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

Mental Health
Inpatient hospital

Diagnosis: Overdose
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a woman who was admitted to the hospital. She was brought to the emergency department by ambulance from home. She had a tooth extraction on the prior day and then attempted to overdose on NyQuil, ibuprofen and antibiotics. She reported having thoughts of suicide that morning. Past history included attention deficit disorder, posttraumatic stress disorder, and depression. At the time of presentation in the emergency department, she denied suicidal ideation and reported feeling better. Review of systems was negative for fevers, chills, chest pain, abdominal pain, nausea and vomiting. Vital signs showed blood pressure 120/76, heart rate 108, temperature 98.4 Fahrenheit, and respiratory rate 18. On physical exam, heart was regular, breath sounds were normal, there was no nystagmus, there were no cranial nerves deficits, and the patient was groggy but awake and alert. Electrocardiogram (EKG) showed normal sinus rhythm with mildly prolonged QT interval at 475ms. Labs showed acetaminophen level 58. The patient was admitted with drug overdose/suicide attempt. 

The inpatient hospital admission was not medically necessary.
The patient presented with a drug overdose and concern for acetaminophen poisoning, but she was hemodynamically stable, and by the time she arrived in the emergency department, she no longer reported suicidal ideation. In addition, she had a stable EKG without evidence of significant changes related to the overdose, did not have persistent altered mental status, and was psychiatrically cleared shortly after her presentation. Overall, she did not meet the acuity for inpatient level of care.
The patient could have received N-acetylcysteine at a lower level of care with continued monitoring of mental status, and also been evaluated by psychiatry at the lower level of care. Because she was cleared by psychiatry promptly after presentation, had no markedly abnormal laboratory findings, and had no suicidal ideation when she first arrived, inpatient care was not appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal-Abdominal pain.
Treatment: Inpatient hospital stay.
The health plan denied the Inpatient hospital stay.
Health Plan's decision is overturned. 

The patient was admitted to the hospital on and left against medical advice 2 days after admission, for nausea, vomiting, and abdominal pain. He has a past history of alcohol use, tobacco use, and polysubstance use. On presentation, the patient had used MDMA (also called ecstasy or Molly) and alcohol and hit his head against a wall and lost consciousness during an altercation.  Vitals were unremarkable. Labs noted creatinine 3.2, white blood cell count (WBC)count of 18.9. A computed tomography (CT) scan of the abdomen/pelvis noted hepatic hematomas and gall bladder wall thickening along with a lumbar(L)3 fracture. CT scan of the head and cervical spine were normal. The patient then left against medical advice.

The patient in question does meet medical necessity for the acute inpatient level of care per current literature and standard of care.
The patient in question does meet medical necessity for the acute inpatient level of care per current literature and standard of care. According to Croce et al., Malhotra et al., and Tinkoff et al., the patient had a severe liver laceration along with a lumbar spine fracture and polysubstance use. Due to the patient's traumatic injuries and findings on imaging, the patient required management at the acute inpatient level of care to monitor for further blood loss from the liver laceration as well as possible lumbar spine fracture management. The patient would not have been appropriate for a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I molar relationship, class I canine, moderate lower anterior crowding, moderate upper spacing, overbite--50%, overjet--4 millimeters (mm), and low frenum.
Treatment: D8080 Braces
The insurer denied the D8080 Braces.
The denial is upheld.

The patient is a male.  The request is for dental benefits for orthodontic treatment (braces). X-rays and photos were taken. The patient presents with a class I molar relationship, class I canine, moderate lower anterior crowding, moderate upper spacing, overbite--50%, overjet--4 millimeters (mm), and low frenum.  The main diagnosis is "deep impinging overbite with soft tissue damage" as indicated on the Handicapping Labio-Lingual Deviation (HLD) index   The Health plan denied the claim because the patient did not score a 26 on the HLD index which is required for treatment approval.

No, the proposed treatment of orthodontic therapy (braces) is not medically necessary.
The information submitted does not support a deep impinging overbite with soft tissue damage. These conditions are not reflected in the photos and X-rays.

