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

Diagnosis: Lower Back Pain.
Treatment: Electrical nerve stimulator.

The insurer denied coverage for electrical nerve stimulator.  The denial is upheld.

This gentleman has a history of atrial fibrillation, congestive heart failure (CHF), and arthritis. He presented to the Pain Management physician's office for a follow up visit for lower back pain. He reported greater than 50% (percent) relief after lumbar medial branch radiofrequency ablation. Pain level is rated at a 5 out of 10. The physician recommended another radiofrequency ablation in three months, continuing pain medications, continuing physical therapy (PT), and a peripheral nerve stimulator (PNS). 
The patient has tried and failed PT, radiofrequency ablation, nerve blocks, and pain medications

The use of the Sprint PNS for chronic low back pain is experimental/ investigational. Gilmore et al (1) published a prospective case series of just 9 patients who had chronic low back pain.  There was no comparison group, and this is a very small, short-term series. In a review by Xu et al. of the role of peripheral nerves stimulation for low back pain they concluded that "... the evidence is limited to Level II or III. There is a clear need for further, better quality research into its efficacy. Future trials also should be designed with the type of low back pain clearly reported, and the technique of PNS placement well described." (2)

Similarly, nationally accepted Center for Medicaid and Medicare Services (CMS) (3) have published guidelines that determined that this is not a standard procedure in low back pain. This procedure is not medically reasonable or necessary.

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

The insurer's denial of coverage for an electrical nerve stimulator is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.

The patient presented with diarrhea and abdominal pain. She had a low-grade fever and a mild tachycardia. A surgical consult was done and there were reports that she had voluntary guarding, but no rebound. The white blood cell (WBC) count was 13.7. A computed axial tomography (CAT) scan showed a diffuse colitis. No acute surgical interventions were advised. She was treated with antibiotics. The repeat WBC count was 7.5. Her symptoms improved.

Clinical indications for admission for Gastroenteritis (MCG [Milliman Care Guidelines] M-170) include having a suspected severe infection, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had a gastroenteritis. She required intravenous (IV) hydration and antibiotics. She improved with this treatment and her diet was able to be advanced. IV hydration, antiemetics, and antibiotics could have been given with observation status. Afterwards, she could have been discharged on a course of oral antibiotics. She responded to the treatment given and the leukocytosis resolved. She did not meet MCG criteria for admission for Gastroenteritis. The health care plan acted reasonably and with sound medical judgment. An inpatient hospital admission was not medically necessary. 

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 admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Weakness (TIA [transient ischemic attack])
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is a female. She presented with the complaint of mental status change and generalized weakness.

At presentation, the patient was confused, but there was no focal deficit. She had CT (computed tomography) scan that suggested chronic infarcts. Serum blood sugar was over 450. She was admitted for the acute inpatient service. MRI (magnetic resonance imaging) after admission showed subacute right parietal occipital stroke.

Yes, the inpatient hospital admission was medically necessary.

The patient had a subacute stroke on MRI that was of significant size; she had mental status change and metabolic derangement. The patient required inpatient level of care for acute and aggressive treatment of hyperglycemia, which if untreated is known to contribute to worse outcomes after stroke. She was also confused to location and required more intensive monitoring (Powers, et al). Finally, the stroke was of significant size that she would have been at risk for malignant edema, which can occur up to 72 hours after the event (Wu, et al).  This, coupled with her confusion, supported an acute level of care for appropriate monitoring.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female. She presented with diarrhea every hour, abdominal pain, headache, nausea, anorexia, and weakness. She was unable to tolerate PO (orally). She completed antibiotics as an outpatient, amoxicillin and azathioprine for cellulitis, but developed progressive diarrhea with nausea/vomiting.

In the emergency room, the patient was noted to have bilateral costovertebral tenderness and significant fever. She was given Toradol IV (intravenous) and treated with Zosyn. She also received Tylenol and IV fluids. She received IV magnesium 2 g (grams). Labs were noted for a UTI (urinary tract infection) and concern for pyelonephritis given back pain. CT (computed tomography) abdomen and pelvis showed thickening of the transverse colon, sigmoid diverticulosis, and a small amount of gas in the urinary bladder. The patient also received oral vancomycin due to suspected Clostridium difficile infection.

The patient was admitted and was in isolation for Clostridium difficile colitis. She was treated with Flagyl 500 mg (milligrams) IV every 8 hours and vancomycin 250 mg orally every 6 hours.

