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

Diagnosis: Cleft palate deformity. 
Treatment: Comprehensive orthodontic treatment. 

The insurer denied coverage for comprehensive orthodontic treatment. 
The denial is upheld. 

This is a female who has been denied orthodontic treatment as her HLD (Handicapping Labio-Lingual Deviation) score was below 26. 

The plan acted reasonably with sound medical judgment. 

To determine the necessity of braces a Handicapping Labio-Lingual Deviation (HLD) index is utilized. To qualify for braces the patient must either meet the criteria for an automatic qualifier, or attain a score of 26 or more on the second section of the HLD. 

Automatic qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9mm (millimeters) or greater and underbite 3.5mm or greater.  No automatic qualifier is claimed. 

If a patient does not meet the automatic qualifier criteria, a scoring of her dentition according to the second part of the HLD occurs. In this case, this reviewer agrees with the insurer that the patient does not attain a score of 26 points. 

A score of 26 or more is required for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, comprehensive orthodontic treatment of the Adolescent Dentition is not medically necessary for this patient. 

The insurer's denial of coverage for comprehensive orthodontic treatment is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung Cancer.
Treatment: Positron Emission Tomography (PET) Scan (78813).
The insurer denied the Positron Emission Tomography (PET) Scan (78813).
The denial is upheld.

The patient is a male with metastatic non-small cell lung cancer (NSCLC). The attending physician (AP) performed a positron emission tomography / computed tomography (PET/CT).  Limited details are provided except for the radiation plan.

No, the positron emission tomography (PET) scan was not medically necessary.
Positron emission tomography (PET) is not needed for the routine management of metastatic non small cell lung cancer. The attending physician (AP) can use conventional imagining to manage metastatic non small cell lung cancer.  The use of positron emission tomography exceeds in scope what is necessary to provide care.  The attending physician has provided no support to the use of positron emission tomography over conventional computed tomography scans for this patient.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Arthritis of bilateral knee
Treatment: Joint surgery
The insurer denied coverage for joint surgery
The denial is upheld

This is the case of an adult male with a history of arthritis of bilateral knee. An office visit with Orthopedic Surgeon for an evaluation of his bilateral knee pain notes that the patient stated he has suffered from severe arthritis of the knee and has often been nearly incapacitated. He has tried nonoperative treatments to relieve the pain but has been unsuccessful and is disinterested in injections and being more aggressive with non-steroidal anti-inflammatory drugs (NSAIDs). He requested to have bilateral knee replacement surgery. The patient's diagnostic imaging showed bilateral tricompartmental degenerative joint disease (DJD) in the left knee with multiple loose bodies, osteopenia, and mild varus. The patient underwent bilateral arthroplasty knee replacement surgery without complications.

Surgical indications include definition of a pain generator and failure to improve with conservative treatment. There should be demonstration of functional limitation and inability to perform activities of daily living. These findings were not present. 

The records showed "pain with driving and difficulty playing with grandchildren". The only treatment provided was limited medications. The physical examination was remarkable for slight loss of motion, varus alignment and joint line tenderness. There was no report of crepitus, instability nor swelling. The motion itself was not reported to be painful. The X rays showed arthritis but no description to extent, such as osteophytes, joint space narrowing, bone on bone or sclerosis. 

The facts were that insufficient conservative treatment had been provided. Recommendations as per National Guidelines and Specialty Organizations include use of activity restriction, bracing, ambulatory support, corticosteroid injection, viscosupplementation injection and simple analgesics. These services were not provided. There would thus not be an indication for the bilateral total knee replacements.

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

The insurer's denial of coverage for joint surgery is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Aide (PCA): 7 days x (by) 12 hours x 2 shifts, 168 hours/week
The insurer denied PCA: 7 days x 12 hours x 2 shifts, 168 hours/week.
The health plan's determination is overturned. 

The patient is a female with past medical history of dementia, arthritis, permanent pacemaker, coronary artery disease, bladder incontinence, bowel incontinence, hypertension, gastroesophageal reflux disease (GERD), atrial fibrillation, depression, macular degeneration, and glaucoma who had been assigned PCA (personal care aide) services. 

