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

Diagnosis: Cardiac/Circulatory Problems/Arrhythmia/Irregular Heart Rhythm
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

This woman presented to the hospital for a scheduled elective electrophysiologic study and possible ablation for paroxysmal supraventricular tachycardia. Her medical history was remarkable for hypertension, prediabetes, and obesity. Upon presentation she was hemodynamically stable in normal sinus rhythm. Electrophysiologic testing showed dual atrioventricular (AV) nodal physiology with echo beats. No supraventricular tachycardia was induced. The slow pathway was successfully ablated. The procedure was uncomplicated. Post-procedure, the patient was monitored in the post-anesthesia care unit (PACU) and then in the ambulatory surgery unit (ASU) for approximately two hours. She was then discharged.
The medical necessity for an inpatient admission is at issue.

I uphold the health plan's determination, in whole, that an inpatient level of care was not medically necessary.

Based on the documentation provided, an inpatient level of care was not medically necessary.
This woman underwent an uncomplicated catheter ablation of her slow pathway for presumed AV nodal reentrant tachycardia. The procedure was uncomplicated. She was discharged home the same day, which is a common practice that has been shown to be both safe and cost-effective. Prior to discharge she was monitored in the PACU and then in the ASU. She remained hemodynamically stable throughout the post-procedure monitoring period, with no evidence of oxygen desaturation, bleeding, or arrhythmias. No specific therapeutic interventions were required. This did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral Claudication

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

This case involves a male with a past medical history of diabetes, chronic kidney (CKD) disease, anemia, hypertension, hyperlipidemia, and tobacco abuse. The patient had presented to the hospital with lower extremity pain upon exertion. He had undergone a staged peripheral angioplasty and drug-eluting stents were placed in the right external iliac. His medication regimen consisted of aspirin, Plavix, and atorvastatin and he was subsequently discharged home hemodynamically stable.

The requested hospital stay was previously denied and stated to be not medically necessary as it was stated that the patient could have been placed in observation under monitoring and that there was no evidence of hemodynamic, pulmonary, neurologic, or metabolic reasoning to treat him at an acute level of care.

The health care plan acted reasonably and with sound medical judgement in denial of the inpatient claim.  This patient and his procedure could have safely been performed either as a completely outpatient procedure or observation.

There was no need for inpatient admission status.

The inpatient admission was not necessary for this patient.

The patient had bilateral lower extremity claudication. There was no documented rest pain or ulceration.  

The patient presented for staged bilateral lower extremity endovascular intervention with the right side first.  The patient's preoperative bloodwork was normal except for mild CKD.  No EKG (electrocardiogram) changes, as they were normal sinus rhythm.  The patient did not complain of other issues.

The patient underwent a routine aortogram, right lower extremity angiogram, right iliac PTA (Percutaneous transluminal angioplasty) and stent, and right SFA (superficial femoral artery) balloon angioplasty with endovascular lithotripsy.  The patient had no complications intraoperatively or postoperatively.  

Thus, there was no need for inpatient admissions.  These types of cases are being done routinely throughout the United States as an outpatient procedure. If the time of day is late or the patient has some transportation issues, it is reasonable for observation, but there is absolutely no indication in this routine patient to have an inpatient admission.

Studies over the past decade have consistently shown that outpatient management of these peripheral Endovascular procedures is safe and is now the standard 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: Upheld

Diagnosis: Psoriasis.
Treatment: Skyrizi pen 150 milligrams/milliliter (mg/ml).
The insurer denied coverage for Skyrizi pen 150 milligrams/milliliter (mg/ml).
The denial is upheld.

The patient is a female with a history of psoriasis affecting the arms, legs and trunk.  The patient has failed topical therapy with triamcinolone and hydrocortisone cream.  The requested medication is Skyrizi.  

Based on the submitted documentation and the standard of care Skyrizi is not medically necessary.  The patient has failed topical therapy and has no true contraindications to numerous appropriate available treatment modalities which would make the use of Skyrizi medically necessary.  There is no comparative, controlled head-to-head studies showing that skyrizi has a superior efficacy or safety profile to reasonable alternatives such as humira, phototherapy, or methotrexate.  According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature alternative effective treatments for the management of psoriasis are available and appropriate for this patient (1,2,6).   Within the peer-reviewed literature, Racz et al writes "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks" (3).  Mehta et al writes "Ultraviolet (UV) B phototherapy is most appropriate for patients with > (greater than) 10 % (percent) affected body surface area who have not responded to topical treatments...NB (narrow band)-UVB effective treatment options for psoriasis...Long-term data on NB-UVB indicate that it has a good safety profile" (4).

