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

Diagnosis: Hyperlipidemia
 
Treatment: Praluent

The insurer denied coverage for Praluent. The denial is upheld. 

This patient is a woman with a history of diabetes mellitus and hyperlipidemia. She had previously tried atorvastatin and simvastatin, both of which caused muscle aches. She underwent coronary calcium scoring, which yielded a level of 565. Her total cholesterol was 246, triglycerides 130, HDL 72, and LDL 148. Due to her elevated coronary calcium, her physician requested a PCSK9 inhibitor. 

Praluent is not clinically indicated for reducing the risk of first acute cardiovascular events, so called primary prevention, in patients who do not have familial hyperlipidemia or prior clinical atherosclerotic cardiovascular disease. Based on results of the FOURIER and ODYSSEY trials (evaluating evolocumab and alirocumab, respectively), PCSK9 inhibitors may reduce the risk of adverse cardiovascular events, however, these trials were conducted in patients with established cardiovascular disease, not in those simply with the presence of coronary calcifications. Although intuitively appealing, the use of PCSK9 inhibitors in this clinical context is not considered standard 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 Praluent is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: Inpatient Hospital Admission

The insurer denied the inpatient hospital admission. The denial was upheld.   

This is a female patient who presented to the Emergency Department (ED) with complaints of right lower quadrant abdominal pain, diarrhea, and the inability to eat that began four days prior to presentation. Laboratory work up revealed a white blood cell count of 14.1.  A computed tomography (CT) of the abdomen was performed that revealed acute appendicitis and wall thickening of the terminal ileum.  The patient underwent a laparoscopic appendectomy without complications. It was reported that the patient developed a post-operative fever of 101.2. A repeat CT scan of the abdomen was performed with negative results. The patient maintained a period of medical stability and was discharge home with outpatient follow up instructions.

The medical literature indicates that a laparoscopic appendectomy is considered an ambulatory procedure.  The documentation indicated that the patient did have a postoperative fever.  However, after observation, the patient's fever decreased.  The patient underwent additional imaging with no other complications found postoperatively.  The patient improved with stable pain and tolerated a regular diet. There was no evidence of complications such as wound infection, continued ileus or postoperative bleeding. Therefore, the requested inpatient stay would not be considered appropriate.

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

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: Ataxia

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was upheld.

This is a male patient with a history of prostate cancer, cardiomyopathy, congenital heart disease, glaucoma, hypothyroidism, dyslipidemia, and prediabetes. The patient presented to the Emergency Department (ED) with complaints of loss of vision from both eyes and being off balance while ambulating. An electrocardiogram (EKG) was done that showed normal sinus rhythm. A chest x-ray was done with negative results. A computed tomography (CT) scan of the head/brain was performed that revealed no intracranial abnormality. The patient was admitted to the hospital and monitored on telemetry. Opthamalogy consulted the patient. A magnet resonance imaging (MRI) was done that showed no evidence of intracranial mass, hemorrhage, infarct, hydrocephalus, or extra-axial collection. Ophthalmology services noted that the patient had an occlusion of the vasa nervorum with perfusion. Neurology consulted the patient. Fall precautions with physical therapy were recommended.  The patient was stabilized and discharged home. 

Based on the review of the medical record, the patient was hospitalized because of ataxia with working diagnosis of stroke. The patient's workup for a stroke was negative including the brain/head MRI. According to the patient records, there was no clear evidence of acute change in the patient neurological examination. No acute motor, sensory or visual deficit that suggested an acute stroke. According to MCG Health guidelines for stroke, the patient did not meet the inpatient criteria for admission. There was no instability, new focal neurological signs, acute stroke, hemodynamic or cardiovascular compromise or acute prolonged metabolic decompensation or seizure. Therefore, the patient's condition could have been managed in a less intensive setting.

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

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

Diagnosis: Chest pain; asthma
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.
The Inpatient admission was not medically necessary.

