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

Diagnosis: Ankle fracture
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

Patient has a past medical history significant for hyperlipidemia, right ankle fracture, status post (s/p) surgical repair admitted for worsening pain and ulceration at surgical site for removal of right ankle hardware and irrigation and debridement.  

Vitals included: Temperature 36.2 degrees Celsius, Blood Pressure 141/69, Pulse 56, Respiratory Rate 15, oxygen (O2) saturation 96% (percent) on Room Air. Laboratory results included the following: white blood cell count (WBC) 9.0, Hemoglobin (HgB)-14.8, Hematocrit (Hct)-44.2, creatinine-0.8, glucose-98, C reactive protein (CRP)<0.5.

Patient was admitted for removal of infected right ankle hardware and irrigation and debridement. He was empirically started on intravenous antibiotics (vancomycin and Zosyn).  Infectious Diseases consulted for management. Cultures grew Finegolda magna and Staphylococcus epidermidis. Patient remained afebrile, clinically, and hemodynamically stable. He was discharged to continue oral antibiotics (Linezolid x (for) 2 weeks) as an outpatient. 

According to documentation, patient was electively admitted for removal of a failing surgical hardware from a right ankle fracture repair thirty years prior. Surgical hardware removal typically occurs due to infection, mechanical failure, or combination of both. Generally, management requires surgical intervention (removal of hardware, irrigation and debridement) and antimicrobial therapy. Review of medical records including pictures of patient's right ankle supports that the hardware was indeed infected. Moreover, cultures grew two separate bacterial pathogens. Based on these findings, hospital admission was medically necessary to prevent further complications of surgical hardware failure.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

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

Diagnosis: Malocclusion
Treatment: D8080 braces and D8670 monthly visit x (times) 12
The insurer denied coverage for D8080 braces and D8670 monthly visit x (times) 12.
The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, open bite, and anterior maxillary and mandibular crowding. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index attaining 44 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 attaining only 18 points on the HLD (Handicapping Labio-Lingual Deviations) index by internal reviewers. The provider is appealing the decision on behalf of the patient.

Upon review of the submitted documentation (study models were not provided for review) 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, New York State requires 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 completes the second portion of the index arriving at 44 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains 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. 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. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D8080 braces and D8670 monthly visit x (times) 12 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8080 braces and D8670 monthly visit x 12

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, ectopic eruption, anterior crossbite and anterior maxillary and mandibular crowding. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index attaining 28 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 attaining only 10 points on the HLD index by internal reviewers, the provider is appealing the decision on behalf of the patient.

Upon review of the submitted documentation (study models were not provided for review) 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, 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 progran1) 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 completes the second portion of the index arriving at 28 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains 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. 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. 

D8080 braces and D8670 monthly visit is considered medically necessary for this patient.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D8080 braces and D8670 monthly visit x 12 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a history of hypertension and migraine headaches. She presented to the emergency room with a few-day history of left-sided chest pain radiating to the left arm, headache, and nausea. Her vital signs were notable for a blood pressure of 193/105. She was alert and did not appear toxic. The physical exam was otherwise unremarkable. Lab results and a chest x-ray were non-contributory. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The patient was admitted for further treatment and evaluation.
Upon admission to a monitored bed, the patient was treated with oral medications. The next day, the cardiologist evaluated the patient. The unremarkable electrocardiogram (EKG) and cardiac markers were noted, and an outpatient echocardiogram and stress test were recommended. Apparently, the patient refused the outpatient testing and remained as an inpatient. An echocardiogram was completed and was unremarkable. The following day, a stress test was performed and was negative. The entire stay was clinically uneventful, and the patient was discharged. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient admission was not medically necessary for this patient.
Based on a review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG (electrocardiogram) of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no hemodynamic instability, respiratory distress, evidence of heart failure, difficult to control severe pain, or any credible evidence of an acute coronary syndrome. The services provided, oral medications, imaging, stress test, were not at the acute inpatient level of intensity.
Therefore, based on the standard of care, as well as the peer reviewed literature and guidelines cited in the references, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Attention deficit hyperactivity disorder (ADHD). 
Treatment: Quillivant XR (extended release) [methlyphenidate ER (extended release)]. 
The insurer denied Quillivant XR (methylphenidate ER). 
The health plan's determination is upheld. 

This is the case of a young male with attention deficit hyperactivity disorder (ADHD) whose provider is requesting a formulary exception for treatment. The requested medication is Quillivant XR (extended release) (methylphenidate ER). 

Based on the medical and health plan information provided, the patient has not trialed and failed, or has contraindications to, multiple stimulant medications which would be considered formulary covered alternatives. Additionally, there are multiple formulary medications listed (methylphenidate ER, dexmethylphenidate ER, amphetamine-dextroamphetamine mixed salts ER) that are capsules which can be opened and sprinkled on foods for children who may not be able to swallow medications whole. All stimulant medications will have similar side effect and potential benefit profiles, while children will have individualized reactions or response to the various stimulants. A formulary exception is not indicated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraines
Treatment: Aimovig 140 milligrams (mg)/ milliliter (mL)
The insurer denied: Aimovig 140 milligrams (mg)/ milliliter (mL)
The denial is overturned.