Based on the medical documentation provided, Skyrizi is not considered medically necessary. 

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

The insurer's denial of coverage for Skyrizi pen 150 milligrams/milliliter (mg/ml) pen injector is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overbite

Treatment D8080 braces and D8670 monthly visits

The insurer denied coverage for D8080 braces and D8670 monthly visits

The denial is upheld

This is a male who has been denied orthodontic treatment as his Handicapping Labio-Lingual Deviation (HLD) is below 26.

The patient has an overjet of 4mm (millimeter) and an overbite of 4mm with crowding in the mandible. The Index of Orthodontic Treatment Need (IOTN) was developed to assess the need for orthodontic treatment according to the highest potential risk to the integrity of the teeth or supporting structures from the malocclusion. The IOTN has two categories, the dental health component (DHC) and the esthetic component (AC). The DHC is determined by considering the potential harm that a particular occlusal trait could have on the longevity of the dentition. The DHC categorizes the detrimental effects of various deviant occlusal traits in order of severity. The severity is categorized into five grades 1-5 based on the relative effect of various deviant occlusal traits on the longevity of the dentition. The AC can be determined once the permanent dentition has erupted. The score reflects the aesthetic impairment and guides the practitioner to treatment need. Grade 5 is a very great need, Grade 4 is great, Grade 3 is moderate, Grade 2 is little, and Grade 1 is no need. 

This overjet and overbite are increased and significant crowding in the lower anterior. This would be a grade 3 which would correspond to a moderate need.  However, New York State requires use of the HLD score which in this case is below 26.  Thus, criteria are not met and the insurer's denial is upheld. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

D8080 braces and D8670 monthly visits is not considered medically necessary for this patient.

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visits is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malignant Neoplasm of Penis. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is a case of an adult male with history of penile cancer and vitamin D deficiency. The patient presented to LIJ-FHH (Long Island Jewish Forest Hills Hospital) for a partial penectomy with ureteral reconstruction and bilateral inguinal lymph node dissections. At the end of the surgery, 2 J-P (Jackson Pratt) drains and a foley catheter were placed. The insurer has denied coverage for an inpatient admission. They stated there was no hemodynamic, pulmonary, neurological or metabolic session for an adult LOC (loss of consciousness). They stated that the patient could have been placed in observation care under monitoring. The appeal by the patient is noted and read in detail. Per MCG (Milliman Care Guidelines) Health (25th): 

1) Urologic surgery or procedure GRG (General Recovery Guidelines); patient appears to meet the GRC discharge parameter within 24 hours post procedure. 
2) Urethroplasty: patient appears to meet the ORC discharge parameter within 24 hours postop. Patient eating, pain controlled; patient able to be discharged home with foley/ JP drains in place, to be removed as outpatient in next 1-2 weeks. 

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

The inpatient admission was not medically necessary for this patient. 

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

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

Diagnosis: Psoriasis. 

Treatment: Taltz 80 milligrams (mg) every 3 weeks. 

The insurer denied coverage for Taltz 80 mg every 3 weeks. 

The denial is overturned. 

The patient is a male with a diagnosis of psoriasis. The patient was previously treated with Taltz monthly injections; however, the patient experienced exacerbations and was changed to every 3 week Taltz injections. The request is for Taltz 80 mg every 3 weeks as a dosing adjustment prior to changing to an alternative biologic. 

Based on the submitted documentation, Taltz dosing adjustment is medically necessary.  The patient requires systemic therapy for control and management of his psoriasis diagnosis. Prior to changing to an alternative biologic, it is reasonable and within the standard of care to attempt an adjusted dosing regimen. Taltz is Food and Drug Administration (FDA) approved for treatment of psoriasis vulgaris and it is reasonable to attempt this dosing schedule.  