The patient is a female. She presented to the emergency room with complaints of chest pain.  It was described more of a tightness in the chest along with wheezing.  She had history of asthma.  

The triage nurse documented that the patient was alert and oriented x 3, calm, in no acute respiratory distress, her temperature 98.6 degrees, pulse 99 regular respiratory rate 20 per minute with a blood pressure 124/86.  Pulse oximetry was 100% on room air.  She had wheezing bilaterally.  Later, the nurse enters the patient was alert and oriented in no acute respiratory distress. She was not noted to be experiencing shortness of breath, compliant with the medication and ready for admission to the floor.  

The patient's laboratory data was unremarkable. The patient's EKG (electrocardiogram) did not show any acute ST-T changes. Chest x-ray was unremarkable for any pathology including consolidation, effusion or pneumothorax.  The emergency room attending physician notes clinical examination states that patient chest examination was unremarkable. Lungs were clear, with normal breath sounds, and no use of accessory muscles.  The patient's WBC (white blood cell) count was 11.2, hemoglobin 12.6, platelet count of 244000. Her chemistry was unremarkable with normal potassium, bicarb in creatinine.  The patient's admission diagnosis was asthma exacerbation.

The patient's clinical presentation did not meet the medical necessity for hospitalization.  The patient's respiratory status was stable, hemodynamically stable, no threatening of the airway. She was calm, alert and oriented, did not appear to be struggling for breathing. She was not in any acute respiratory distress, and there was no hypoxemia documented. Clinical examination was unremarkable.  

Therefore, given the above, the Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems / Other
Dental/Orthodontic Procedure

The patient is a male who presented to the office of his dental provider for evaluation and treatment of his periodontium. Provided for review are previous letters of appeal and denial, previous full mouth radiographic images, one page of American Dental Association (ADA) claim forms, previous periodontal indices, and previous clinical notes. Previous denials have been on the basis that for scaling and root planing to be authorized, there needs to be noticeable bone loss on the radiographs or buildup on the roots which is visible on the radiographs. In question is the medical necessity of the planned treatment of four quadrants of scaling and root planing (4341) for the entire mouth.
From the documentation, the patient has no recordings of bleeding upon probing at any site along the teeth that were probed, no recording of periodontal attachment loss, no radiographic evidence of bone loss beyond typical dimensions for biologic width, and no diagnosis of periodontal disease.

The health plan's determination is upheld.

The requested deep cleaning is not medically necessary for this patient. The utilization of scaling and root planing as a periodontal therapy requires that the patient have evidence of attachment loss. The mere presence of deep probing depths does not indicate that the patient has any attachment loss as periodontal pocketing also occurs due to anatomical variation and is considered to be a psuedopocket. The therapy of scaling and root planing in a patient without periodontal attachment loss has been shown to damage the periodontal attachment and result in attachment loss. For patients who have evidence of attachment loss in the presence of active inflammation and with concomitant pocketing, scaling and root planing is the therapy of choice. Radiographic presence of an intact lamina dura, radiographic evidence of intimate proximity of the bone to the cement-enamel junction (CEJ), no recorded attachment loss, and absence of bleeding upon probing are typically signs of an absence of periodontitis. For this patient, there is no bleeding on probing, no recording of attachment loss, no diagnosis of periodontal disease, and radiographic evidence that negates the presence of attachment loss.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance and alcohol use disorder
 
Treatment: Inpatient detoxification admission 

The insurer denied coverage for inpatient detoxification admission. The denial is reversed. 

This patient is a male and was admitted to this inpatient substance detoxification treatment for alcohol, Xanax, and heroin detoxification. He had withdrawal symptoms including tremors, joint pain, irritable mood, and anxiety. He reportedly had been drinking 1/2 pint of vodka per day with 6 beers for with over three decades, using 4 mg of Xanax per day for more than a decade, and inhaling 3 bags of heroin per day for over a decade. He had past reported multiple inpatient substance detoxification and rehabilitation treatments. He also reportedly had a diagnosis of bipolar depression in addition to his alcohol, Xanax, and heroin use disorders. He also had past psychiatric hospitalizations for past reported suicide attempts. He was put on a Librium protocol for detoxification and was discharged with a referral to substance residential rehabilitation treatment scheduled.

