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

Diagnosis: Malocclusion
Treatment: Full braces and monthly braces adjustment visits
The insurer denied coverage for full braces and monthly braces adjustment visits.
The denial is upheld.

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 orthodontist identified several clinical findings including upper arch length deficiency and has recommended orthodontics. 

Upon review of the submitted documentation (study models were not provided for review) 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 the use of an orthodontic 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 provide the required documentation. The documentation provided is insufficient and inadequate to approve care. 

Regarding the validity of the HLD (Handicapping Lingual Deviation) Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. 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.

Clinical documentation provided for review is inadequate and does not substantiate the medical/dental necessity of orthodontic care.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for full braces and monthly braces adjustment visits is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, congestive heart failure and osteoarthritis
Treatment: Social Day Care (SDC) - Daily: 1 day(s) - 3 day(s) per week- a total of 3 days per week
The insurer denied coverage for SDC - Daily: 1 day(s) - 3 day(s) per week- a total of 3 days per week.
The denial is overturned.

This is an adult female with dementia, congestive heart failure and osteoarthritis. She lives alone in a private home. She is currently receiving consumer directed personal care services (CDPCS). She was also receiving social day care (SDC) 3 days/week, which was discontinued by the insurer. Under review is the request for reinstatement of SDC- 3 days/week.

The Uniform Assessment System (UAS) report that the patient's cognitive status is described as moderately impaired- "Decisions consistently poor or unsafe; cues/supervision required at all times." She requires extensive assistance for activities of daily living including bathing, personal hygiene, dressing, and toilet transfer/use. She is frequently incontinent of bladder and continent of bowel. She also requires extensive assistance for bed mobility and ambulation. She is currently receiving CDPCS totaling 132 hours/week (12 hours/day 7 days/week and 12 hours/day 4 days/week).

This physician generally agrees with the insurer that "SDC services cannot substitute for the personal care services that you require to support your physical needs." However, the SDC services were effectively used for this purpose. It was unreasonable for the insurer to abruptly discontinue SDC without substituting additional CDPCS of 12 hours/day for 3 days, which is medically necessary for the patient's health and safety as well as allowing her to continue living at home.

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

The insurer's denial of coverage for social day care (SDC) - Daily: 1 day(s) - 3 day(s) per week- a total of 3 days per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

This patient is a previously healthy adult female who presented to the emergency department with the complaint of abdominal pain of one-day duration. The patient's examination revealed abdominal tenderness. Her vital signs identified a normal temperature at the time of presentation. The heart rate was 107 beats per minute. The white blood cell count was elevated at 16 thousand. Surgical consultation was obtained with tenderness noted in the right lower quadrant. Abdominal computed tomography (CT) scan was completed showing findings consistent with acute appendicitis. 
The patient was admitted to the hospital and was started on intravenous antibiotics. The patient then underwent laparoscopic appendectomy. Purulent fluid was noted and aspirated from the pelvis. The patient was monitored following surgery and 
remained stable. She was discharged from the hospital the following day after the initial surgical recovery with instructions for surgical follow-up.

The health plan rationale for denial is that there is no documentation of a need for an inpatient level of care and the care rendered could have been provided without admission to the hospital. This letter references the Milliman Care Guidelines (MCG).

The inpatient hospital admission was not medically necessary.

Inpatient care was not medically necessary. The Plan's reason for denial is that the patient had a procedure with no complications that would require inpatient admission. Specifically, the patient did not need inpatient care prior to surgery. There was not a complex surgical approach or situation anticipated. The patient was not at high risk for adverse perioperative event. There was not a drug related risk, abnormal heart condition or breathing status. Vital signs were normal. There were not complications of surgery, and the operation was not extensive or prolonged. This rationale is supported by the submitted medical records. Inpatient care for this patient was not medically necessary based on the standard of care. The care provided could have reasonably and appropriately been provided with a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Genitourinary/Kidney Disorder/Acute Kidney Injury.
Treatment:  Inpatient Hospital.

The health plan denied the requested inpatient stay. The health plan's determination is upheld.

