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

Pneumonia
Inpatient hospital

The patient is a female with a history of gastric sleeve surgery in past who presented to the emergency department (ED) with recurrent symptoms of fever, cough, congestion, shortness of breath. Prior to this, she was seen in the ED where she was diagnosed with pneumonia in the left lung base on chest computed tomography (CT) and treated with 2 weeks of Augmentin. She also received prednisone for a few days. She had noted improvement in her symptoms but two days after finishing her antibiotics course, she noted recurrence of above mentioned symptoms. In the ED, she was noted to be febrile with other vital signs being stable. The white blood cell (WBC) count was elevated at 17k. Her chest x-ray (CXR) showed improving pneumonia in the left lung base. She was started on treatment with intravenous (IV) antibiotics and IV hydration. She was admitted to the inpatient med-surg unit with failure of outpatient management for pneumonia and continued on IV hydration and IV antibiotics of Zosyn and doxycycline. 

The health plan's determination is overturned. The inpatient stay is medically necessary for this patient. The patient continued to have symptoms despite an extended course of treatment as outpatient with antibiotics with residual pneumonia on chest imaging with persistently an elevated WBC count and fever. The patient was having persistent symptoms of fever cough and residual pneumonia on imaging with low BP which raises concern for sepsis and is best treated in an inpatient setting with IV antibiotics and hydration to avoid serious complications. The patient needed IV antibiotics and hydration in an inpatient setting in this clinical situation.
Appeal type: Medical necessity
Decision: Upheld

The patient has polycythemia vera, requiring weekly phlebotomy, coronary disease, and tobacco abuse.  He presented to the emergency department secondary to 2 episodes of left facial, tongue and arm numbness, lasting for about 30 minutes, and spontaneously resolving.  There were no other associated symptoms with this, including headache or vision changes and no chest pain or shortness of breath.  No gait disturbance was noted.  The patient was admitted to the hospital under the suspicion of transient ischemic attack (TIA) for further work-up.

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  This is a patient who presented with TIA, with resolved symptoms.  NIH score 0.  Head CT was negative.  The patient was essentially admitted, to evaluate with brain MRI, MRA, as to possible causes of TIA symptoms.  Both imaging modalities were negative.  The patient experienced no hemodynamic instability, did not require infusions to control the hypertension, did not require thrombolytics, or interventional radiology thrombectomy for an acute CVA.  This type of presentation of TIA symptoms are typically evaluated with observation at a lower level of care.  The Inpatient admission is not warranted.
Appeal type: Formulary Exception
Decision: Overturned

This is a patient  with a medical history of Samter's Triad (asthma, chronic rhinosinusitis and aspirin sensitivity) who has tried and failed Asmanex and Qvar Redihaler for the chronic rhinosinusitis and is currently on therapy with Xhance with good efficacy. The issue for review is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug or would have adverse effects.
The health plan's determination is overturned.
The formulary drugs have been ineffective and have not been as effective as the non-formulary drug and have caused adverse effects.
Per the clinical information provided, the patient has a diagnosis of Samter's Triad, which is a condition defined by asthma, sinus inflammation with recurring nasal polyps (chronic rhinosinusitis), and aspirin sensitivity. The provider is requesting Xhance, a nasal corticosteroid for the treatment of the patient's chronic rhinosinusitis associated with this condition. Intranasal glucocorticoids are the cornerstone of maintenance treatment for chronic rhinosinusitis. Per the clinical documentation from the provider, the patient has tried and failed both Asmanex and Qvar Redihaler; he was unable to tolerate them due to side effects.
Appeal type: Medical necessity
Decision: Upheld

The patient was had a past medical history significant for kidney stones and sigmoid diverticulosis who presented to the emergency department with a one-day history of left lower quadrant abdominal pain with no complaints of diarrhea, nausea or vomiting. At the time of admission, the patient rated his pain as 5/10 in severity, it was non-radiating. The pain was aggravated by palpation with no alleviating factors. The pain was associated with mild dysuria. His physical exam was reassuring, there was no evidence of dehydration or significant electrolyte abnormalities based on the results of the laboratory studies. The acute inpatient level of care admission was not medically necessary. Treatment at a lower level of care would have been the most appropriate in this clinical case to ensure improvement in the symptoms after initiation of the treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  COPD
Treatement:  Nursing Services (including Private Duty Nursing)