The claim was denied based on the fact that Handicapping Labio-Lingual Deviation (HLD) index score was less than 26. The required score for treatment approval.  The main diagnosis is "deep impinging overbite with soft tissue damage" as indicated on the Handicapping Labio-Lingual Deviation (HLD) index; this was not supported in the information supplied.  Therefore orthodontic treatment (braces) is not warranted.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urosepsis

Treatment: Full Hospital Admission

The insurer denied coverage for full hospital admission

The denial is upheld

The patient is a male with no significant past medical history. He presented to the emergency department with complaints of a 4 day history of fatigue, high fever, headache. Emergency department labs revealed leukocytosis, macrocytic anemia, hypochloremia, hypokalemia, alkalosis, and acute kidney injury.  Urinalysis was positive for leukocyte esterase. The patient was admitted with diagnosis of urosepsis/ urinary tract infection. Hypokalemia successfully treated, urine culture positive for Escherichia coli. Computed tomography scan and renal ultrasound were both done and were unremarkable. The patient received intravenous Rocephin. He was deemed stable for discharge after a period of medical stability, on oral Cipro for 7 days. The insurer denied coverage for the full hospital admission as not medically necessary. They noted the patients' presentation and lack of severe underlying medical problems that would warrant a full hospital admission. The appeal on behalf of the hospital is noted and read in detail.

 Per Milliman Care Guideline Health (24): 

i)	UTI-RRG: patient fails to meet clinical indications for admission to inpatient care
ii)	Sepsis and other febrile illness, without focal infection - patient also fails to meet clinical indications for admission to inpatient care. No hemodynamic instability, bacteremia, hypoxemia, altered mental status that is severe or persistent, failure of outpatient treatment, new coagulopathy, tachypnea not responsive to observation care treatment.

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dyslipidemia

Treatment: Vascepa (icosapent ethyl)	

The insurer denied coverage for Vascepa (icosapent ethyl)

The denial is overturned

This is the case of a female with a history of diabetes mellitus, polycystic ovarian syndrome, and polymyositis. Cholesterol panel revealed total cholesterol of 163 milligrams (mg)/ decilitre (dl) and Triglycerides of 526 mg/dl. Given her polymyositis, statin therapy was not prescribed. She was treated with vascepa (icosapent ethyl), gemfibrozil and ezetimibe. Repeat cholesterol panel revealed total cholesterol of 187 mg/dl, low-density lipoprotein (LDL) 112 mg/dl, high-density lipoprotein (HDL) 40 mg/dl, and triglycerides (TG) 181 mg/dl.

The American Heart Association (AHA) guidelines recommend intensive statin therapy and Omega 3 fatty acid therapy for the treatment of moderate to severe hypertriglyceridemia. (1) There have been conflicting trial results demonstrating the efficacy of omega 3 fatty acids in reducing atherosclerotic cardiovascular disease (ASCVD) risk in those with hypertriglyceridemia. However, these findings were largely due to differing patient enrollment and differing doses of omega 3 fatty acids. The Reduction of Cardiovascular Events with Icosapent Ethyl - Intervention (REDUCE-IT) trial was a prospective double blind placebo controlled trial that enrolled patients with high cardiovascular risk. Over half of the patients had diabetes and all had statin resistant hypertriglyceridemia. Among patients with elevated triglyceride levels despite the use of statin, the risk of ischemic events and cardiovascular death was significantly lower in the patients treated with vascepa. (2) The AHA science advisory noted that the use of vascepa is an effective and safe option for reducing triglycerides. (3) 

This patient has a history of diabetes and polymyositis, hypercholesterolemia and hypertriglyceridemia. She is unable to take statin therapy. She meets guideline criteria for therapy with vascepa. (4) 

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

The insurer's denial of coverage for Vascepa (icosapent ethyl) to treat dyslipidemia is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Radiopaque lesion
Treatment: Removal of Tumor or Cyst from Jaw or Jaw Bone (benign tumor or cyst of maxilla, requiring intraoral osteotomy)
The insurer denied the Removal of Tumor or Cyst from Jaw or Jaw Bone (benign tumor or cyst of maxilla, requiring intraoral osteotomy)

The denial is upheld.

This patient is a female with a 5 millimeter by 12 millimeter radiopaque lesion at the superior aspect of the maxilla and nasal floor. The plan is to remove the lesion in the operating room (OR). This has been denied due to lack of documentation.