The patient is a male, who initially presented with concerns of dizziness. Pertinent history included hypertension. Initial vital signs revealed a temperature of 97.5 F (Fahrenheit), a heart rate (HR) of 87 bpm, a blood pressure (BP) of 109/79 millimeters of mercury (mmHg), a respiratory rate (RR) of 20/minute, and a peripheral capillary oxygen saturation (SpO2) of 100% (percent) on room air. Initial examination documented the patient as alert and oriented without focal physical findings. An electrocardiogram (EKG) revealed normal sinus rhythm. Initial laboratory testing revealed a white blood cell count (WBC) of 5.0, a hemoglobin of 13.9, platelets of 203, a sodium of 138, a potassium of 3.3, a blood urea nitrogen (BUN) of 20, a creatinine of 2.89, a glucose of 123, a magnesium of 1.2, a total bilirubin of 3.3, an aspartate aminotransferase (AST) of 75, and an alanine aminotransferase (ALT) of 90. The patient was placed in the hospital thereafter with an impression of acute kidney injury versus unknown chronic kidney disease. The treatment plan included intravenous fluids, electrolyte replacement, a computed tomography (CT) of the abdomen, renal sonogram, and a urinalysis. There were no new events overnight. The patient noted he had been doing heavy lifting for 1-2 weeks and experienced bilateral calf soreness. Hemodynamics were stable. Serum creatinine decreased to 1.39, potassium to 3.0, and the creatine kinase (CK) was 1021. The patient repeatedly requested to be discharged and eventually left against medical advice.

At issue is the medical necessity for the inpatient stay.

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

Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at an alternate level of care.

The patient had a history of hypertension and presented to the emergency department with dizziness. Initial evaluation revealed stable hemodynamics and laboratory testing revealed a creatinine of 2.89, a potassium of 3.3, and a magnesium of 1.2. An EKG did not reveal any conduction abnormalities related to these electrolyte abnormalities nor were severe symptoms contributed to such. The treatment plan included intravenous fluids. Following observation care, serum creatinine markedly improved to 1.39, oral intake was not an issue, and the patient requested to be discharged. No other issues or complications requiring ongoing inpatient care were documented.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Atopic Dermatitis. 
Treatment: Adbry. 

The insurer denied coverage for Adbry. 

The denial is Modified. 

The patient is a diabetic adult with a diagnosis of atopic dermatitis.  The condition is exacerbated by prurigo nodularis.  The patient has been treated with Dupixent and topical therapy with Opzelura and topical steroids.  The request is for Adbry with continuation of topical Opzelura and discontinuation of Dupixent.  

The patient has atopic dermatitis with prurigo nodularis.  Dupixent is Food and Drug Administration (FDA) approved for both conditions.  It is unclear from the provided documentation the exact length of treatment with Dupixent.  In light of the lack of appropriate clearance of the atopic dermatitis, the use of Adbry would be a reasonable next management step with discontinuation of Dupixent.  The simultaneous use of Adbry and Dupixent would not be within the medical standard. Topical therapies, steroids or Opzelura, may be required for breakthrough atopic lesions while on Adbry but this cannot be determined until the patient has had an adequate trial of Adbry monotherapy.  

Thus, the use of Adbry monotherapy is approved with the documentation of failed therapy with Dupixent.   Should Adbry inappropriately control the patient's symptoms, and with appropriate documentation of failure of topical steroids and tacrolimus or pimecrolimus to treat residual flares, the use of Opzelura topical may be and alternative topical adjuvant.  It is within the standard of care for the patient to treat with Adbry monotherapy and use topical steroids for any breakthrough flares, should they occur.  

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

The insurer's denial of coverage for the Adbry is modified. Medical Necessity is substantiated for the patient to treat with Adbry monotherapy and use topical steroids for any breakthrough flares, should they occur.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Possible Diverticula

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned.

The patient is an adult female with a history of abdominal pain, hyperlipidemia, and asthma. The patient was noted to have left sided abdominal pain radiating to the flank. The patient denied nausea, vomiting, or diarrhea. The patient was afebrile and hemodynamically stable. The patient's physical examination (exam) revealed left upper quadrant (LUQ) and left lower quadrant (LLQ) pain. There was no evidence of rebounding or guarding. The computerized tomography (CT) scan of the abdomen and pelvis revealed tiny diverticula or microperforations. The treating provider ordered inpatient admission.

The admission was medically necessary secondary to the presence of complicated diverticulitis with the presence of possible microperforations noted on CT scan of the abdomen and pelvis. The patient was at risk of developing sepsis.

