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

Diagnosis: Cerebral vascular accident
Treatment: Admission to Custodial and Respite Services/Long Term Custodial Care
The insurer denied: Admission to Custodial and Respite 
Services/Long Term Custodial Care
The denial is overturned

The patient is an adult male with history of general debility secondary to perianal abscess, with history of cerebral vascular accident (CVA), diabetes mellitus, epilepsy, schizoaffective disorder, hypertension, hepatitis C, et cetera. The patient has cognitive deficits affecting his ability to care for himself along with his being prone to seizures. He is also incontinent of bladder and bowel. The patient has poor prognosis in rehabilitation which is guarded in view of poor functional status and multiple co-morbidities and complex medical conditions. Prior to admission, the patient required supervision for most activities of daily living (ADLs) and as of 7 months ago required moderate-maximum assistance with some activities of daily living and showed some improvement until 3 months ago. Possible discharge would be to the patient's son who goes to work.

The proposed treatment is medically necessary.

The requested transfer to a long-term custodial care facility is medically necessary because the patient has general debility, gait imbalance, ambulation difficulty and confusion while requiring maximum assistance for most activities of daily living.
Custodial care is needed when a patient requires:
1. Non-health-related services, such as help with daily living activities. Examples include eating, dressing, bathing, transferring and ambulating, or
2. Health-related services that can safely and effectively be performed by trained non-medical personnel and are provided for the primary purpose of meeting the personal needs of the patient or maintaining a level of function as opposed to improving that function to an extent that might allow for a more independent existence.
This patient has poor prognosis in rehabilitation which is guarded in view of poor functional status and multiple co-morbidities and complex medical conditions. The patient needs to be in a long-term custodial care because there are needs for help with daily living activities including, dressing, bathing, transferring and ambulating, while requiring rehabilitation in occupational therapy (OT) and physical therapy (PT) for the purpose of improving function to an extent that might allow for a more independent existence.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.

Treatment: Braces.

The insurer denied coverage for braces.

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 deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. 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 11 points on review by internal reviewers. 

Upon review of the submitted documentation, 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 the use of an HLD 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 deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer with a total of 11 points (4 points overjet, 5 points overbite, 2 points labiolingual spread).

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

Based on the above, the insurer's denial must be 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 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

 
Acute cholecystitis is a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. Ambulatory and/or outpatient laparoscopic cholecystectomies do not compromise patient outcomes.

Per clinical documentation, this patient presented to the emergency department (ED) with right upper quadrant abdominal pain. There was no associated nausea or vomiting. Vital signs in the ED were within normal limits. The white blood cell count was normal at 8.2. Liver function tests were within normal limits. An abdominal ultrasound did not demonstrate findings to suggest acute cholecystitis. The patient was subsequently diagnosed with biliary colic and chronic cholecystitis. The patient was taken to the operating room for a laparoscopic cholecystectomy. There were no reported complications. The patient was discharged. 

Per Milliman Care Guidelines (MCG) criteria, admission is indicated for calculus or obstruction of gallbladder or bile duct and either hemodynamic instability, common bile duct obstruction, severe or persistent vomiting or dehydration, severe pain, or bacteremia. According to clinical documentation, the patient did not meet criteria for inpatient admission. Peer-reviewed literature indicates that laparoscopic cholecystectomy can successfully be performed as an outpatient procedure. 

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

Diagnosis: Sickle Cell Disease.

Treatment: Full hospital admission.

The insurer denied coverage for full hospital admission.

The denial is upheld.

According to the clinical documentation provided for review, the patient is a child. The patient has the medical diagnosis of sickle cell disease (SSD) with vaso-occlusive crisis. The patient has a history of hemoglobin (hbg) SSD, who presented to the hospital with leg pain that was unresponsive to Motrin and/or Tylenol. The patient was admitted and given intravenous fluids (IVF) and narcotics. The patient was discharged (d/c) the following day. The treating provider ordered full hospital admission which was denied. The treating provider is requesting plan approval for full hospital admission.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient, as the request was not medically necessary.      

This patient presented with an acute uncomplicated vaso-occlusive crisis (VOC) and pain crisis. These patients can typically be managed in a lower level of care (LOC), such as observation, as this typically improves within 24 to 48 hours. As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate. The request is denied.

Sickle cell anemia is an inherited disorder caused by a point mutation (affecting a single nucleotide) in the gene that encodes the globin chain of hemoglobin (Hb). Two globin chains and two globin chains form a hemoglobin, the multisubunit protein in red blood cells that carries oxygen. The mutation results in the replacement of negatively charged glutamate by a neutral, hydrophobic valine that produces sticky patches on the protein surface. Upon delivering oxygen to the tissues, the mutant hemoglobin (HbS) polymerizes into fibers, which distort ("sickle") red blood cells and cause blockage of the circulation, resulting in acute, severe pain called a sickle cell crisis. Pauling and colleagues reported the molecular basis of sickle cell anemia in 1949, giving birth to the field of molecular medicine. Research on sickle cell anemia has again taken center stage because of new drug therapies, cures through stem cell transplantation, and the promise of gene therapy.