The insurer denied coverage for inpatient substance detoxification treatment. This reviewer disagrees with the decision to deny coverage for inpatient substance detoxification treatment as the as the chart notes did provide enough specific evidence to support that he needed this level of care. The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. In this case this patient had use of multiple substances including large amounts of alcohol, Xanax, and heroin and was at risk for death from overdose as result of this use. 
According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use multiple serious substances of use despite multiple past inpatient substance detoxification and rehabilitation treatments, and he needed two detoxification medications including Librium and Clonidine to modify withdrawal from alcohol, Xanax, and heroin. Also, he had reports of long term multiple substances of use and was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including severe, complicated, and life threatening withdrawal such as delirium tremens due to the large amount of alcohol and Xanax use. Also, he likely would have relapsed again as evidenced by relapsing after past treatments.
As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance detoxification. It did not appear that the health care plan acted reasonably or in the best interests of the patient.

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

Diagnosis: Low back pain
 
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial upheld.

This patient is a - male with complaints of back pain.  He was evaluated in the Emergency Department (ED). He reported lifting a box of coins at work.  He had difficulty ambulating secondary to pain.  He was admitted to the hospital with the diagnosis of low back pain. The physical examination was significant for thoracic tenderness and inability to stand up.  He had to walk with a tilt. He received intravenous (IV) Morphine and Ketorolac. He was discharged a day after presenting and recommended to take Salonpas Lidocaine patch with Motrin.

The man presented with a one week history of back pain.  He did not have radicular signs nor evidence of "red flags", i.e, infection, nerve compression, fracture, or tumor. He received IV medication and reported improvement with VAS markedly reduced. The record demonstrates he had less pain.  He had no positive physical findings.  There were no focal deficits. He did not require ongoing pain management, invasive testing or operative procedures.  He did not require treatment for other underlying medical conditions.  He was able to tolerate oral medications. 

There was thus no medical condition to warrant the level of care provided. (i.e. response to initial pain medications).  There was no reason why he could not have received oral pain medication and be discharged. There were no extenuating circumstances to substantiate acute admission and length of stay as provided. 

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

Back Pain
Pain Management

The patient is a male with a long-standing history of (h/o) lower back pain. He has a complex medical history of gait dysfunction and weakness in the lower extremities. His neurology work-up revealed chronic innervation of right iliopsoas muscle without clear differentiation of femoral nerve versus right L2-L3 nerve root. His pain is localized in the lower back without any radicular symptoms in the lower extremities. A lumbar magnetic resonance imaging (MRI) scan showed multi-level degenerative changes, stable L4 vertebral body deformity with Modic type 2 changes, no central canal stenosis. He has tried spinal injections, physical therapy (PT) and pain medications without adequate pain relief. His physician recommended this Intracept procedure for his persistent back pain. The health plan denied the procedure as not medically necessary. The issue is whether this Intracept procedure is medically necessary.

The health plan's determination is overturned. This Intracept procedure is a new, minimally invasive intervention with radiofrequency ablation of the basivertebral nerves for patients who suffer chronic pain generated from the vertebral body. Recent clinical studies have provided strong evidence that this intervention is effective in vertebrogenic pain. According to the inclusion and exclusion criteria of these recent clinical studies, this patient is a candidate for Intracept procedure. This patient has other medical conditions. However, his low back symptomatology is consistent with L4 vertebrogenic pain. He has tried conservative treatments including spinal injections and PT without success. Given this clinical scenario, the patient is a candidate for the Intracept procedure. Without further intervention, this patient will continue to suffer disabling chronic back pain, and he will most likely require more doctor's visits, hospital stays and chronic use of pain medications. Recent clinical studies have provided strong evidence that this intervention is effective in vertebrogenic pain. Therefore, it is medically necessary to consider the Intracept procedure as the next step treatment.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems - Other
Dental/Orthodontic Procedure