PCA: 7 days x (by) 12 hours x 2 shifts, 168 hours/week are medically necessary for this patient.

There is documentation from the patient's medical provider of medical necessity of increased PCA services as well as documentation of worsening cognitive and physical functioning. The insurer's own assessment documented an increased need for assistance with tasks of managing medication, bathing, dressing lower body, bed mobility, and eating when comparing the recent assessment to the previous assessment. The patient's medical provider documents medical necessity of turning and repositioning every 2 hours due to patient's inability to do this independently and the patient's history of urinary and bowel incontinence. The patient's care needs would not allow an aide to obtain at least 5 hours of uninterrupted sleep. The patient has 24-hour care needs, therefore a task-based tool should not have been utilized to calculate PCA hours. The requested increase in PCA services is not solely for safety and supervision, but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The insurer stated denial as patient did not have a sleep study to assess overnight needs however, the patient's medical provider documented medical necessity of turning and repositioning at least every 2 hours. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 x 2 hours/day, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypotension. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This patient was admitted for worsening weakness. She was found to have hypotension in addition to elevated creatinine and was started on IV (intravenous) fluid for acute kidney injury (AKI) resolved and was discharged. 

In the KDIGO (Kidney Disease Improving Global Outcome) classification system, her acute renal failure meets stage 2 acute kidney injury which comes with significant mortality if not immediately reversible (i.e., acute tubular necrosis). 

A systematic review and individual patient data meta-analysis (1879 patients) with patients randomized to either early vs late (25 to 57 hours later) initiation of renal replacement therapy (RRT) in the setting of stage 2 or 3 kidney injury found significant increased mortality in patient with acute renal failure with evidence acute tubular necrosis (ATN) [1]

The gold standard for the distinction between prerenal disease secondary to volume depletion and post-ischemic and nephrotoxic ATN is the response to fluid repletion per KDIGO and National Kidney Foundation guidelines. If sufficient fluid is given to reverse any signs of volume depletion (e.g., hypotension, cool extremities, low urine-sodium concentration), return of the serum creatinine to the previous baseline within 24 to 72 hours is considered to represent a correction of prerenal disease, whereas persistent acute kidney injury (AKI) is considered to represent ATN, this member's kidney function improved in back to baseline in 48 hours, which is not consistent with acute tubular necrosis or significantly increased mortality.

Therefore, her condition could have been treated safely under lower level of care and inpatient admission was not medically necessary. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 
The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Preterm premature rupture of membranes
Treatment: Inpatient hospital admission 
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is a female. She presented to her physician's office at 16 weeks two days gestation complaining of a gush of fluid per vagina. Examination revealed cervix dilated to 2-4 cm (centimeters) with a bulging bag of water. She was sent to the hospital, at which point gross pooling of fluid was noted, diagnostic of preterm premature rupture of membranes in a previable gestation.

The patient was counseled and elected to be induced for the ruptured membranes given the poor prognosis and maternal risks. She was admitted to the hospital, and induction of labor was performed using cytotec. She delivered the fetus, but had significant hemorrhage in the third stage of labor. She stabilized and was discharged home on hospital day #1.
The health plan contends that the admission was not medically necessary because there were no abnormalities of vital signs, refractory bleeding or pain, intolerance of oral intake, and referenced MCG (Milliman Care Guidelines) 25th edition GRG:MG-OBD (ISC GRG) Obstetric and Gynecologic Disease GRG. The facility contends that the admission was medically necessary and cites MCG (Milliman Care Guidelines) 26th Edition Preterm Labor, Threatened RRG (M-287-RRG), Hospital admission is needed for appropriate treatment of the patient because of one or more of the following: Preterm pre-labor rupture of membranes (PPROM).
The Inpatient Hospital Admission was medically necessary. The patient had previable preterm rupture of the membranes at greater than 16 weeks. She elected
not to continue the pregnancy, and labor was induced. Induction of labor at this gestational age is not performed on an outpatient basis, because it requires close observation of the patient in the same manner as induction of labor of an older gestation. The patient is at risk of infection, complications secondary to the medications used for induction, hemorrhage as did occur for this patient, and also requires medical intervention on the part of the physician or midwife to perform the delivery of baby and placenta, and to do the post-delivery exam to ensure that there was no trauma to the genital tract and no uterine atony or other hemorrhagic complication that would require emergent medical intervention. Therefore, the admission was medically necessary.
The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient, in that it declined coverage for the appropriate level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Malocclusion.
Treatment:  Plate replacing all upper teeth (denture).
The insurer denied coverage for plate replacing all upper teeth (denture).
The denial is overturned.

