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

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

The patient is a man with a history of alcohol use disorder. He presented to the emergency room with worsening tremors and a possible seizure. His last drink was the previous day. The initial vital signs showed blood pressure was 161/97, pulse 120, and respiration 26. There was some diaphoresis, but he appeared non-toxic and in no acute distress. The physical exam was also notable for tongue fasciculations and asterixis. There were no clinically significant lab abnormalities. The chest x-ray was unremarkable, and the electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. He was treated with lorazepam, chlordiazepoxide, and vitamins. Soon thereafter, the blood pressure was down to 126/92, with a pulse of 99, and respirations of 22. The patient was admitted for further treatment and evaluation.

The inpatient admission was not medically necessary for this patient.
Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no hemodynamic instability, mental status changes, or severe metabolic disarray. He responded well to straightforward therapy. The services provided - intravenous fluids, benzodiazepines, and vitamins- were not at the acute inpatient level of intensity. Therefore, the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: open fracture to radius and ulna

Treatment is full hospital admission

The insurer denied coverage for full hospital admission

The denial is overturned

This patient presented the emergency department (ED) status post (s/p) a fall at home. The patient fell on their right arm and presented with right arm pain, swelling, bleeding, deformity, and tingling in the right fingers. A physical exam showed three lacerations over the volar surface of the forearm with deformity, ecchymosis, and edema. There was significant tenderness to palpation and thrombotic thrombocytopenic purpura (TTP) over the right forearm. The patient had limited range of motion (ROM) secondary to severe pain and weakly was able to move all 5 fingers secondary to pain. Diagnostic imaging revealed mid radius and ulna fractures. The patient was admitted to Orthopedic Services for fixation and started on antibiotics. The patient underwent incision and drainage (I&D), open reduction internal fixation (ORIF) of the radius and ulna. The patient did well post-operatively. 
 
The medical record demonstrates a diagnosis of open fracture to the radius and ulna. This is an orthopedic emergency type condition. Surgical management is essential to include irrigation, debridement, operative fixation and post-surgical IV (intravenous) antibiotics. The post-surgical course is also painful, and requirements of intravenous analgesia to control pain were noted. 

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 full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ADHD (attention deficit hyperactivity disorder)
Treatment: Jornay PM 20MG (milligrams) ER (extended release) Capsule
The insurer denied:  Jornay PM 20MG (milligrams) ER (extended release) Capsule
The denial is upheld

The patient is an adult female. She has diagnoses of ADHD (attention deficit hyperactivity disorder), Bipolar II disorder, and anxiety disorder, unspecified. She has failed Adderall XR (extended release) for ADHD (attention deficit hyperactivity disorder). Methylphenidate ER (extended release) has been prescribed at various doses with little effect. She was not prescribed immediate release stimulant due to bipolar disorder. Methylphenidate LA (extended release) was prescribed in the past by former provider with poor effect. The request for Jornay PM (methylphenidate hydrochloride) was denied coverage by the health plan, as they note that she must try methylphenidate extended release, dexmethylphenidate extended release, and the doctor must provide clinical documentation that she met the condition above. The denial is being appealed.

The treatment with Jornay PM is not medically necessary.

The patient has failed Adderall XR (extended release) for ADHD (attention deficit hyperactivity disorder). Methylphenidate ER (extended release) has been prescribed at various doses with little effect. She was not prescribed immediate release stimulant due to bipolar disorder. Methylphenidate LA (extended release) was prescribed in the past by a former provider with poor effect.
While the patient has tried and failed methylphenidate extended release, she is not documented to have tried and failed dexmethylphenidate extended release, nor is she documented to have any contraindications to this medication. Having the patient trial dexmethylphenidate extended release before Jornay PM (methylphenidate hydrochloride) is reasonable and consistent with the standard of care. Dexmethylphenidate extended release would reasonably be expected to be at least as efficacious as the requested medication and would not be expected to jeopardize the patient's health.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion. 
Treatment: Braces and monthly visits. 

The insurer denied coverage for Braces and monthly 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 recommended comprehensive orthodontics due to impacted permanent anterior teeth among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated (right maxillary canine). 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 on the HLD index attaining only 8 points on review by internal reviewers. 

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

In this case, the treating orthodontist claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of impaction and does not support comprehensive orthodontic care using this criterion. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several referenced studies. 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 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 braces and monthly visits is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbites.
Treatment: D8080 Braces and D8670 x12 Monthly Visits.
The insurer denied: D8080 Braces and D8670 x12 Monthly Visits.
The denial is overturned.

