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

Diagnosis: Hypercholesterolemia. 
Treatment: Livalo (pitavastatin) 2MG (milligrams) OR (oral) TABS (tablets). 

The insurer denied coverage Livalo (pitavastatin) 2MG (milligrams) OR (oral) TABS (tablets). 

The denial is upheld. 

This patient has a history of atypical chest pain, hypertension, mild mitral regurgitation, palpitations and hypercholesterolemia.  Exercise stress testing revealed good exercise tolerance with no evidence of ischemia. Echocardiography revealed normal left ventricular ejection fraction (LVEF) and no wall motion abnormalities. No history of atherosclerotic cardiovascular disease was noted in the medical records submitted. Serum blood testing revealed hypercholesterolemia with a mild elevation of LDL (low-density lipoprotein) cholesterol. Treatment for hypercholesterolemia was initiated. Simvastatin was, Rosuvastatin 5 milligrams (mg) was prescribed, Atorvastation was prescribed, pravastatin was prescribed thereafter.  The patient reported myalgias following treatment with these agents. Cholesterol panel revealed a total cholesterol of 227 mg/dl milligrams per deciliter, LDL 153, HDL (high-density lipoprotein) 58. The patient's physician is requesting renewal of livalo (pitavastatin). 

The health care plan acted reasonably, with sound medical judgment, and in the best interest of the patient. This patient has no history of atherosclerotic cardiovascular disease and has 10-year risk of arteriosclerotic cardiovascular disease (ASCVD) of less than 5% (percent).  American heart association guidelines recommend lifestyle modification without the use of statin therapy for primary prevention of ASCVD in this setting.  (Reference 1).  This patient has been treated with several low intensity statin agents and noted intolerance due to myalgias.  Current guidelines support lifestyle modification without statin therapy. (Reference 1,2).  Pitavastatin therapy is not medically necessary in this case. 

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

The insurer's denial of coverage for Livalo 2MG OR TABS is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class II subdivision left malocclusion.
Treatment: braces.
The insurer denied braces. 
The health plan's determination is upheld. 

The patient in question is a male with a diagnosis of Class II subdivision left malocclusion, 5 millimeter (mm) overjet and a slight anterior open bite on tooth 8, but all other teeth are in occlusion. The upper and lower arches both have crowding. 

Braces (Comprehensive Orthodontic Treatment) are not medically necessary.
The HLD (Handicapping Labio-Lingual Deviations) score of 15. The patient does not have a skeletal anterior open bite, the patient does not have ectopic eruption of any teeth (a tooth blocked out more than 50% in the arch), and crowding in the mandible is not significant.
The patient has overjet and crowding but those alone do not rise to the threshold of necessitating braces. Anterior open bites of a dental nature may even close spontaneously in a growing patient. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. There does not appear to be any wear present on the teeth due to his occlusion. In the absence of a functional problem, orthodontic treatment would not be medically necessary to prevent future problems.
Appeal type: Medical necessity
Decision: Upheld

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

This is the case of a male with autism who presented to the emergency department (ED) with acute tonic-clonic seizure. The episode was witnessed by the patient's mother, lasted approximately 2 minutes, and subsided without intervention. Emergency Medical Services (EMS) was called to transport the patient to the ED. There was a similar episode 2 weeks prior with urinary incontinence and lethargy. During the ED stay, the patient became increasingly more alert. The patient was admitted to the hospital for neurological evaluation and video electroencephalogram (EEG). 

The requested inpatient hospital stay was not considered medically necessary. This patient is a stable teenager without underlying medical condition or history of trauma or illness. He presented after a witnessed and unprovoked general seizure that was brief and self-limited. Per current guidelines for both children and adults, the necessary follow-up evaluation and care could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overjet, open bite, ectopic eruption, and anterior crowding and posterior crossbite.

Treatment D8080 braces and D8670 monthly visits.

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

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, open bite, ectopic eruption, and anterior crowding and posterior crossbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 34 total points. 

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, an HLD index is utilized. This index provides six specific conditions that automatically qualify tor 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 completes the second portion of the index arriving at 34 points to justify orthodontic care. This reviewer in general concurs with the index completed by the orthodontist except that either ectopic eruption or anterior crowding is to be counted, not both. This reviewer attains a total of 27 points on the HLD index (3 overjet, 4 open bite, 12 ectopic emption, 4 labiolingual spread, 4 posterior unilateral crossbite) which remains above the threshold of 26 points to support 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 referenced below.

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 meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval.

The healthcare plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for D8080 braces and D8670 monthly visits is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

The health plan denied the requested inpatient stay. 
The health plan's determination is overturned. 