"Diverticulitis is a prevalent gastrointestinal disorder that is associated with significant morbidity and health care costs. Approximately 20% (percent) of patients with incident diverticulitis have at least 1 recurrence. Complications of diverticulitis, such as abdominal sepsis, are less likely to occur with subsequent events. Several risk factors, many of which are modifiable, have been identified including obesity, diet, and physical inactivity. Diet and lifestyle factors could affect risk of diverticulitis through their effects on the intestinal microbiome and inflammation. Preliminary studies have found that the composition and function of the gut microbiome differ between individuals with vs without diverticulitis. Genetic factors, as well as alterations in colonic neuromusculature, can also contribute to the development of diverticulitis. Less-aggressive and more-nuanced treatment strategies have been developed. Two multicenter, randomized trials of patients with uncomplicated diverticulitis found that antibiotics did not speed recovery or prevent subsequent complications. Elective surgical resection is no longer recommended solely based on number of recurrent events or young patient age and might not be necessary for some patients with diverticulitis complicated by abscess. Randomized trials of hemodynamically stable patients who require urgent surgery for acute, complicated diverticulitis that has not improved with antibiotics provide evidence to support primary anastomosis versus sigmoid colectomy with end colostomy. Despite these advances, more research is needed to increase our understanding of the pathogenesis of diverticulitis and to clarify treatment algorithms." (Strate, et al, 2019)

Based on the above, the insurer's denial must be overturned. 

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

The medical necessity for the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Otezla
The insurer denied Otezla.
The denial is overturned.

The patient is an adult female diagnosed with moderate to severe psoriasis involving the trunk and extremities and guttate psoriasis. She has tried and failed topical medications including halobetasol, Clobetasol, triamcinolone, calcipotriene and tacrolimus. The treating provider is now requesting approval of Otezla. The request was denied so the provider is appealing the denial.

The proposed treatment with Otezla is medically necessary.

The patient has already tried and failed multiple topical treatments and acitretin, and the medical records indicate that the disease has worsened.  

Per Saleh D, et al (2022), "Approximately 2% [percent] of the world population is afflicted with psoriasis; in the United States and Canada, the prevalence is as high as 4%. In general, psoriasis has a bimodal peak of onset. Onset can peak at 20 to 30 years of age and 50 to 60 years of age. Guttate psoriasis accounts for less than 30% of all total cases of psoriasis. It occurs equally in both genders and is more common in children and adolescents than adults over the age of 30." Saleh writes that 40% of guttate lesions progress to plaque type and patients with this disease require treatment options.  

Per Chambers R, et al (2019), "Despite the fact that the appearance and clinical course of guttate psoriasis is known to differ from that of chronic plaque psoriasis, many studies treat patients with these diseases as one group. Although there are studies that include patients with guttate psoriasis, they are seldom stratified separately to different treatment groups." 

Since there are not well-defined studies for treatment of just guttate psoriasis, and because 40% of these patients progress to plaque psoriasis, and because this patient has already tried and failed conventional therapy, Otezla is medically necessary.  

Afra TP, et al (2019) writes, "The efficacy and safety of apremilast were established through well-conducted clinical trials which showed superior efficacy over placebo. Unlike the clinical trials that followed strict protocols in patient follow-up and treatment plan, the real-world data have revealed even better efficacy with the achievement of Psoriasis Area and Severity Index (PASI)-75 in half of the studied population [5,6] (c.f. one-third in ESTEEM trials). Apremilast was also found to improve psoriasis at difficult sites like palmoplantar, nails, and scalp."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee osteomyelitis. 
Treatment: Continued Stay in Subacute Level 2 Rehabilitation. 

The insurer denied Continued Stay in Subacute Level 2 Rehabilitation. 
The denial is upheld. 

The patient is an adult male with a past medical history of anemia, neurogenic bladder and paraplegia who presented to the hospital with nausea, vomiting and cough. He was diagnosed with osteomyelitis of the left knee. He was managed with IV (intravenous) antibiotics and discharged to a subacute rehab facility. Continuation of his stay was denied coverage by the health plan and is being reviewed upon appeal. 

The continued subacute rehab stay was not medically necessary. 