No, the proposed treatment is not medically necessary.
There is no documentation to determine if the patient has a periapical lesion, nasopalatine duct cyst or central giant cell granuloma. Although rare, calcifying epithelial odontogenic cyst should be considered in the differential diagnosis of lesions in the maxillofacial region and anterior maxilla. Radiographically, they appear as unilocular or multilocular radiolucencies with calcifications of variable density in one third to one half of the cases reported. Vitality testing of teeth adjacent to or involved in a cyst-like lesion is mandatory and the final diagnosis could only be performed after histological analysis.  A periapical lesion arises as the result of chronic infection of dental pulp, which then evolves into one of the following types of chronic inflammatory lesion: granuloma, periapical cyst, or scar tissue (although noninflammatory benign and malignant lesions also occur in this area). The definitive diagnosis of these lesions can be made only through histological examination. 

The diagnosis of a cyst can be established when a cavity, lined by epithelium, is present, and a granuloma if the lesion is formed of granulation tissue with epithelial proliferation but without cavitation. A preliminary clinical diagnosis of periapical cyst can be made if all of the following conditions exist: 1) The periapical lesion involves one or more teeth with necrotic pulp; 2) the lesion is greater than 20 millimeters (mm) in diameter or has a cross-sectional area of 200 millimeters squared (mm2); 3) straw-colored fluid is produced on aspiration or on drainage through an access; and 4) the fluid contains cholesterol crystals. 

Further documentation would be needed to substantiate medical necessity.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic intractable migraine headaches.

Treatment: The prescription medication Emgality.

The insurer denied coverage for the prescription medication Emgality.

The denial is overturned. 

This patient is a female child with a history of chronic intractable migraine headaches.  The patient presented to an office visit with her Pediatric Neurology Specialist with a chief complaint of headaches.  Per the visit notes, the patient's headache frequency and intensity has improved with Emgality.  The patient's Pediatric Neurology Specialist recommended that the patient continues to use the prescription medication Emgality. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.  Emgality and other calcitonin gene-related peptide (CGRP) antagonist medications have been shown to be helpful in children.1,2

Does the prescription medication Emgality need/have final approval from the appropriate regulatory bodies for this diagnosis?  No, it is not approved in people under 18. However, this patient is a good candidate for the prescription medication Emgality.
 
This patient's headaches have responded to Emaglity but not to other medications.  The prescription medication Emgality is the best available treatment for this patient at this time.  This medication has already proven effective for this patient.

This patient's Neurologist believes Emgality is likely to be more beneficial than other available medications for this patient's refractory headaches, and this reviewer agrees. The adverse risks are not likely to be increased over other standard treatment.
 
The carrier's denial of coverage for the prescription medication Emgality should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic intractable migraine headaches.

Treatment: The prescription medication Emgality.

The insurer denied coverage for the prescription medication Emgality.

The denial is overturned. 

This patient is a female child with a history of chronic intractable migraine headaches.  The patient presented to an office visit with her Pediatric Neurology Specialist with a chief complaint of headaches.  Per the visit notes, the patient's headache frequency and intensity has improved with Emgality.  The patient's Pediatric Neurology Specialist recommended that the patient continues to use the prescription medication Emgality. 

Emgality has been shown to be helpful for preventing or treating chronic or frequent migraine headaches in adult patients.  There is not enough data yet to support the use in adolescents and children. It is Food and Drug Administration (FDA) approved for 18 years and older.  It is not approved in children or adolescents.     

Despite the fact that it is FDA approved for 18 years old and older, and the patient does not meet this age requirement, the patient is a good candidate for Emgality.  She has been treated for her intractable migraine headaches with topiramate and amitriptyline, but still is having headaches.  She also was tried on Aimovig and Ajovy without significant improvement.  Many medications used in pediatric patients are off-label, since they are often only studied in adults.  

There is literature that supports the use of Emgality in children and adolescents with chronic or frequent migraine headaches, especially when the patient has not had documented improvement. The patient has tried topiramate and amitriptyline, but still has headaches.  She was also trialed on Aimovig and Ajovy without relief. So she was then started on Emgality and per her provider has had improvement with the use of it.
  
