Persius/hicric huggingface dataset:
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 maxillary and mandibular crowding, and anterior crossbite (mandibular left canine). The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the requirements of the HLD index attaining 17 points by internal reviewers when 26 points are required for approval. The orthodontist is appealing on behalf of the patient.

Upon review of the submitted documentation, 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, and HLD 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 claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify 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.

The denial is overturned as the clinical circumstance as presented does meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval.

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

Diagnosis: Traumatic Brain Injury
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission
The denial is upheld

This case involves a child who presented to the Emergency Department. The patient was being transferred from another facility after falling backwards approximately 3 feet. There was concern for subdural hematoma. There was no loss of consciousness during the injury. It was noted a Computed Tomography (CT) scan of the head showed posterior scalp hematoma with questionable slightly hyperdense thickening of the anterior falx with a very thin subdural hematoma unable to be excluded. The patient was transferred for trauma surgery evaluation. Examination noted a large hematoma in the occipital region. History and physical reported the patient required intensive care due to impairment. Neurosurgical consultation reported review of prior imaging was felt to most likely represent a thin parafalcine subdural hematoma. It was noted the patient was irritable with no focal deficits on neurological examination. The patient was recommended for Keppra prophylactic dosing for 7 days. Neurosurgery follow-up indicated the patient remained stable and was eligible for downgrade with decreased frequency of neurological checks. Discharge summary reported the patient remained hemodynamically stable throughout the admission. The patient was discharged with a plan to complete Keppra 7-day course for seizure prophylaxis in the setting of subdural hematoma. The patient was discharged home. 

Milliman Care Guidelines recommends inpatient admission when there is hemodynamic instability; post-resuscitation or presenting Glasgow coma scale score of less than 13; worsening of neurologic function post presentation; new focal signs on neurologic examination; new signs or symptoms that are severe, or persist despite observation care; altered mental status that is severe or persistent; evidence of increased intracranial pressure; new or presumed new intracranial pathology on imaging that requires intervention or monitoring beyond the observation care time frame; Cerebral Spine Fluid (CSF) leak; recurrent seizures; significant respiratory or cardiac abnormalities secondary to brain injury; and/or increased intracranial pressure or cerebral edema monitoring. In this case, the patient had a head injury with concern for subdural hematoma. However, the patient did not have neurological deficits and remained hemodynamically stable throughout the stay. Treatment could have been rendered under observational level of care. As such, the inpatient hospital admission was 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 the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: rectal bleeding
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

This case involves an adult under review for a denied hospital stay. The emergency department (ED)note reported the patient had complaints of rectal bleeding and multiple episodes of diarrhea. The patient also reported fainting with several minutes of loss of consciousness. Past medical history was significant for hemorrhoids status post banding. There is also a history of gastric bypass and abdominoplasty. The rectal exam noted a small amount of dark red blood.  There were concerns for complications from hemorrhoid band ligation. The treatment plan was for labs and an admission. The hospital records note that the patient had acute blood loss anemia with a hemoglobin of 10.5. Flexible sigmoidoscopy revealed ulcers and no bleeding hemorrhoids. The patient was discharged.

Milliman Care Guidelines (MCG) recommends inpatient admission for lower gastrointestinal bleeding when there is evidence of ongoing active bleeding to include decreasing hematocrit.  In this case, the patient had evidence of bleeding on rectal examination. In addition, there was decreasing hematocrit documented in the setting of recent surgical intervention. Therefore, hospital admission would have been supported. As such, the request for hospital admission was considered medically necessary.

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 hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth #3 infection. 
Treatment: Cleaning Inside Roots of the Back Tooth (For Tooth #3). 

The insurer denied: Cleaning Inside Roots of the Back Tooth (For Tooth #3). 
The denial is overturned. 

The patient is an adult male. The request is for root canal therapy for tooth #3, which has an infection in it. The health plan's prior denial of coverage was due to the tooth not being an anchor tooth for a bridge or partial denture. The denial is being appealed. 

The requested health service is medically necessary. 

Tooth #3 is stated to have an infection in it requiring a root canal procedure to treat it. Unless the infected nerves are removed, this tooth will continue to be painful. This tooth has plenty of tooth structure remaining, and it also has good bone (periodontal) support. There is no restorative or periodontal reason why this tooth should not remain a functioning tooth. It needs the infected nerve removed to stop the discomfort to the patient. Without the root canal procedure, the only thing that can be done is to extract this tooth. Extracting this tooth will create other problems. The tooth behind it, tooth #2, will most probably, over time tilt forwards into the space created by the 
extraction. This will make that tooth harder to keep clean and will probably become a food trap, because of the increasing tilt it will have. Therefore, removal of tooth #3 will start a chain reaction in the upper right quadrant, causing tilted teeth in jeopardy of decaying. Keeping tooth #3 by performing the needed root canal procedure is the most conservative treatment and it has medical necessity to prevent this patient's dentition from shifting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Right-Hand Pain and Swelling
Treatment:  Inpatient admission