The joint American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) guidelines for psoriasis treatment with biologics states that Taltz is recommended for monotherapy in the treatment of psoriasis with a strength of recommendation of "A" -the highest recommendation. Based on the submitted documentation, Taltz dosing every 3 weeks is approved and the decision is overturned in whole based on the current evidence-based medical literature. 

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 medication Taltz 80 milligrams every 3 weeks is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Inpatient admission. 

The insurer denied coverage for an inpatient admission. 

The denial is upheld. 

This is a case of a woman that presented to the hospital with chest pain while seated in a motorized wheelchair.  Relevant past medical history includes hypertension, diabetes mellitus, and stroke with residual left sided weakness. Upon arrival to the ED (emergency department) vital signs were stable (BP (blood pressure) 152/88 mmHg (millimeters of mercury) and Pulse 96 bpm (beats per minute)). Physical exam was significant for pedal edema with tense edema of the left leg and positive Homan's sign and reproducible chest pain. A 12-lead electrocardiogram (ECG) revealed sinus rhythm with heart rate of 96 bpm and no evidence of ischemic segment ST (interval on ECG) or T wave (interval on ECG) changes or right sided strain. Serum blood testing revealed no elevation in serial troponin levels (<0.012 ng/ml [nanogram per milliliter]) and an elevated D-dimer (2298 ng/ml. CT (computed tomography) angiogram was within normal limits and no pulmonary embolism was noted.  Likewise, lower extremity duplex study revealed no evidence of deep vein thrombosis.  The patient was admitted to the hospital for observation and treatment and ultimately discharged on medical therapy. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with atypical, reproducible chest pain and a past medical history of hypertension, diabetes and CVA (cerebral vascular accident). Her pretest probability of coronary artery disease was intermediate (Reference 1). She had a HEART (history, ECG, age, risk factors, and troponin) score of three and was considered low risk (Reference 2). Utilizing the TIMI (thrombolysis in myocardial infarction) risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all-cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically 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 inpatient is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient hospital stay. 
The denial is upheld. 

The patient is a male with medical history of Loeys-Dietz syndrome, brain aneurysms, seizures, congenital heart disease, and wheelchair-bound. He presented to the emergency department with four days of right lower quadrant abdominal pain, vomiting, and recent constipation, sore throat, and testicular pain. 
Vital signs were unremarkable. Physical examination was notable for disorientation and right lower quadrant abdominal tenderness. Labs showed low white blood cell count of 3.9 thousand per microliter (K/uL), low platelet count of 102 K/uL, and low sodium of 130 millimoles per liter (mmol/L). Computed tomography scan of the abdomen and pelvis showed small bowel malrotation with the majority of the small bowel located in the right abdomen, abnormal orientation of the superior mesenteric artery and vein with a swirl sign, free fluid in the right lower quadrant concerning for possible midgut volvulus, lack of small bowel obstruction, and lack of signs of bowel ischemia. He was treated with intravenous fluids and morphine. He was made nothing by mouth (NPO). He had less abdominal pain and was tolerating a full liquid diet without nausea. Labs showed low white blood cell count of 3.0 K/uL, low platelet count of 106 K/uL, and low sodium of 126 mmol/L. He was discharged, with a plan for general surgery follow-up. At issue is coverage for the inpatient level of care. 

The inpatient stay is not medically necessary for this patient. The care provided could have been accomplished at a lower level of care. 

The patient presented with abdominal pain, constipation, and vomiting; he had improvement in symptoms with conservative therapy [1-7]. Imaging did not show definite bowel obstruction or ischemia, and no other gastrointestinal cause for the inpatient level of care, such as gastrointestinal bleeding, peritonitis, toxic megacolon, sepsis, abscess, or other complication was documented. He regained tolerance of oral intake without surgical intervention. All of the measures that were undertaken, including monitoring, labs, and advancement of diet, could have been performed without the inpatient level of care [3-7].
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite,crowding.
Treatment: Braces.
The insurer denied the braces.
The denial is overturned.

The patient is a female. The patient has class III malocclusion. She has right side posterior crossbite (reverse bite). She has mild crowding in upper and lower jaws. Her lower jaw is larger than the upper. The prior denial of coverage was due to handicapping index being less than 26.

