ideation and without psychosis and generalized anxiety disorder; unspecified posttraumatic stress disorder (PTSD), and moderately severe substance use disorder with alcohol.

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

Residential Treatment facility as requested was medically necessary for the treatment of this patient's conditions. The Residential Treatment Center Services are in keeping with prevailing standards of medical practice for the conditions under treatment in this case with evidence-base treatments; and the requested services/treatment being provided in this case are clinically appropriate and are backed by credible scientific evidence known to benefit patients with the conditions diagnosed in this case.
Appeal type: Medical necessity
Decision: Upheld

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

The patient presented to the emergency department (ED) with complaints of severe flank pain. She has a past medical history significant for multiple sclerosis (MS) and asthma. She was afebrile and hemodynamically stable on presentation. Her white blood cell count (WBC) was 15.3. She was diagnosed with an obstructing ureteral stone on a computed tomography (CT) scan. She was admitted to the inpatient service and urology was consulted. She underwent a cystoscopy, lithotripsy and placement of a ureteral stent under general anesthesia. The patient had an uneventful hospital course and was discharged. The medical necessity for an inpatient stay is under review.
The inpatient stay was not medically necessary.
A majority of patients who present with renal colic can be discharged within 24 hours of presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. The procedure was not done on an emergent basis; it was done the next morning. The procedure performed is considered a minimally invasive outpatient procedure and as such in the absence of a "high risk surgical patient" does not warrant acute inpatient care. The information provided and the patient's perioperative clinical status does not suggest the need for acute inpatient care. A lower level of care for this patient's clinical presentation and postoperative course was the safe, effective, generally accepted standard and the most appropriate treatment option.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: myelomeningocele of lumbar region with hydrocephalus

Treatment: Consumer directed personal assistance services (CDPAS)

The insurer is denied coverage for Consumer directed personal assistance services (CDPAS)

The denial is overturned. 

This male patient has a history of Arnold-Chiari malformation, type ll, auditory neuropathy, ventriculomegaly of brain, enteric duplication cyst, myelomeningocele of lumbar region with hydrocephalus, neurogenic bladder, acquired plagiocephaly, low weight, developmental delay, and status post small bowel resection and ventriculoperitoneal shunt.

In this case, the child is dependent on all ADLs, needs assistance for turning and positioning, feeding, transferring and frequent transportation to medical appointments. He needs 1:1 supervision always. He is nonverbal and has behavioral issues. He has episodes of vomiting, fever, increased drowsiness, and crying.  

Upon considering the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations, the insurer's decision for denial of coverage for CDPAS should be reversed.

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 CDPAS is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hematuria

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This male patient has no significant past medical history.

Per Milliman Care Guidelines (MCG) Health:

i) Abdominal Pain, Undiagnosed - Patient fails to meet clinical indications for admission to inpatient care

ii) Urologic Disease  - Patient fails to meet clinical indications for admission to inpatient care under subsection "gross hematuria requiring inpatient care".

Per InterQual 2021 Acute Pediatric General Medical - GI criteria for admission

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 inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: right knee pain

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission

The denial is upheld. 

This female patient has no significant past medical history.

The facts were the patient did not demonstrate findings which would support that diagnosis. ie. The patient was afebrile and vital signs were stable. Laboratory studies were normal. It would not be likely to have normal values in the presence of osteomyelitis. Nevertheless, the aspiration did not show evidence of bacteria. The cultures were negative. The child was reported to be comfortable taking Advil watching movies. 

These findings do not substantiate necessity of an admission to rule out osteomyelitis. The services provided could have been obtained in a physician office. ie. Aspiration with orthopedic consultation. An orthopedic oncological evaluation could have been made as well. 
There were no extenuating circumstances to warrant the level of service. It could have been completed at a lower level.

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 inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures.

Treatment hospital admission.

The insurer denied coverage for hospital admission.

The denial is upheld.

The patient has a history of absence seizure and recent generalized tonic-clonic seizures.  The paramedics found the patient lying face down on the carpet with the father holding him because the patient was vomiting.  Per the father, the patient had a seizure at 7 AM (ante meridiem) and another 110 minutes before emergency medical services (EMS) arrival.  The mother noted the patient was diagnosed with seizures 3 weeks before this incident.  The patient was utilizing Keppra and ethosuximide.  The patient was postictal and confused at triage. After triage, the patient was alert and oriented.  The Glasgow Coma Scale was 15.  The patient was admitted for a video electroencephalogram (EEG).  The patient was loaded with Depakote.  The patient was stable during his hospitalization.  The patient was stabilized on stabilized and discharged later.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient admission is not considered medically necessary for this patient.

The patient was alert and oriented on re-evaluation and showed no neurologic deficits. The video EEG could have been performed either on an outpatient basis or under observation status.   The patient did not need to be admitted. 

The insurer's denial of coverage for the hospital admission is upheld. Medical necessity is not substantiated.