Although the risks are not fully known for using Emgality in children and adolescents, the disability associated with chronic, recurrent migraine headaches warrants treatment with Emgality as she has failed multiple other treatment options.  The family understands it is off-label and the risks may not be known, and the treating provider accepts the liability associated with using this medication off-label.  This medication is the best available option and is likely to be more beneficial than any standard treatment options.

The carrier's denial of coverage for the prescription medication Emgality should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic intractable migraine headaches.

Treatment: The prescription medication Emgality.

The insurer denied coverage for the prescription medication Emgality.

The denial is overturned. 

This patient is a female child with a history of chronic intractable migraine headaches.  The patient presented to an office visit with her Pediatric Neurology Specialist with a chief complaint of headaches.  Per the visit notes, the patient's headache frequency and intensity has improved with Emgality.  The patient's Pediatric Neurology Specialist recommended that the patient continues to use the prescription medication Emgality. 

The submitted documentation indicated the patient has trialed amitriptyline as well as topiramate which failed to improve her condition.  The documentation does indicate the patient has trialed Emgality which led to drastic improvement.  The documentation indicated the patient went  from having daily headaches to 1 headache a week.  The physician indicates even though the medication is technically off label due to the patient's age there is nothing approved for pediatric patients for chronic migraines.  The physician indicated the patient is 5 feet 5 inches tall weighing 262 pounds and therefore she should utilize the requested medication.  The documentation detailed the patient has had an improvement in frequency and intensity with the use of Emgality.  She was recommended to continue utilizing this medication given it is well-tolerated.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.  The prescription medication Emgality has final approval from the appropriate regulatory bodies for this diagnosis. This patient is a good candidate for the prescription medication Emgality.  The prescription medication Emgality is the best available treatment for this patient at this time.   

This patient has failed first-line migraine prophylaxis treatments and has had a favorable response to galcanezumab (Emgality).  Off-label therapy in this case is warranted if the prescribing physician and family have weighed the risks and benefits and determined that Emgality is an appropriate therapeutic choice. The adverse risks would not likely be increased over standard treatments and this medication is likely to be more beneficial than any standard therapy.

The carrier's denial of coverage for the prescription medication Emgality should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overjet, overbite, anterior crowding vertical growth pattern, maxillary and mandibular crowding

Treatment: D8080 (braces)

The insurer denied coverage for D8080 (braces).

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care.  The patient's orthodontist identified overjet, overbite, anterior crowding vertical growth pattern, maxillary and mandibular crowding.  The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index, attaining 27 total points.  The insurer has denied coverage for orthodontic treatment as not medically necessary, as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements having attained a score of 10 points on the HLD index.  The orthodontist is appealing the decision on behalf of the patient.

It is evident that the patient exhibits a significant 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, arriving at 27 points to justify orthodontic care.  This reviewer concurs with the index completed by the orthodontist, attaining a total of 27 points on the HLD index (7 overjet, 6 overbite, 10 anterior crowding, 4 labiolingual spread), which is above the threshold of 26 points to support orthodontic care.

Regarding the validity of the HLD 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 cited below.
 
Each of these 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 meet and substantiate the medical/dental necessity of orthodontic care, as it meets the accepted criteria for approval.

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

D8080 braces are considered medically necessary for this patient.

The insurer's denial of coverage for D8080 (braces) is reversed.  Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied tooth restoration on tooth #6. 
The denial is upheld.

The patient is a female who presented to the office of her dental provider for evaluation and treatment of tooth #6. Included for review are previous letters of appeal and denial, a peri-apical radiographic image, multiple pages of American Dental Association (ADA) claim forms, and multiple pages of explanation of benefits. In question is the medical necessity of the planned treatment tooth restoration for tooth #6.

The health plan's determination is upheld.

Based on the provided documentation, tooth restoration on tooth #6 is not medically necessary for this patient. From the provided documentation, the treating provider did not include any diagnosis for the tooth in question and did not provide any objective documentation to support the desired prosthesis, nor did he provide any rationale within his notes explaining what the status of the tooth is. The requested procedure cannot be supported as medically necessary for this patient.