The patient is a teenaged female; the request is for orthodontic benefits. The patient has a Class III skeletal and molar relationship. She has bilateral posterior crossbites with and open anterior bite tendency. The prior denial was due to rescoring her handicapping index scale to 21.

The proposed treatment with D8080 braces and D8670 x12 monthly visits is medically necessary.

The patient has bilateral posterior crossbites. She also has no lower canines in contact with her upper canines. Both of these conditions do not allow for the proper meshing of her teeth during the chewing cycle. Instead of her lower canines gliding along her upper canines in a controlled, atraumatic fashion, the patient's teeth will bang and grind together in a traumatic way. This will ultimately cause trauma and fracturing of multiple teeth over time. This lack of what is called "canine guidance", will also contribute to eventual temporomandibular joint (TMJ) issues due to excessive forces on her joints. Orthodontic treatment (with monthly follow up visits) is needed to correct this extremely traumatic malocclusion. Medical necessity has been established for this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hidradenitis Suppurativa. 
Treatment: Rinvoq 15 milligrams (mg) OR TB24. 

The insurer denied coverage for Rinvoq 15 milligrams (mg) OR TB24. 

The denial is overturned. 

The patient is a teenager with multiple medical problems, including a past medical history significant for Chiari malformation, craniosynostosis, Alport syndrome with hydrocephalus, focal segmental glomerulosclerosis, acne conglobate, and hidradenitis suppurativa.  The patient has failed therapy with prednisone, topical agents, and Humira, which is contraindicated due to cardiac/renal comorbidities.  The request is for Rinvoq.  

The patient has multiple significant comorbidities, including significant renal and cardiac disease which precludes the use of Humira for treatment of the patient's hidradenitis suppurativa.  The patient has limited treatment options given his history.  Rinvoq is a reasonable alternative for treatment and will require close medical supervision.  The use of Rinvoq is approved based on the submitted documentation with careful continued medical monitoring.  

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 Rinvoq 15 milligrams (mg) OR TB24 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 male patient with a history of hypertension, hyperlipidemia, and diabetes. He underwent an elective cardiac catheterization for chest pain, which was worse with exertion. An outpatient computed tomography (CT) angiogram was abnormal. The left ventricular ejection fraction (LVEF) was normal. His vital signs were essentially normal. He remained stable and underwent an uncomplicated percutaneous intervention of a severe left anterior descending (LAD) stenosis. He was ultimately discharged. At issue is the medical necessity of an inpatient stay.

This patient underwent successful elective and nonemergent stenting without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications or oxygen support, or introduction of high risk medications requiring prolonged in-hospital monitoring. In this setting, an inpatient level hospitalization, compared to for example outpatient, has not been established as standard of care towards percutaneous catheterization or overall cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Metastatic Lung Cancer.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.
 
This patient is an adult who has a history of a hernia and presented to the hospital with back pain. It was noted the patient had metastatic lesions to the spine. Imaging was concerning for metastatic disease and the patient was admitted to the hospital for pain control. It was noted that he was not a surgical candidate. Because he had lung nodules, a central nervous system (CNS) evaluation was done with a computed tomography (CT) scan that showed a brain lesion. This was confirmed with magnetic resonance imaging (MRI). He was placed on steroid and anti-epileptics and was discharged.

This patient could have been managed in a lower level of care such as observational status on the date of service (DOS) in question. The patient had no neurological issues and did not require a complete staging of his diagnosis on an inpatient basis.      

The patient did not have acute issues requiring surgical intervention in his spine. There was no evidence of cord compression documented in the records provided for review. This individual could have been managed for his pain, placed on steroids and an anticonvulsant within 24-48 hours and then discharged for outpatient management of his newly diagnosed cancer.  The patient had no neurological impairments, and did not need to complete staging of his condition on an inpatient basis. As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would have been appropriate. 

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental decay
Treatment: Retainer crown - porcelain/ceramic (D6740) and Pontic, porcelain/ceramic (D6245)
The insurer denied coverage for retainer crown - porcelain/ceramic (D6740) and Pontic, porcelain/ceramic (D6245)
The denial is upheld
 
Upon review of the documentation provided it appears that this patient presented to the dentist for dental care. The treating dentist recommended fixed crowns and Pontic in the area of the right maxilla spanning (teeth number) #2- #5. The insurer has denied these services stating upon review, that documentation is insufficient to approve treatment as it does not meet clinical criteria for coverage. The patient is appealing.

The only objective documentation provided for review that is relevant to the issue at hand is a clinical note. There are no other dental treatment records provided for review. There are no radiographs nor are there dental charting or periodontal charting provided. The provided documentation does not substantiate the requested dental service as enumerated above and therefore the crown is deemed 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 retainer crown - porcelain/ceramic (D6740) and Pontic, porcelain / ceramic (D6245) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pudendal (pelvic) Pain
Treatment: Neurolytic Nerve Destruction
The insurer denied: Neurolytic Nerve Destruction
The denial is Upheld.