The patient is an adult female with migraines who is currently on Aimovig and is doing well from a migraine standpoint with as needed sumatriptan. The provider wishes to continue Aimovig. The request was previously denied as patient had not tried the required formulary alternatives.

The health plan should cover the proposed treatment.

The health plan should cover the proposed treatment as it is a continuation of care. A potential switch to another anti-calcitonin gene-related peptide (CGRP) with slightly different pharmacokinetics could potentially worsen migraines and lead to increased healthcare utilization. There is evidence in the medical literature that insurance driven medication changes negatively impact patient health outcomes. Lastly different anti-calcitonin gene-related peptides have different potential side effects and could lead to lack of compliance.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient admission
The health plan denied inpatient admission. The denial is upheld.

The patient is an adult male with a history of asthma. He presented complaining of three days of progressive wheezing associated with dry cough and nasal congestion.

The patient's vital signs stable. His heart rate was 111. His respiratory rate was 18. Oxygenation saturation was 96% on room air. His exam was remarkable for bilateral wheezing. His pertinent labs included WBC (white blood count) of 22. His chest x-ray was with no acute disease. He had persistent wheezing after nebulizer, solumedrol, and magnesium in the emergency department.

The patient was admitted with asthma exacerbation. Plan of care included nebs, solumedrol, and pulmonary consult.

The following day, the patient's vital signs were stable. His heart rate was 105. His oxygen saturation was 95% on room air. He was deemed stable for change to oral steroids, oral antibiotics, and discharge to home.

This patient was admitted with asthma exacerbation. Vital signs showed tachycardia. He did not have hypoxia. He had persistent wheezing after receiving a nebulizer treatment in the emergency room. Chest x-ray was unremarkable. The MCG (Milliman Care Gudelines) Guideline for Asthma is not met. The patient was hemodynamically stable. He did not have hypoxemia and did not require ventilatory support. He did not have altered mental status. There is no evidence of peak expiration flow measurements. Chest X-ray was negative. He had not failed a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain 

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is the case of a patient that presented to the hospital with intermittent right sided chest pain that was intermittent and worse with exertion. Past medical history was significant for hypertension, coronary artery disease, chronic obstructive pulmonary disease (COPD) and heart failure. On arrival to the hospital, vital signs were stable (blood pressure (BP) 158/72, Pulse 98).  Physical examination revealed no major abnormality.  12 lead electrocardiogram (ECG) revealed sinus rhythm with a right bundle branch block and left anterior fascicular block without  evidence of ischemic ST(segment on ECG) or T wave abnormalities. Serum troponin levels were not elevated (<[less than]0.01 nanograms (ng)/milliliter (ml)). A stress test was attempted on 12/6. Notes indicate could not do perfusion stress. Test was limited by claudication.  Nondiagnostic ECG due to submaximal study. The patient was treated transferred to a tertiary care center for cardiac catheterization and vascular work up.
  
The health plan did act reasonably, with sound medical judgement and in the best interest of the patient. The patient presented and as noted there were no acute ECG or troponin changes supporting an acute event. As the patient previously failed to obtain a stress test as an outpatient, the decision was made to keep the patient inpatient and a stress was attempted. This resulted in an inpatient admission when the patient was transferred for cardiac catheterization. This was an unnecessary delay in providing the planned services.  The admission is thus denied. 

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated prostate-specific antigen (PSA

Treatment: service 81479 (unlisted molecular pathology procedure)

The insurer denied coverage for service 81479 (unlisted molecular pathology procedure)

The denial is upheld

 
Reviewer Findings:

The patient is an adult male with elevated prostate-specific antigen (PSA). He complains of left testicular pain. He then had a radical prostatectomy. He had a history of prostate cancer in the family and a panel for hereditary risk was selected to be performed. The test appears to have been VistaSeq Prostate Panel; however, per submitted lab order, it states that the test was canceled and not performed.

First, the test appears to not have been performed. Secondly, VistaSeq prostate panel is a 13- gene profile intended to test presymptomatic patients and assess their risk. In this case, after a prostatectomy, the utility of the test is unproven. There is no information that a panel is superior to individual tests based on family history. The National Comprehensive Cancer Network (NCCN) Prostate Cancer guidelines recommend testing for at least BRCA1, BRCA2, ATM, CHEK2, PALB2, MLH1, MSH2, MSH6, and PMS2 (gene names) for men meeting specific testing indications. A consensus conference in 2019 addressed the role of genetic testing for inherited prostate cancer. Family history-based indications for testing included testing for BRCA1/BRCA2, HOXB13, DNA mismatch repair (MMR) genes, and ATM. Tumor sequencing with potential findings of germline variants in BRCA1/BRCA2, DNA MMR genes, or ATM as well as other genes, is supported for confirmatory germline testing. Finally, the utility of this test is not prospectively studied, even in pre-diagnosis of prostate cancer. In conclusion, the service 81479 (unlisted molecular pathology procedure) is not considered medically necessary for this patient.