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

This is an adult female with past medical history significant for hypertension and asthma, who presented to the emergency room with complaints of right-hand pain and swelling after being punctured with glass. Vitals on presentation included: Temperature 98.5 degrees Fahrenheit, Blood Pressure 160/103, Pulse 89, Respirations 16, O2 (oxygen) saturation 100% (percent) on room air. Laboratory results included the following: white blood count (WBC) 9.1, hemoglobin (Hgb) 14.5, hematocrit (Hct) 42, glucose 90, creatinine 0.9. The patient was started empirically on intravenous (IV) antibiotics (vancomycin and ceftriaxone). X-ray of the right hand was negative for fractures/dislocation/abnormalities. Surgery was consulted and deemed no surgical intervention was required. Infectious Diseases also evaluated patient. The patient remained afebrile, hemodynamically and clinically stable. She was discharged to continue oral antibiotics (doxycycline and Augmentin) as an outpatient.       

According to documentation, the patient was admitted following a right middle finger injury.  Otherwise, she was afebrile, stable hemodynamically. Laboratory values were unremarkable including normal WBC. The patient showed no evidence of a disseminated infection, and no surgical intervention was required. Based on these findings, the patient did not fulfill criteria for acute inpatient admission. The patient was medically stable for observation level of care.

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

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

Diagnosis: Unstable angina.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is overturned.

This is an adult with a history of multivessel coronary artery disease and seven previously placed stents that presented to the hospital complaining of left sided chest pain radiating to the jaw similar in character to the pain he had at the time of a previous myocardial infarction. The patient also reported accompanying dyspnea. Past medical history was relevant for hypertension and hyperlipidemia. Upon arrival, the patient had stable vital signs and a normal physical examination. 12 lead electrocardiogram (EKG) revealed normal sinus rhythm with nonspecific T wave changes. Serum blood testing revealed no significant abnormality. The patient was admitted for observation and treatment and continued to complain of chest pain despite treatment with nitrate and beta blocker therapies. Cardiac catheterization was performed and revealed in-stent stenosis of the proximal right posterior descending and posterolateral coronary arteries. Drug eluting stents were successfully placed in the aforementioned vessels. The procedure was uncomplicated, and the patient was discharged the following day.

This patient presented with unstable angina. There was a history of multivessel coronary disease and previous percutaneous coronary intervention. The pretest probability of coronary artery disease related symptoms was high. (Reference 1) The patient had a high risk of developing a major adverse cardiovascular event based on the HEART (History, EKG, Age, Risk factors, and troponin) score risk scale. (Reference 2) A complete work up was performed, and the patient underwent cardiac catheterization and stent placement to the right, posterior descending and posterolateral arteries. Discharge was the following day.  

In an expert consensus document focused on length of stay following coronary intervention, Seto and colleagues reported that hospital admission was more likely in patients with a history of previous coronary intervention. (Reference 3) In conclusion, inpatient hospital admission was medically necessary.

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 inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical fracture
Treatment: Hospital-to-hospital transfer via air ambulance 
The insurer denied coverage for hospital-to-hospital transfer via air ambulance. 
The denial is upheld.

Air ambulances provide rapid transportation for those who are seriously ill or injured. Air transport has been studied mainly in trauma patients and has been shown to improve symptoms by decreasing time interval from injury to definitive intervention. For non-trauma patients, air transport may have the benefits of time savings, airway and ventilatory management, and critical care delivery for those patients that need it. 

Per the clinical documentation, this patient presented as a trauma activation, after crashing a dirt bike, to a hospital. The patient had a Computed Tomography (CT) scan of the cervical spine that demonstrated fractures of the Cervical (C)5 - C7 transverse processes, medialization of the right vocal cord, and soft tissue gas from the thyroid cartilage to the trachea. The patient presented with hoarseness. Vital signs were within normal limits. The Glasgow Coma Scale (GCS) was 15. There was a need for transfer as specialist services were not available at the original hospital. The patient was intubated prior to being transferred to a different hospital that could provide services. Air transport was necessary as the patient was intubated. However, transport was not to the closest facility that could provide appropriate services for this patient. Per provided clinical documentation, the health plan acted reasonably, and the requested service was not medically necessary. 

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 the hospital-to-hospital transfer via air ambulance is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 diabetes
Treatment: Vascepa 1gm (gram) Capsule
The insurer denied: Vascepa 1gm Capsule
The denial is overturned

This is an adult female with type II diabetes, hyperlipidemia and hypertriglyceridemia. She is on maximally tolerated simvastatin. Request for Vascepa is under review. The prior request was denied because: "This decision is based on health plan criteria for Vascepa. You must have certain heart and/or blood vessel diseases (ASCVD), or diabetes with 2 other risk factors. These risk factors include things like smoking, hypertension, eye disease and kidney disease. It also includes certain laboratory markers of risk. The notes from your doctor did not show any of these."
The provider is appealing this determination. The patient's triglyceride level was 450 milligrams per deciliter (mg/dL). She has tried and failed fenofibrate.