Upon review of the submitted documentation which included copy of panoramic radiograph indicating an edentulous maxilla and mandible, narrative letter from patient's physician, dental treatment note, treatment records, insurer correspondence and claim history, it appears that this patient presented to the dentist with a complaint of ill-fitting and fractured maxillary denture that was beyond repair. The patient, who is diabetic, reports difficulty with eating. The insurer has denied a new maxillary compete denture stating that their criteria state that a new denture is not allowed if the current prosthesis is under 8 years of age, which is the case for this patient based on the claim history. The patient is appealing.

Based on the documentation, it is evident that the patient is edentulous. Narrative letter and treatment notes state that the denture is nonfunctional and non-repairable. Further, the patient's physician states that the inability of the patient to masticate food appropriately will negatively impact her health as she has uncontrolled diabetes. Therefore, fabrication of a new denture is indicated for patients underlying health despite the current one being less than 8 years of age. Based on these documented findings, the clinical situation meets insurer criteria for approval as the patient has a serious medical condition that will potentially be exacerbated without the denture. Therefore, as the current circumstance meets the insurer criteria for approval a new maxillary denture is considered medically necessary.

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

The insurer's denial of coverage for plate replacing all upper teeth (denture) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior cruciate ligament (ACL) reconstruction
Treatment: Ongoing physical therapy (PT) treatment of 2-3x/week x 12 weeks
The insurer denied coverage for ongoing PT treatment of 2-3x/week x 12 weeks
The denial is overturned

This is a patient who underwent a right knee ACL reconstruction and meniscus repair.  She began post-surgical physical therapy. Under review is the medical necessity of continued therapy treatment of 2-3x/week x 12 weeks.

The physical therapy notes were reviewed. Patient began physical therapy, after undergoing right ACL reconstruction. Rehabilitation protocols for ACL reconstruction often exceed the physical therapy currently under review. The physical therapy notes document gradual improvement over the next several months. The therapist provided appropriate functional goals, which included range of motion, decreased pain, increased strength and independence with home exercise program. The treatment notes document continued functional improvement supporting the requested therapy currently under review. Transitioning the patient to self-care prior to the requested physical therapy currently under review, would have been premature, clinically inappropriate and placed her at greater risk of re-injury.  

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient. Including but not limited to, 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, nation or professional medical societies boards and associated were taken into consideration. All decisions are evidenced based.  

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, ongoing therapy treatment of 2-3x/week x 12 weeks, was medically necessary.

The insurer's denial of coverage for ongoing physical therapy (PT) treatment of 2-3x/week x 12 weeks is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: diabetes, OA (osteoarthritis), atrial fibrillation, CAD (coronary artery disease), anxiety/depression, and chronic pain
Treatment: Increase personal aide (PCA) services to a total of 56 hours per week
The insurer denied the increase in personal aide services to a total of 56 hours per week.  
The denial is overturned. 

The requested Increase Personal Aide (PCA) Services To a Total of 56 Hours Per Week is medically necessary.

The patient is a female. She has a past medical history of diabetes, OA (osteoarthritis), atrial fibrillation, CAD (coronary artery disease), anxiety/depression, and chronic pain. She reportedly has tracheostomy wound and right heel wound. The patient was also found to have sacral wound. The patient has urinary incontinence. She is bed-bound and is at risk of worsening sacral ulcers. She lives alone and needs help with all her ADLs (activities of daily living). Increase in home care services is being requested.
The review is for increased personal aide services to a total of 56 hours/week. Health plan approved personal aide services are 4 hours/day 7 days a week for a total of 28 hours/week. The health plan's reason for prior denial of coverage was that services are not medically necessary. The denial is being appealed.