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 service 81479 (unlisted molecular pathology procedure) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient with a past medical history significant for human immunodeficiency virus (HIV), polysubstance abuse, and chronic kidney disease (CKD), who was brought to the emergency department (ED) by Emergency Medical Services (EMS) for evaluation of chest pain, shortness of breath and a cough. Urine drug screening (UDS) was positive for cocaine and cannabinoids. The patient was admitted to the telemetry service under an inpatient level of care for evaluation and treatment of acute heart failure with intravenous (IV) Lasix, acute coronary syndrome (ACS) evaluation, and treatment of bilateral pneumonia with intravenous (IV) antibiotics. Blood cultures were positive. A computed tomography (CT) scan of the chest demonstrated pulmonary edema/pleural effusions. An echocardiogram demonstrated a newly diagnosed severely reduced left ventricular ejection fraction (LVEF)of 15 percent (%) with severe diastolic dysfunction. He was started on guideline-directed heart failure medical therapy. A stress test was negative for infarction (infarct)/ischemia. A Lifevest was ordered for the patient for protection against sudden death. Afterward, the patient left against medical advice (AMA). At issue is the medical necessity of an inpatient stay.

Inpatient admission was medically appropriate, necessary, and in the best interest for the safety of this patient.
This patient presented with signs and symptoms of acute heart failure, ACS, and bilateral pneumonia. His presentation was notable for high risk clinical features including a significantly elevated cardiac troponin and BNP (Brain natriuretic peptide), newly diagnosed acute systolic heart failure indicative of high risk for short-term adverse cardiac events, and positive blood cultures overall warranting inpatient admission. Based on peer reviewed medical literature on acute coronary syndrome (ACS) and acute heart failure management, inpatient admission would be considered standard of care for this patient presenting with high cardiac troponins, chest pain consistent with non-ST elevation myocardial infarction (NSTEMI) and newly diagnosed systolic heart failure to achieve adequate decongestion, determine revascularization needs, telemetry monitoring and initiate guideline directed medical therapy (1-3). Evaluation and treatment of this patient under a lower level of care would have been medically inappropriate and unsafe in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Wound Dehiscence

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

The patient is a child who initially had a myelomeningocele repair. The patient developed wound dehiscence and required admission to the hospital with intravenous (IV) antibiotics and wound care. Vitals signs were pulse 128, temperature 36.6 Celsius (97.8  [degrees] Fahrenheit) (Tympanic), respiratory 28, weight 12.6 kilograms (kg) (27 pounds (lb) 12.5 ounces (oz)), and oxygen saturation (SpO2) 98%. Laboratory shows carbon dioxide (Co2) 19, creatinine (Cr) 0.52, white blood count (WBC) 7.5, hemoglobin (Hgb) 13.4, mean corpuscular volume (MCV) 74.2, and platelets (PLT) 418.

The patient had a complication from a previous surgery, and this was the most appropriate option for treatment. The wound dehiscence in the setting of myelomeningocele repair is a very high-risk issue that could lead to meningitis, or death. This patient was very sick and required close acute inpatient hospitalization. This could not be managed at a lower level of care. The admission in question is supported by standard of care and medical necessity for acute inpatient hospitalization and this would be the most appropriate management option for this patient.

Belfort, M. A., Whitehead, W. E., Shamshirsaz, A. A., Espinoza, J., Nassr, A. A., Lee, T. C., Olutoye, O. O., Keswani, S. G., & Sanz Cortes, M. (2020), "Maternal demographics and mean gestational age (GA) at fetal surgery (25.0  0.7 vs 25.0  0.5 weeks' gestation; P = 0.96), and at delivery (36.5  3.5 vs 37.6  3.0 weeks; P = 0.14), were similar between the single-layer closure (SLC) and three-layer closure (3LC) groups, respectively. The rate of preterm prelabor rupture of membranes (PPROM) < 37 weeks (28% vs 29%; P = 0.9), mean GA at PPROM (32.3  3.4 vs 32.7  1.9 weeks; P = 0.83) and rate of vaginal delivery (50% vs 47%; P = 0.84) were similar for the SLC vs 3LC groups, respectively. In pregnancies that had SLC compared with those that had 3LC, there was a significantly higher incidence of cerebrospinal fluid (CSF) leakage at birth (8/32 (25%) vs 0/17 (0%); P = 0.02) and a significantly lower rate of reversal of hindbrain herniation at 6 weeks postoperatively (18/30 (60%) vs 14/15 (93%); P = 0.02). The rate of infants that met the Myelomeningocele Study (MOMS) criteria for shunt placement or died before 12 months of age (23/31 (74%) vs 7/12 (58%); P = 0.31) and those that required treatment for hydrocephalus by 12 months (15/32 (47%) vs 4/12 (33%); P = 0.42) were similar between the SLC and 3LC groups, respectively."

Alruwaili, A. A., & M Das, J. (2022), "Surgical complications include infections at the site of the lesion, bleeding, delayed wound healing, re-tethering of the spinal cord, and cerebrospinal fluid leakage."                                                         

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.