The patient is a male with impacted tooth #27. He presents with a skeletal Class II malocclusion and moderate crowding. He has a significant overjet and 100% deep bite. He is treatment planned for 24-30 months of orthodontics with a surgical exposure and ligation of impacted #27 to address the crowding and to create space to bring the impacted tooth into the arch, but treatment was denied due to lack of medical necessity.

The health plan's determination is overturned.

The comprehensive orthodontic treatment is medically necessary for this patient. Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology. The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth. These could be immediate problems and it is in the best interest of the patient to treat this before problems occur. Since there is not room for tooth 27 to erupt on its own without orthodontics it will almost certainly cause damage to one of the adjacent teeth.
If left untreated the damage that can occur to the patient's teeth will be more time consuming to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior Crowding

Treatment: Braces (comprehensive orthodontic treatment) and Adjustments for Braces (periodic orthodontic treatment visit)

The insurer denied the Braces (comprehensive orthodontic treatment) and Adjustments for Braces (periodic orthodontic treatment visit). The denial was upheld.

This is a female patient who consulted an orthodontist for orthodontic care. Several imaging studies were performed that included lateral cephalometric radiograph, panoramic radiograph, and montage of extraoral and intraoral clinical images. The orthodontist completed the Handicapping Labio-Lingual Deviation (HLD) index which resulted in 21 total points to support orthodontic care. It was determined that she had anterior crowding. 

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, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary. 

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 21 points to justify orthodontic care.  This reviewer concurs with the index completed by the orthodontist attaining a total of 21 points on the HLD index 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 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. 

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.  The carrier's denial of coverage for braces (comprehensive orthodontic treatment) and adjustments for braces (periodic orthodontic treatment visit) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Schizophrenia 

Treatment: Continued Mental Health Inpatient Admission

The insurer denied the Continued Mental Health Inpatient Admission. The denial was upheld. 

This is a male patient with a history asthma, schizophrenia, bipolar disorder, and chronic alcohol abuse. It was reported that the patient had been in the Emergency Department (ED) the day before presentation due to a witnessed seizure but was later discharged home. He presented to the ED accompanied by his mother for a psychiatric evaluation. It was reported that the patient had been talking to himself, hearing voices and having hallucinations telling him to hurt others. It was noted that he had been using alcohol and cannabis.  Psychiatry consulted on the patient. His treatment plan included Risperidone, Depakote, and Benadryl. He was discharge when he was deemed stable. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior are candidates for inpatient treatment.  In this case there were no reports of further serious psychotic symptoms such as delusions, hallucinations, or disorganized behavior, suicidal or homicidal ideation, intent, or plan, manic symptoms, aggressive, threatening, self-injurious, or agitated behavior, withdrawal symptoms or acute medical instability.  Notes reported that there were no complaints voiced.  Notes from several weeks into his hospital course reported that he had organized thinking, denied suicidal or homicidal ideation or self-harm, and that he had no behavioral or medical issues, was calm, cooperative, denied auditory or visual hallucinations, suicidal or homicidal ideation or self-harm.  Further documentation reported that he had no behavioral issues and that he was calm, cooperative, denied suicidal or homicidal ideation, auditory or visual hallucinations, and that he took his medications and ate meals. Notes also reported that he had no complaints, denied auditory or visual hallucinations or perceptual disturbances and he reportedly refused the recommendation for substance and alcohol rehabilitation then.  

Continued inpatient psychiatric treatment in this hospital was not medically necessary.  It appeared that the health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.

The carrier's denial of coverage for the mental health inpatient admission is upheld.  The medical necessity is not substantiated.