The patient continued to have a temperature of 39.3 degrees Celsius. Her pulse rate went up to 115 bpm (beats per minute). She received intravenous morphine sulfate on 5 occasions and IV Zofran on two occasions. The patient was on a clear liquid diet which was advanced as tolerated. The WBC (white blood cell) count was trending down to 13.3.

The patient had a fever overnight and continued to have loose watery stools. The potassium was 3.3, which was replaced. She continued to have pain and required morphine sulfate x (times) 4 doses. The patient continued IV Flagyl and oral vancomycin.

Urology was consulted for the patient's possible colovesicular fistula due to gas in the bladder per CT scan. CT cystogram showed no evidence of fistula.

The patient had much improvement, was tolerating a regular diet, and was discharged home.

Yes, the inpatient admission was medically necessary.

Inpatient level of care was medically necessary, as the patient required IV antibiotics, treatment with IV pain medication, electrolyte replacement, and slow advancement of diet. Additionally, the patient also required workup for possible gas in the bladder.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The medical records do support that the acute inpatient admission was medically necessary. The patient did require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would have been threatened by providing the care given in a lower level of care setting.
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, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, open bite, and anterior crowding and has recommended orthodontics. The orthodontist has completed the handicapping labio-lingual deviation (HLD) index, attaining 26 total points to support orthodontic care. 

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, a Handicapping Labio-Lingual Deviation index is used. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used, utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary.

In this case, the treating orthodontist does not claim an automatic qualifying condition
and completes the second portion of the index, arriving at 26 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer, attaining a total of 18 points on the HLD index (4 overjet, 12 open bite, 2 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

Regarding the validity of the Handicapping Labio-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. This is confirmed by several studies cited below.

Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

Braces and monthly visits are not considered medically necessary for this patient.

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

The insurer's denial of coverage for braces and monthly visits is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dyspnea

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay.

The denial is overturned. 

This infant had a history of a premature birth and was sick with a viral illness for one month. There was a sick sibling in the home. The child had been seen in the emergency room (ER) on the day prior to admission with a cough and wheezing. The child had been treated with albuterol in the ER and sent home with a prescription to continue albuterol in the home. On the day of admission, the child was brought to the pediatrician's office because the breathing rate had increased, and the child did not tolerate the treatment with albuterol in the home. The pediatrician noted that the child had a low oxygen saturation and significant wheezing with increased work of breathing. The pediatrician recommended that the child be brought back to the ER for additional treatment.

In the ER, he was noted to be in significant respiratory distress with suprasternal retractions and a pulse oximeter of 90% (percent). He was started on supplemental oxygen. On physical exam, the child was febrile and had diffuse wheezing upon auscultation of the chest. He was treated with albuterol and was found to be positive for the respiratory syncytial virus (RSV) virus. He had an episode of low oxygen saturation during his treatment with oxygen in the ER and the decision was made to admit the child to the hospital with a diagnosis of bronchiolitis for continued treatment with albuterol and oxygen.

The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The inpatient hospital admission is considered medically necessary for this patient.

The patient was treated appropriately in the ER for an acute episode of wheezing, hypoxemia, and difficulty breathing. The child has a history of prematurity and did not tolerate albuterol in the home, which had been prescribed in the ER the day prior to the hospitalization. When he did not respond to treatment in the ER, and he was noted to have a low oxygen saturation despite oxygen supplementation in the ER, it was appropriate and consistent with the standard of care to admit the infant to the hospital with a diagnosis of bronchiolitis for ongoing oxygen supplementation. He was not stable enough to be safely discharged home. 

The insurer's denial of coverage for inpatient hospital stay is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a female status post fall who presented to the emergency department. The patient fell 5 steps with questionable loss of consciousness. She has a history of previous falls in the past. She is not on any blood thinners. Physical exam showed an 8 centimeter (cm) left (L) shaped forehead laceration, right anterior tibia abrasion, left tibia ecchymosis and left wrist tenderness. Computed tomography (CT) scan of head and cervical (C)-spine were negative for any traumatic injuries. X-rays were negative for fractures. The patient had a forehead laceration repaired at the bedside. Orthopedic surgery was consulted for possible left ulna styloid fracture with non-operative recommendations. The patient was discharged home. The subject under review is the medical necessity for an inpatient stay.