Current treatment options focus largely on best supportive care, including blood transfusions and pain medication (Tisdale, J. F. et al. 2020).   
                                                      
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:  Tinea Pedia.
Treatment:  Naftin 2 percent (%) Gel.

The insurer denied the Naftin 2% Gel.  The health plan's determination is upheld.

The patient is a male, who presented for an evaluation of his interdigital tinea. He had macerated interdigital tinea to the 3rd and 4th interspace of both feet. The patient has tried alcohol and betadine to dry out his interspaces, but this has not helped. A prescription (Rx) for Naftin 2 percent (%) gel was recommended.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient in its determination of medical necessity. There is no documentation that the patient has tried any other medications prior to Naftin 2% gel.

After review of the submitted records and formulary, the requested health service/treatment of Naftin 2% gel is not medically necessary for this patient. There is no evidence of the patient trying and failing 3 preferred drugs for his condition including Clotrimazole, Nystatin cream/ointment and Tolnafate cream. Thus, this request is not medically necessary.

The health plans determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Gait Dysfunction.
Treatment:  Personal care aide (PCA) level 2: 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 Personal care aide (PCA) level 2: 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 determination is overturned.

This is a female patient with a medical history notable for end stage renal disease on dialysis and gait dysfunction. The patient is approved for 5.5 hours per day, 7 days per week (38.5 hours per week) of level 2 personal care services. The patient and her care team requested an increase to 24 hours per day (2-12 hour split-shift), 7 days per week (168 hours per week) and this request was denied by the health plan.

The patient is currently residing in a skilled nursing facility after recovering from a hospitalization. Progress notes from this facility were provided and reviewed in detail.
A social worker from the nursing facility provided a letter of support for this appeal. The letter states that she was intended to stay there only for short-term rehabilitation. The letter states that her current allotment of 38.5 hours is insufficient to meet her needs if she is discharged.

A Uniform Assessment System (UAS) was completed and was available for review. The assessment was completed in the skilled nursing facility. The patient was alert and oriented to person and place. Her recall was 1/3 at five minutes. She is self-directing but forgetful. For her instrumental activities of daily living (IADLs), she requires total dependence for meal preparation, housework, finances, medications, stairs, and transportation. For her activities of daily living (ADLs), she requires total dependence for locomotion. She requires maximal assistance for bathing, dressing lower body, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper body, and bed mobility. She is frequently incontinent of urine and continent of stool. She uses pullups for incontinence care. Compared with a prior UAS, she showed a decline across several functional domains. At issue is the medical necessity of personal care aide (PCA) level 2: 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 requested health service of personal care aide (PCA) level 2: 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 medically necessary for this patient.

The patient requires hands on assistance for all ADLs and IADLs. She is dependent on others for functional needs, including assistance for toileting and incontinence care. These are, by definition, unscheduled and continuous personal care needs. She lives by herself and requires this assistance to be safely discharged home. If she does not receive this care, she will be required to spend 18 plus (+) hours per day in the same soiled diaper, which could result in skin breakdown and/or infection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hearing Problem/Loss - Meniere's disease
Treatment: Replacement sound processor for hearing aid (cochlear implant)
The insurer denied the replacement sound processor for hearing aid (cochlear implant).
The determination is overturned.

The patient has a history of Meniere's disease approximately 18 years prior to presentation with resulting right vestibular weakness diagnosed on Videonystagmography (VNG), right profound sensorineural hearing loss with 0% discrimination diagnosed on audiogram. The patient presented to the physician for consideration of simultaneous right cochlear implant and right labyrinthectomy after attempting to use a Contralateral Routing of Signals (CROS) hearing aid. At issue is the requested health service/treatment of replacement sound processor.

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

The requested health service/treatment of replacement of sound processor (single sided cochlear implantation) is medically necessary for this patient who has right profound sensorineural hearing loss and has been unable to benefit from use of a Contralateral Routing of Signals (CROS) hearing aid. A cochlear implant is necessary to allow the patient to understand speech more appropriately in the affected ear/unaffected ear (example: discrimination with noise background), localize sound, and more easily cope with bothersome tinnitus. Cochlear implantation for single sided profound sensorineural hearing loss is a standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 
 
The patient is an adult female with multiple myeloma, end-stage renal disease (ESRD) on hemodialysis (HD) presented to the emergency room (ER) after dialysis with chest pain and altered mental status. She had a hemoglobin of 5.5, sodium of 129, and potassium (K) of 2.8. She was admitted to the hospital and given intravenous (IV) fluids, electrolytes and transfusions. 