The patient is a young adult female with past pain medical history is significant for migraines, vulvodynia, abdominal pain, and pelvic pain. Past treatments include sacrospinous ligament transection, Flexeril, nortriptyline, Duloxetine, Lidocaine ointment, Tylenol, pudendal nerve radiofrequency ablation in 2021 with 20% (percent) relief for two months twice 6 months ago, bilateral pudendal nerve blocks with 50% relief for 4 and 8 hours respectively. The request for radiofrequency ablation of bilateral pudendal nerve block was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The Neurolytic Nerve Destruction is not medically necessary.

There is limited peer-reviewed literature and guidelines that support the use of pudendal nerve radiofrequency ablation. The studies submitted for appeal include a case study, and a study of 77 patients that showed this treatment may provide long term relief for pain symptoms. The safety and efficacy of this procedure has not been well documented. In addition, this patient has previously had this procedure with results of only 20% pain relief for two months a few years ago.  As such, the requested Neurolytic Nerve Destruction is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder
Treatment: Transcranial Magnetic Stimulation (TMS)
The insurer denied the request for Transcranial Magnetic Stimulation. 
The health plan's determination is overturned.

The patient is a female with a history of major depression. She has had numerous trials of antidepressant medications. She has a several year history of failed cognitive behavioral therapy in addition to numerous trials of medications many at maximum doses. 
At issue is the medical necessity for the requested health service/treatment of Transcranial Magnetic Stimulation (TMS).

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

The TMS (Transcranial Magnetic Stimulation) treatment is medically necessary for this patient. The patient has evidence of significant treatment resistant depression which did not respond to 7 (seven) antidepressant regimens. Five of these antidepressants were used at maximum doses and combination strategies were used to improve outcomes. The claimant has also failed a prolonged course of cognitive behavioral therapy.
The patient also shows evidence of current symptoms that are impairing based on their depression. Given the above, transcranial magnetic stimulation (TMS) is a medically necessary treatment which would be in the best interest of the patient. The TMS is Food and Drug Administration (FDA) approved and a proven effective treatment for treatment-resistant depression. There is copious evidence that TMS is effective for the treatment of depression, particularly in treatment resistant cases and there is wide consensus in the psychiatric community that use of TMS provides significant results and improvement for patients (Irarte and George, 2018,. Perera et al., 2016, and Burke et al., 2019).

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class II Malocclusion
Treatment: Braces and monthly visits
The insurer denied: Braces and monthly visits
The denial is: Upheld

The patient is a male with Class II malocclusion. He has mild maxillary crowding and mild mandibular crowding. He has a moderate overjet and severe overbite. The provider has requested orthodontic treatment for the patient. The subject to be determined is if the requested treatment with braces and monthly visits is medically necessary.

Using the Handicapping Labio-Lingual Deviation (HLD) index, which is a standard of care tool, the malocclusion would score a 11 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, deepening impinging overbite with severe soft tissue damage, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the standard criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, the requested treatment for braces and monthly visits is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, diabetes and osteoarthritis
Treatment: Personal care aide level 2: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift), a total of 168 hours per week
The insurer denied coverage for personal care aide level 2: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift), a total of 168 hours per week
The denial is overturned

This is an elderly patient with medical problems that include dementia, diabetes and osteoarthritis. She lives with her daughter in a 3-bedroom home. The insurer approved personal care aide (PCA) live-in per diem, 24 hours/day, 7 days/week and the request is for PCA level 2: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift), a total of 168 hours/week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition was described as severely impaired with late-stage dementia and non-verbal. She is totally dependent for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She is also totally dependent for bathing, personal hygiene, dressing and mobility (bed mobility, locomotion and ambulation). She is bed bound and totally dependent for toilet transfer/use. The patient is completely incontinent of bowel and bladder.  

The combination of the patient's severe cognitive deficits, total dependence for IADL/ADL (activities of daily living) and total incontinence support the medical necessity of the requested PCA level 2: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift), a total of 168 hours/week. Based on the records reviewed, a live-in PCA is less optimal as they are unlikely capable of consistently providing for the patient's functional needs with the ability to consistently obtain an uninterrupted 5 hours of sleep; particularly given the need for routine repositioning/turning in bed and suctioning. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained at home by increasing PCA level 2: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift), a total of 168 hours/week.  

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 personal care aide level 2: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift), a total of 168 hours per week is substantiated.