The patient is a female with past medical history of oxygen dependent COPD, diastolic heart failure, atrial fibrillation, coronary artery disease, legal blindness and history of falls, who had been hospitalized with a head injury following a fall when attempting to get from her bed to toilet.  The patient subsequently had another admission with acute on chronic respiratory failure, and during hospitalization the patient was seen by palliative care and transitioned to home hospice.  The patient was set up for personal care services through managed long term care and approved at 8 hours per day/7 days a week to total 56 hours a week.  There was request for more hours.  There was a letter from a social worker from hospice that noted the patient needed almost total care and that the patient's daughter, who worked two jobs, was not able to manage overnight care and needed to sleep to be able to work her two jobs.  The patient's provider requested an increase in personal care aide services, noting that the patient required incontinence care up to 3 times per night and had multiple end-stage conditions and was on hospice.  There was a letter from one of the patient's daughters indicating there were inaccuracies from the previous assessment, in that, the patient did not wear diapers, pull ups and liner and cannot use a wheel chair, due to the size of her home, and uses a walker that must be guided because she is blind.  The patient's physician made another request for 24 hour continuous care and the patient was seen by a physical therapist. 

The health plan's determination is overturned.  The Personal Care Aide (PCA) Level II 24-Hour Continuous Care/7 days a week is medically necessary for this patient.
The patient was initially allowed 8 hours per day/7 days a week to total 56 hours of personal care services, but the patient's provider requested 24 hour continuous care due to her medical condition requiring incontinence care at least 3 times per night.  Hospice further noted that this care could not be provided by the patient's daughter.  Per the recent assessment tool used, the patient needed weight bearing support for all ADL's.  Per physical therapy (PT) assessment, the patient required maximum of two assist for bed transfers.  The assessment noted the patient did not wear a diaper, pull up or liners, which was not the case, necessitating help with incontinence cares.  The assessment also noted the patient could use a wheelchair in the home, however, the size of her home would not allow for a wheelchair, and the patient uses a walker that required help and guidance, due to the patient's blindness and patient's oxygen use.  Due to the patient's medical conditions, living space and family circumstances, it is medically necessary for patient to have 24 hour continuous care/7 days a week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient Substance Abuse Services 
The insurer denied the Inpatient Substance Abuse Services. The denial was reversed. 

This is a male patient who was admitted to for inpatient substance detoxification treatment in early 2019 for alcohol, benzodiazepine, and heroin withdrawal. His withdrawal symptoms included tremors, sweats, yawning, joint pain, sleeping problems, anxiety, irritable mood, runny nose, teary eyes. His Clinical Institute Withdrawal Assessment (CIWA) was 10 and his Clinical Opioid Withdrawal Scale (COWS) was 16. He reportedly had a 27 year history of drinking and a 25 year history of using benzodiazepine and IV heroin per day. He had 3 past reported inpatient substance detoxification treatments. He reportedly was homeless. He had a medical history of liver disease, anxiety and bipolar disorder and fractures due to a motor vehicle accident. He was admitted and started on a Methadone and Ativan protocol.  He reportedly left against medical advice. 

According to the LOCADTR he did require 24 hour treatment. He could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use substances despite 3 past inpatient detoxification treatments, and he needed 2 detoxification medications to modify withdrawal including Ativan and Methadone. He was at risk for worsened withdrawal symptoms including severe, complicated, or life threatening withdrawal if not in this 24 hour setting then. He was also homeless and did not have a sober support system and lacked coping skills. He had reported medical issues including fractures. It was unlikely that he would remain abstinent while having withdrawal symptoms and he had reports of withdrawal symptoms including tremors, sweats, yawning, joint pain, sleeping problems, anxiety, irritable mood, runny nose, teary eyes, and had a systolic blood pressure of 132, and he had a CIWA of 10 and COWS of 16 initially so he required the time in this treatment setting. He could not safely and effectively be treated for detoxification in an outpatient setting as he likely would still would use substances and alcohol if not in a 24 hour setting for detoxification and also he required 24 hour medical detoxification treatment as he was using large amounts of heroin, alcohol, and benzodiazepines and was at risk for overdose and severe, complicated, and even life threatening withdrawals. The risk of delirium tremens can occur even 4 days after stopping alcohol use and this is considered a life threatening withdrawal so he was still considered at risk even past his discharge date which is when he left AMA before the completion of his detoxification treatment. 