The patient was hospitalized with knee osteomyelitis and discharged to the subacute rehab facility for IV (intravenous) antibiotics and rehabilitation. As of the dates of service under review, he has plateaued with the rehabilitation provided. He continues to require assistance with mobility and ADLs (activities of daily living). He has remained medically stable. As of the dates in question, he no longer required daily skilled rehabilitation or skilled nursing. His care could be provided in a less intensive setting. 

Therefore, given the above, the continued subacute rehab stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: obstructive sleep apnea
Treatment: Breathing Assist Machine (BiPAP) 
The insurer denied Breathing Assist Machine (BiPAP). 

The health plan's determination is overturned. 

This is a female with a medical history of hypertension who was found to have obstructive sleep apnea on a split night polysomnography and positive airway pressure (PAP) titration showing that the patient has severe obstructive sleep apnea (OSA) with an apnea-hypopnea index (AHI) of 83.4 events/hour.

Durable Medical Equipment: Breathing Assist Machine (BiPAP) is medically necessary for this patient.
As per the clinical documentation provided, the patient has a split night polysomnography and positive airway pressure (PAP) titration showing that the patient has severe obstructive sleep apnea (OSA) with an apnea-hypopnea index (AHI) of 83.4 events/hour. As per her PAP titration study, it was noted that her apnea-hypopnea events were not controlled with continuous positive airway pressure (CPAP). She was subsequently titrated to a bi-level positive airway pressure (BiPAP) pressure of 21/15 cmH2O (centimeters/water) to adequately control her obstructive apnea-hypopnea events.
BiPAP can be considered in the management of OSA in cases where high pressure is needed and the patient experiences difficulty exhaling or controlling apnea-hypopnea events against a high fixed pressure. In this type of situation, it is reasonable and in accordance with the American Academy of Sleep Medicine (AASM) guidelines for the treatment of OSA to prescribe BiPAP. The use of BiPAP has been proven to be effective for treating this member's sickness or condition, as shown by published peer-reviewed guidelines. Therefore, the requested Durable Medical Equipment: Breathing Assist Machine (BiPAP) is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD) exacerbation

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient has a history of asthma, chronic obstructive pulmonary disease (COPD) and hypertension who presented to the emergency department (ED) with complaints of substernal chest pain, shortness of breath and a productive cough. The patient also reported some emesis.

Vital signs at presentation to ED - Temperature 97.7 degrees Fahrenheit, Heart Rate 83, Respiratory Rate 18, Blood Pressure 187/107 millimeters of mercury (mm Hg). Oxygen saturation was 98 percent on room air. By the time the patient arrived at the ED the chest pain had subsided and there was no acute distress. Lung exam revealed bilateral wheezes. The patient was alert and oriented times 3. White blood cell (WBC) count was 10,400, electrolytes were within normal limits and chest x-ray had no acute infiltrates. There were no acute ischemic changes on the electrocardiogram (EKG).

The patient was treated with Magnesium, bronchodilators via nebulizer, oral steroids, and oral Doxycycline. The patient was admitted with the diagnosis of COPD Exacerbation. As per a History & Physical (H&P) note his vital signs were normal, and he was in no acute distress. The lungs had improved with treatment in the ED, they were clear. The Respiratory Virus Panel was negative. There was a mild elevation of D Dimer to 275. The findings of a Ventilation Perfusion (V/Q) scan were consistent with pulmonary embolism. Echocardiogram did not reveal any right heart strain. Oral anticoagulants were started. Steroids, bronchodilators, and oral antibiotics continued. The patient remained stable after admission, was afebrile and hemodynamically stable. No hypoxia noted. WBC increased to 18,000 the next day, likely a steroid effect. The patient remained stable after admission and was discharged home on oral medications.

This patient did not need acute inpatient hospitalization. The patient could have been placed in Observation status while diagnostic testing and treatment were initiated. The COPD was mild. He improved with treatment in the ED and the lungs were clear on physical exam as per H&P. The patient was not hypoxic and was hemodynamically stable. The patient was tolerating oral food, fluids and medications. This patient's Pulmonary Embolism was also not life threatening. There was no hypoxia documented and no tachycardia. The patient was treated with oral anticoagulants. and did not need acute hospitalization for treatment of his Pulmonary Embolism.

This patient could have been under observation status (which could be for up to 48 hours). Once stable, the patient should have been discharged on oral medications with close follow up in an outpatient setting.

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

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