For individuals with anemia, or hyponatremia with altered mental status acute level care is warranted per current applicable guidelines and peer reviewed literature. This individual presented with anemia and hyponatremia with reported altered mental status. Acute level care would be warranted. 

Turner, J. et al. (2023), "Anemia is a reduction in hemoglobin (Hb) or hematocrit (HCT) or red blood cell (RBC) count. It is a presentation of an underlying condition and can be subdivided into macrocytic, microcytic, or normocytic. Patients with anemia typically present with vague symptoms such as lethargy, weakness, and tiredness. Severe anemia may present with syncope, shortness of breath, and reduced exercise tolerance." 

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

The medical necessity for the hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Braces and Monthly Visits
The insurer denied Braces and Monthly Visits.
The determination is upheld.

This is a female patient with a Class I occlusion, no crossbites, 4 millimeter (mm) overjet, 4 mm overbite, and mild maxillary/mandibular crowding. She has extensive untreated decay on teeth 3, 19 and 30. She is treatment planned for comprehensive orthodontics to correct her malocclusion. At issue is the medical necessity of braces and monthly visits.

Orthodontic treatment is not medically necessary in this patient. The patient has major decay, and orthodontic treatment can dramatically increase the risk of tooth decay. (1) The health of the patient's teeth must be addressed before orthodontic treatment should be considered. If these teeth are extracted, the patient still does not have a medical necessity for orthodontic treatment. There is no detectable anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (2) This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. (3) The patient has a 4 mm overjet but this amount of overjet does not affect oral health related quality of life. (4) If her teeth were aligned, it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic membranous nephropathy. 
Treatment: Rituxan, also called rituximab. 
The insurer denied coverage for Rituxan, also called rituximab. 
The denial is overturned. 

This case involves an adult female diagnosed with celiac disease, antinuclear antibodies positive, high cholesterol, prediabetes, pruritus ani, psoriasis, psoriatic arthritis, and sleep apnea.  The patient was prescribed Rituxan (rituximab) but received a notice of adverse determination denying coverage of the medication.  The report stated that the physician ordered Rituxan because of the patient's kidney problem consisting of idiopathic membranous nephropathy. 

The provided clinical records noted that when the patient was seen there were concerns about possible lupus as etiology of proteinuria.  QuantiFERON plus tuberculosis (TB) was negative.  Lab results indicated the patient was nonreactive to hepatitis B.  However, the patient had elevated white blood cell count, red blood cell count, hemoglobin, hematocrit, and platelets with elevated neutrophils and auto immature granulocyte.  The patient's glucose levels were elevated at 119 with blood urea nitrogen elevated at 27.  She had low protein at 5.5 and albumin at 3.2.  She was prescribed Rituxan as a means of treating her condition. 

Literature has noted that membranous nephropathy (MN) is the most common cause of primary nephrotic syndrome among adults.  The efficacy of rituximab in inducing remission has been investigated in several studies, including 3 randomized controlled trials, in which complete and partial remission of proteinuria was achieved in approximately two-thirds of treated patients. Due to its favorable safety profile, rituximab is now considered a first-line treatment option for MN, especially in patients at moderate and high risk of deterioration in kidney function.  Recent evidence has shown the benefits with the use of rituximab in treating the patient's condition.  Given that long-term use of steroids is ill advised, with the patient endorsing side effects from taking prednisone, it was recommended that she trial Rituxan to help control her symptoms.  While she did not meet criteria exactly, she was a suitable candidate for the use of this drug.  As such, the request for Rituxan 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 Rituxan, also called rituximab is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins. 
Treatment: Outpatient procedure (37766, 37765, 37799) x 1 - Stab phlebectomy. 
The health plan denied the outpatient procedure (37766, 37765, 37799) x 1 - Stab phlebectomy. 
The determination is overturned. 

The patient is a female with symptomatic varicose veins of her right leg. The patient underwent a right leg venogram with common and external iliac vein stents. She complained of persistent, painful, and itchy varicose veins of her right leg. 
On examination, the patient was noted to have ropey varicose veins of the right anterior knee and shin, with no wounds or ulcerations. The patient was ordered a right leg reflux study and was prescribed compression stockings. She was instructed to follow up in one month. 
The patient was seen for follow up where she reported little relief of symptoms with daily compression stocking use. A venous duplex exam of the right leg demonstrated no venous insufficiency. The patient was offered stab phlebectomy and then sclerotherapy injections of her right lower extremity varicose veins. 
At issue is the medical necessity of the outpatient procedure. 
The health plan's determination of medical necessity is overturned in whole. 
The requested health service/treatment of outpatient procedure is medically necessary for this patient. The patient has symptomatic right lower extremity varicose veins. Stab phlebectomy of the right lower extremity varicose veins is medically necessary for this patient. Stab phlebectomy is the standard of care for treatment of symptomatic varicose veins. Therefore, the patient will benefit from the treatment, and this treatment is medically necessary.