Based on the above, the medical necessity for inpatient substance abuse services is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Tumor
Inpatient hospital

This is a female who was status post left thyroid lobectomy who underwent a right thyroidectomy/isthmusectomy for a single thyroid nodule. Surgery  was uneventful intraoperatively. Postoperatively, her vital signs were stable in the post anesthesia care unit. It is reported that she denied pain, was moving all extremities, breathing and coughing, and was fully awake with no nausea and vomiting. She received hydromorphone for pain and Zofran for nausea; these were discontinued when she was discharged to the floor. Overnight according to the postoperative note, she complained of neck pain; there was no documentation of hematoma or active bleeding.

The health plan's determination is upheld. The inpatient hospital admission was not medically necessary for this patient. In the postanesthesia care unit, there was no indications of respiratory distress, the surgical wound was stable, she was fully awake with no nausea or vomiting, and she was admitted. According to the post-operative checkup documented, the patient's pain was managed with oral agents, vital signs were stable, oxygen saturations 100%, blood calcium levels were normal, and she was discharged. She did not meet Milliman Care Guidelines (MCG) national guidelines for admission postoperatively. According to Balentine (2016), multiple studies have now demonstrated that careful patient selection combined with surgeon experience can result in successful and safe surgery without a full inpatient admission. In a 2018 study by Lee et al, in 1665 patients, there were fewer post thyroidectomy complications in the outpatient group that the inpatient group There was no difference between outpatient and inpatient symptomatic hypocalcemia (6.3% vs 9.6%, p=0.09), 30-day postoperative ER visits (8.8% vs 9.6%, p=0.73), and postoperative hematoma (0.39% vs 0%, p=0.39) in a cohort of 1460 patients, in 1272 outpatient thyroidectomies. Based upon the peer reviewed medical literature, a post thyroidectomy inpatient stay was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

The patient in question is a teenage male with a Class I occlusion, no crossbites, moderate overbite and overjet, and mild maxillary and mandibular crowding. He is treatment planned for 36 months of comprehensive orthodontics to correct his malocclusion. The health plan denied the treatment as not medically necessary. The health plan's determination is upheld. 

The patient has mild maxillary and mandibular crowding. According to Caucasian cephalometric norms, the patient has protrusive maxillary incisal angles. However, this patient is not Caucasian and it is more appropriate to use an analysis that takes the patient's ethnic heritage into account, as ethnic differences lead to different cephalometric norms. Both patients of African descent and Hispanic descent have cephalometric norms that include more protrusive incisors than Caucasian norms. It is not medically necessary to upright the patient's incisors to adhere to cephalometric norms that are not in line with the patient's ethnic heritage. Additionally, there is no evidence provided that the patient is currently wearing his mandibular incisors due to his bite. For these reasons, orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is a young male with a skeletal class II molar and cuspid malocclusion, an overjet of 6mm, and an overbite of 6mm, mild maxillary spacing and moderate mandibular crowding. The proposed treatment is braces for 34-36 months. The health plan has denied the braces as not medically necessary. The health plan's determination is upheld.

The patient's malocclusion does not meet the criteria used in most programs to be classified as handicapping and therefore, treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 20 with no auto qualifiers. Most programs using these evaluation methods require a score of 26 or more for treatment to be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is a patient  with a class I skeletal occlusion.  She has a moderate overbite and overjet and moderate maxillary and mandibular crowding.  The proposed treatment is braces.  The issue for review is the medical necessity for braces.  
Question(s):
1. Did the health plan, in its determination of medical necessity, act reasonably, with sound medical judgment and in the best interest of the patient?
Yes. The health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient.
2. Is the requested health service/treatment of Braces medically necessary for this patient?
No, the requested health service/treatment of Braces is not medically necessary for this patient.
Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion in this case would score a 10 with no auto qualifier present.  The malocclusion in this patient does not meet the standard medical necessity criteria to be classified as handicapping, and, therefore, treatment would not be considered medically necessary.  Using this standard of care criteria, the patient would require a score of 26 or greater for treatment to be considered medically necessary.
3. Do you uphold or overturn, in whole or in part, the health plan's determination of medical necessity?
The health plan's determination is upheld, in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class I Malocclusion, Buccal Crossbite, Anterior Open Bite, Moderate Crowding, Protrusion, and Lip Incompetence 
 
Treatment: (D8080) Braces

The insurer denied the (D8080) Braces. The denial was reversed.    