The health plan's determination is upheld.

The requested health service/treatment of inpatient stay is not medically necessary for this patient.
The patient is status post fall who presented to the emergency department for evaluation. She was found only to have a forehead laceration that was repaired in the trauma bay. All imaging studies were negative for fracture or significant traumatic injuries. She was discharged home the same day of hospital presentation. Based on her injuries, inpatient admission was not medically necessary.  There are no references found that support the hospital admission for a forehead laceration and there were no other traumatic injuries identified. She could have been evaluated and treated at a lower level of care status.
According to Multiple trauma General Recovery Guidelines (GRG) guidelines from Milliman Care Guidelines (MCG) Health 25th edition,

Hospital admission is indicated when patient with significant multiple trauma requires inpatient care for 1 or more of the following:
1). Major surgical and postprocedural care (Criteria not met)
2). Nonoperative care of significant injury (Criteria not met)
3). Multiple trauma and one or more general admission criteria. (Criteria not met)
Patient does not meet criteria for admission. She did not any major surgeries. She did not have a significant injury. Her only injuries identified were a forehead laceration and lower extremity abrasions.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied the Braces.
The determination is overturned.

The patient has an anterior crossbite on tooth 7. She presented with a skeletal Class I malocclusion with severe crowding in the maxilla and mandible. She is treatment planned for orthodontics to address the crowding and crossbite. At issue is the medical necessity of braces.

Yes, the requested service is medically necessary.
This patient presented with an anterior crossbite on tooth 7. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3)
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For this reason, the treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck Pain and Muscle Spasm.
Treatment: Chiropractic treatment for ongoing care.
The insurer denied Chiropractic treatment for ongoing care.
The determination is upheld.


The patient presented for chiropractic treatment of neck pain with diagnoses of neck pain and muscle spasm. Treatment included spinal manipulation. There were periods of non-treatment due to the coronavirus pandemic. The patient was seen for neck pain, diagnosed as cervical radiculopathy, and treated. Billing included spinal manipulation, ultrasound, re-examination and adjunctive physical therapy. At issue is the medical necessity of chiropractic treatment for ongoing care (CPT codes 99212 and 97035)

The treatment was for a chronic condition which was not different in kind when the patient returned to care. Care was all on a maintenance schedule of care, based on chief complaints and examination findings, as well as dates of service. There was no indication that a non-supervised home rehabilitation program was in place to effectuate patient care and outcomes. Ongoing Oswestry scoring was not utilized. There were no new chief complaints, so no re-examination was medically necessary. Ultrasound is meant as useful for acute care, and this patient had a chronic problem, and ultrasound should have led to a non-supervised active home rehabilitation program, rather than passive care. There was no objective evidence of ongoing clinical improvement, making the treatment not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Ubrelvy. 
The denial is overturned. 

The patient is a female diagnosed with migraine headaches. Ubrelvy was denied because chart notes were not submitted that the patient has tried and failed plan preferred alternatives. The provider appealed the determination with the submission of chart notes. The subject under review is the medical necessity for Ubrelvy. 

The health plan's determination is overturned. 

The requested treatment with Ubrelvy is medically necessary for this patient. The provider indicates that the patient has already tried and failed rizatriptan and sumatriptan. Chart notes are submitted showing that the patient was prescribed rizatriptan and sumatriptan. The physician has demonstrated that triptans are ineffective for treatment of the patient's migraines. It is next the standard of care to use a gepant for acute migraine. These drugs, such as Ubrelvy, are Food and Drug Administration (FDA) approved for treatment of acute migraine and literature supported for this indication. In clinical trials, 2 hours after taking Ubrelvy, 12.7% [percent] to 15.4% of people who had no migraine pain continued to have no migraine pain for up to 24 hours after taking Ubrelvy. In comparison, 8.2% to 8.6% of people who had no migraine pain 2 hours after taking a placebo also had no migraine pain up to 24 hours later.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.

Treatment D8080 braces and D8670 monthly visit.

The insurer denied coverage for D8080 braces and D8670 monthly visit.

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to excessive overjet and impacted maxillary canines 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 anterior where extraction is not indicated. 

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
impacted permanent anterior where extraction is not indicated. 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 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. This is confirmed by several studies.

Each of the peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

The clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care.

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 D8080 braces and D8670 monthly visit is overturned. Medical Necessity is substantiated.