The patient is a female with multiple comorbidities. The patient lives alone in the community and has underlying CAD (coronary artery disease), hypertension, CHF (congestive heart failure), diabetes, atrial fibrillation, tracheostomy and has chronic hypoxic respiratory failure. The patient has stage IV decubitus ulcer. The patient has underlying urinary incontinence. Her sacral ulcers can be become easily infected from urinary incontinence. The patient has chronic pain because of limited mobility. The patient is wheelchair- and bed-bound. The patient requires assistance with all her ADLs (activities of daily living). Because of underlying depression anxiety and chronic pain it is difficult for her to coordinate her care and take her medications. She lives alone and does not have any other help. Because of limited mobility, she will require increased home aide services.

The patient needs frequent repositioning and help with urinary incontinence. Her sacral ulcers are at risk of worsening without adequate repositioning.

Based on above reasons, 28 hours/week are not adequate. The patient will require increased personal aide services to ensure safety and avoid further complications. Therefore, the requested Increase Personal Aide (PCA) Services To a Total of 56 Hours Per Week is medically necessary.

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

The patient is wheelchair- and bed-bound. The patient has pressure ulcers and are at risk of worsening. The patient is at risk of sepsis and septicemia. She needs frequent help because of urinary incontinence. Because of progression of the disease, the patient will require increased home care services.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal muscular atrophy and global developmental delays

Treatment: TiLite wheelchair and accessories

The insurer denied coverage for TiLite wheelchair and accessories

The denial is overturned

This is a toddler with diagnosed spinal muscular atrophy and global developmental delays. He is non-ambulatory. He has a power wheelchair that was approved. Under review is the treating physician's recommended manual (TiLite) wheelchair and accessories.

The requested (back-up) manual wheelchair is clinically appropriate and medically necessary. This individual with diagnosed spinal muscular atrophy and global developmental delays is unable to ambulate. The back-up manual wheelchair provides a level of mobility in the event of a power wheelchair malfunction/repair or for use in limited accessible environments (e.g. family members' homes). In addition, the light weight TiLite wheelchair with accessories affords this child the opportunity to self-propel short distances and is easily transportable.  

Taken into consideration were the clinical standards of the plan, 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 society, board and associations. All decisions are evidence-based.  

From a physical medicine & Rehabilitation/Pain Management perspective, as well as within a reasonable degree of medical certainty, based on the documentation available for review, the requested TiLite wheelchair and accessories is medically necessary.  

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 TiLite wheelchair and accessories services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Heart Disease.
Treatment:  Transthoracic Echocardiogram.

The insurer denied coverage for Transthoracic Echocardiogram.  The denial is overturned.

This is an adult patient with a history of diabetes mellitus, gastroesophageal reflux disease (GERD), asthma and obstructive sleep apnea who presented to his physician complaining of palpitations and heart racing. Physical examination revealed stable vital signs and no abnormalities. 12 lead electrocardiogram (EKG) revealed sinus rhythm without ST or T wave abnormalities. A thirty-day mobile telemetry monitor revealed sinus rhythm with atrial premature contractions (APCs) and premature ventricular contractions (PVCs). The patient noted symptoms of palpitations, dizziness and passing out during the study. EKG tracings during symptoms included sinus tachycardia and single PVCs. A single 5 beat run of non-sustained ventricular tachycardia (VT) was noted at a rate of 207 beats per minute. An echocardiogram was ordered to assess cardiac structure and function. 

This patient reported symptoms of palpitations and premature ventricular beats were noted on mobile electrocardiography. The American Heart Association and American Society of Echocardiography appropriate use criteria for echocardiography classify routine echocardiography for patients with symptoms of lightheadedness, palpitations, and sustained or non-sustained VT as appropriate. (Reference1) Patients with frequent premature ventricular beats are at risk for developing cardiomyopathy and echocardiography upon initial evaluation is indicated. (2) This patient had evidence of symptomatic ventricular premature beats and non-sustained ventricular tachycardia noted on thirty-day EKG monitoring. In conclusion, echocardiography for palpitations was medically necessary for this patient. 

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 a transthoracic echocardiogram (TTE) is overturned. Medical necessity is substantiated.