This patient is a young male patient who presented to his orthodontist for a consult for orthodontic treatment. Upon exam the patient was noted to have Class 1 Molar, Class 1 Canine, Buccal crossbite UR4 with LR4, Moderate crowding upper and lower, Anterior open bite: 4mm, OJ: 3MM, Tongue Thrust, Proclined and procumbent incisors, Lip incompetence, Mentalis strain, Convex profile, and Hyperdivergent. A total score of 34 was indicated on the Handicapping Labio-Lingual Deviation (HLD) Index Report.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 34 total points.

The treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 34 points to justify orthodontic care.  This reviewer concurs with the index completed by the orthodontist attaining a total of 34 points on the HLD index (3 overjet, 16 open bite, 3 ectopic eruption, 10 anterior crowding, 2 labiolingual spread) which is 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.  This is confirmed by several studies including:

Beglin, et al. A comparison of the reliability and validity of 3 occlusal indexes of orthodontic treatment need. Am J Orthod Dentofacial Orthoped 2001; 120: 240-6, 

Parker. A study of 1000 malocclusions selected by the HLD Index. Am J Orthod Dentofacial Orthoped 1999; 115:343-51, 

Theis, etal. Eligibility for publically funded orthodontic treatment determined by the handicapping labiolingual deviation index. Am J Orthod Dentofacial Orthoped 2005; 128:708-15. 

Based on the above, the medical necessity for (D8080) Braces is substantiated.  The insurer's denial is reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #3

This is a male patient currently diagnosed with obstructive sleep apnea. His past medical history includes of hypertension, tonsillectomy, and uvulopalatopharyngoplasty (UPPP). The patient was unable to tolerate the continuous positive airway pressure (CPAP), as he removes the mask during sleep. The patient had a sleep endoscopy revealing no complete concentric collapse of the upper airway.  The treatment plan for the patient was to receive an upper airway stimulation device.

According to literature, the recommended device was initially approved in 2014 for treatment of moderate to severe obstructive sleep apnea.  While CPAP is a first-line treatment, long-term use for many patients is suboptimal. The selection criteria for the use of the nerve stimulator may include a body mass index of less than 32, as well as a lack of central apnea and a favorable pattern of palatal collapse during drug-induced sleep endoscopy.  Therefore, given the submitted documentation detailed that the patient has had a trial and failure of a CPAP device with multiple masks, as well as a body mass index of less than 32 and a diagnosis of obstructive sleep apnea, the patient would be an appropriate candidate for the requested service.  There was no evidence of concentric collapse on endoscopy.  As such, the requested upper airway stimulation device would be the most appropriate treatment for this patient.

The carrier's denial of upper airway stimulation device; CPT codes 64568 (Incision for implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator) and 0466T (Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator [List separately in addition to code for primary procedure]) should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer # 2:

This case involves a male currently diagnosed with obstructive sleep apnea.  He has a body mass index was 30.42 kg/m2.  The patient was unable to tolerate continuous positive airway pressure (CPAP).  The patient reports he has tried various masks and he removes them during sleep. The mask caused difficulty breathing and dry mouth.  The patient had tried a dental appliance without relief. He had a history of a deviated septum repair, removal of the uvula, hypertension and daytime fatigue.  The patient underwent a drug-induced sleep endoscopy which revealed anterior-posterior collapse, a favorable pattern of palatal collapse. An upper airway stimulation device was requested for the patient. 

Continuous positive airway pressure (CPAP) is a first line of treatment for obstructive sleep apnea; however, long-term use for many patients is suboptimal.  The hypoglossal nerve stimulator was US Food and Drug Administration (FDA)-approved in 2014 for the treatment of moderate and severe obstructive sleep apnea.  A five-year study indicated that the treatment was effective and improved sleepiness, quality of life and respiratory outcomes.

The carrier's denial of upper airway stimulation device; CPT codes 64568 (Incision for implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator) and 0466T (Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator [List separately in addition to code for primary procedure]) should be reversed.