The requested Vascepa is medically necessary.

This request is for Vascepa for the treatment of a patient with type II diabetes with obesity, hypertension and hypertriglyceridemia with a triglyceride level of 450 milligrams deciliter (mg/dL) despite maximally tolerated statin therapy. The REDUCE-IT trial demonstrated a reduction in cardiovascular events with the use of Vascepa in people living with type II diabetes with elevated triglycerides between 150-499 milligrams per deciliter. The REDUCE-IT trial included patients 45 years of age or older with established cardiovascular disease and patients 50 years of age or older living with diabetes mellitus and at least one additional risk factor, such as this patient who has hypertension. Zetia is not an appropriate alternative as it has not been shown to have the same cardiovascular benefit. The appeal letter indicates that the patient is on maximally tolerated statin therapy. In addition, this patient has significantly elevated triglyceride levels and switching statin therapy is not expected to lower triglyceride levels less than 150 milligrams per deciliter. Without Vascepa, this patient will be at increased risk of an adverse cardiovascular event. Therefore, yes, the requested Vascepa is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia
Treatment: Increase in Consumer Directed Personal Assistance Program (CDPAP) services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift), for a total of 168 hours per week
The insurer denied coverage for an increase in Consumer Directed Personal Assistance Program (CDPAP) services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift), for a total of 168 hours per week.
The denial is overturned.

This is an elderly female with Alzheimer's dementia. The patient lives with the son and his family in a private residence. The insurer approved Consumer Directed Personal Assistance Program (CDPAP) services live-in per diem, 24 hours per day, 7 days per week. The patient is requesting an increase in CDPAP services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift), for a total of 168 hours per week; which is under review.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Severely impaired." The patient is totally dependent to maximal assistance for Instrumental Activities of Daily Living (IADL) including meal preparation, ordinary housework and managing finances. Maximal assistance is required for bathing, personal hygiene, dressing, bed mobility, and toilet use. The patient is totally dependent for locomotion, eating, toilet transfer and ambulation. The patient is incontinent of bowel and bladder. The patient's functional ability has declined compared to the previous UAS report. The development of pressure ulcers on the patient's back and heels have been another recent concern. Bed repositioning approximately every 2 hours is necessary to prevent further decubitus ulcers. The currently approved live-in CDPAP services are unlikely capable of providing for the patient's functional needs while having the ability to consistently obtain uninterrupted 5 hours of sleep. The combination of the patient's severe dementia and total to maximal assistance for IADL/Activities of Daily Living (ADL); which continue to deteriorate and decline, respectively, are at a level and unpredictable as to require the requested CDPAP services 24 hours per day, 7 days per week split shift.
  
From a physical medicine and rehabilitation perspective, increase in CDPAP services: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift), for a total of 168 hours/week is medically necessary. 

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 an increase in Consumer Directed Personal Assistance Program (CDPAP) services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift), for a total of 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart Failure
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.
 
This is an adult patient with a history of congestive heart failure (CHF), Ejection Fraction (EF) 20%, with Automatic Implantable Cardioverter Defibrillator (AICD), atrial fibrillation (on Eliquis), hypertension, hyperlipidemia, and obesity. The patient presented to the Emergency Department (ED) with chief complaints of shortness of breath, cough, and lower extremity edema for over 1 week. On presentation the vital signs were stable, the patient was not in acute distress, had diminished breath sounds, abdominal distention, and bilateral lower extremity edema. The White blood cell count was 10.6, electrolytes were within normal limits, the brain natriuretic peptide (BNP) was 1484, and the troponin was 56. The patient denied chest pain and the Electrocardiogram (EKG) remained unchanged. The patient received intravenous (IV) Lasix and was seen by Cardiology. The patient was recommended for an echocardiogram (ECHO). The patient was admitted for management of Acute Systolic Heart Failure. 

Precipitants are triggers or contributing factors for decompensation in patients with established chronic heart disease (UpToDate). The patient admitted to some non-compliance with diuretics and dietary indiscretions likely contributing to the heart failure exacerbation. The patient did have an increase in Troponins, but it was likely from demand ischemia. The ECHO was done which revealed an EF of 18 % (Prior EF 20%). A myocardial infarction was ruled out. The patient remained hemodynamically stable, responded well to IV Lasix in the ED and the decision was made to discharge the patient home with oral Lasix the day after admission. This patient did not need acute inpatient hospitalization. The patient could have been placed in Observation while diagnostic testing and treatment were initiated. The observation period could be for up to 48 hours. The patient could have received IV diuretics and discharged once stabilized and at baseline on oral medications with close follow up in the outpatient setting.

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 the inpatient admission is not substantiated.