Yes, the requested Braces are medically necessary.
The patient has a crossbite on the right side where the lower right canine is in crossbite with the upper teeth with gingival attachment loss. This is an "automatic qualifier" for orthodontic benefits. Orthodontic treatment is the only way to correct this, and the case has medical necessity. The patient also has crossbites of multiple posterior teeth on the right side. These crossbites need to be corrected to prevent the teeth from traumatizing themselves during chewing and causing fractures over time. The crossbite also increases the probability of future TMJ (temporomandibular jaw) problems due to the extra pressure created on the jaw joints by the malocclusion where the upper teeth are "inside" of the lower teeth, which is backwards.

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

Diagnosis: s/p (status post) Fall.
Treatment: Air Ambulance Transport (A0431-A0436).
The insurer denied the Air Ambulance Transport (A0431-A0436).
The denial is upheld.

The patient is a woman. She was injured during a fall. The patient fell onto a metal wire, which became impaled in her posterior left thigh. First responders found the patient awake and alert. It was noted that there was no motor or sensory deficit to the left lower leg. There was no other injury. There was no respiratory difficulty. The patient became agitated according to EMS (emergency medical services) notes and was treated with IV (intravenous) Midazolam.

The decision was made to summon an air ambulance to the scene to transport the patient to the nearest trauma center. Flight notes from the air ambulance crew indicate that the patient had normal mental status and normal vital signs. There was no bleeding from the leg wound. There was no neurovascular deficit of the left leg. There was no change in the patient's condition following transfer. The patient had the wire removed from her leg in the ED (emergency department). The wound was sutured closed. She was later discharged from the ED (emergency department).

The patient's health plan denied coverage for this air ambulance transport on the grounds that it was not medically necessary.

The air ambulance service has appealed this denial on behalf of the patient. In the appeal letter, it is written that air transport was necessary to minimize out of hospital time.

No, the air ambulance transport was not medically necessary.
At the time this patient was evaluated by first responders, she was clinically stable. She had a metal wire impaled in her posterior left thigh. Despite this, there was no active bleeding. There was no neurovascular deficit. There were no other injuries. The patient was awake and alert. She was having no difficulty breathing.

A MapQuest search by this reviewer found that ground ambulance transport between the two facilities would take approximately one hour. This patient was clinically stable for all the reasons described above. She could have safely undergone a one hour ground transport. There would be no reason to believe that such a ground transport would have placed her health in jeopardy.

Yes, the health plan did act reasonably in denying coverage for the air ambulance transport.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing tooth

Treatment: D6245 prosthodontics fixed, pontic- porcelain/ceramic, tooth 8 and 9; D6740 white glass cap, tooth 10 and 7

The insurer denied coverage for D6245 prosthodontics fixed, pontic- porcelain/ceramic, tooth 8 and 9; D6740 white glass cap, tooth 10 and 7.

The denial is overturned.

Upon review of the submitted documentation, which includes copies of panoramic radiograph copies of occlusal/periapical radiographs, intraoral clinical photographs, narrative letter, and insurer correspondence, it appears that this patient presented for dental care with a failing preexisting fixed bridge in the anterior maxilla that had been present for many years. Recommended treatment was to replace the pre-existing bridge with a new one spanning teeth # (number) 7-10, The insurer has denied this service stating that medical necessity criteria are not met. 

Upon review of the documentation, in particular the clinical photographs and radiographs, it is evident that the preexisting bridge was failing. To restore function to the anterior maxillary dentition, in this case since the patient has pre-existing fixed bridge, replacement with a fixed prosthesis spanning #7-10 site as recommended is the standard of care dental treatment in general dental practice. As the dentition is already restored with a fixed bridge prosthesis, the only treatment that would be considered an appropriate replacement of the current fixed bridge is another.

Overturn denial and approve coverage for D6245 prosthodontics fixed, pontic - porcelain/ceramic, tooth 8 and 9; D6740 white glass cap, tooth 10 and 7 as medically necessary, as this would be the standard of care dental treatment in clinical practice.

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

The insurer's denial of coverage for coverage for D6245 prosthodontics fixed, pontic- porcelain/ceramic, tooth 8 and 9; D6740 white glass cap, tooth 10 and 7 is overturned. Medical necessity is substantiated.