This is a male who presented to the emergency room with acute gastrointestinal (GI) symptoms (progressive suprapubic pain, nausea), abnormal vitals (tachycardia, fevers, tachypnea, and hypotensive blood pressure). This was accompanied with abnormal labs (leukocytosis, hyponatremia, and abnormal liver function test) in the setting of an abnormal diagnostic computed tomography (CT) scan concerning for sigmoid diverticulitis. He was admitted to the inpatient floor, placed on bowel rest, and received intravenous (IV) fluids, antiemetics, and broad-spectrum antibiotics. His signs and symptoms (acute GI symptoms and infective indices) slowly improved. He tolerated oral intake and was switched from IV to oral antibiotics before being discharged home. 
At issue is the medical necessity of the inpatient stay. 

The health plan's determination of medical necessity is overturned, in whole. 

Inpatient care was medically necessary. This is a male presenting with sepsis secondary to diverticulitis. His clinical presentation required IV fluids for correction of tachycardia and febrile illness, broad-spectrum IV antibiotics for the management of diverticulitis to prevent complications of diverticulitis, which may lead to increased mortality, and morbidity. This detailed inpatient care such as IV fluids, bowel rest, serial monitoring labs, IV antibiotics, and IV analgesics cannot be prudently provided under an observation level of care to prevent diverticulitis complications, including intra-abdominal abscesses/perforation, which may lead to death.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion, deep bite, mild crowding. 
Treatment: D8080 Braces. 

The insurer denied the D8080 Braces. 
The denial is overturned. 

The patient is a female with a Class I malocclusion.  She has a deep bite and mild upper and lower crowding.  The reason for prior the denial is a Handicapping Scale score of 11. 

Yes, the requested braces are medically necessary. 

The photos and x-rays show that the patient has a deep, impinging overbite with soft tissue damage to her palate. This is an automatic qualifier for orthodontic benefits. 

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: Impetigo. 
Treatment: Inpatient Hospital Stay. 

The insurer denied coverage for inpatient hospital stay. 

The denial is upheld. 

This was a male with a history of autism, supraventricular tachycardia, and eczema who was seen by the pediatrician and treated with oral cephalexin and topical mupirocin for impetigo, then was seen in the ED (emergency department) the next day for rash worsening (the rash had spread from the face and cheeks to the palms, soles, trunk, and gluteal region), was sent home and came back the next day again. 

The ED exam clearly documents that the child was in no distress and was interacting appropriately with the caretaker. The clinical impression was severe impetigo. CBC (complete blood count) and chemistry were within normal limits, he was hemodynamically stable, afebrile with vital signs within normal limits. 

The Pediatricians progress note mentions that due to mother's delay in obtaining oral antibiotics there was progression of the rash, so he was admitted for treatment of impetigo. The team's working diagnosis was coxsackie virus infection, because of a few buccal lesions, with differential diagnoses of herpes with superinfection or varicella with superinfection. 

The reviewer agrees with the insurer that admission was not warranted. It is not evident from the medical record that the patient was ill appearing, toxic, at risk for sepsis, or unable to take oral medication. Therefore, whether he had severe impetigo, or coxsackie infection, (it does appear that he had eczema herpeticum), his condition did not warrant parenteral antimicrobials or inpatient care.  Moreover, no adequate justification is presented in the ED notes. The reviewer does not see anything in the history or review of systems saying he was refusing oral intake. It is noted that the acyclovir was administered PO (by mouth) in the hospital. 

Although his impetigo was relatively limited, even if he is classified as "Extensive Impetigo" because more than 2 sites were involved, the treatment regimen recommended is an oral course of antibiotics. (Baddour, UpToDate) 

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

The inpatient admission is not considered medically necessary for this patient. 

The insurer's denial of coverage for inpatient hospital stay is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Disease. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This patient has a history of sickle cell disease, priapism, and status epilepticus. He presented to the emergency room (ER) with complaints of back pain and knee pain. There was no priapism this time. The chest x-ray was normal. He was admitted. During the admission, the patient was given 4 milligrams (mg) of intramuscular (IM) Dilaudid every four hours (Q4H) as needed (PRN) and 25 mg of IM Benadryl every (Q) 4H PRN. Folic acid and multivitamins were also given. The patient's condition improved after treatment and he was discharged Against Medical Advice (AMA). 

"Sickle cell disease (SCD) is a group of inherited red blood cell disorders affecting about 1 in 500 African American children and 1 in 36,000 Hispanic American children. SCD results in anemia and "sickle cell crisis" (SCC). The main clinical feature of sickle cell disease is the ''acute painful crisis,'' which often requires hospitalization. The term "sickle cell crisis" is used to describe several acute conditions such as the vaso-occlusive crisis (acute painful crisis), aplastic crisis, splenic sequestration crisis, hyperhemolytic crisis, hepatic crisis, dactylitis, and acute chest syndrome. Other acute complications include pneumonia, meningitis, sepsis and osteomyelitis, stroke, avascular necrosis, priapism, and venous thromboembolism." (Borhade , M. B., & Kondamudi, N. P.). 

According to the records and the Milliman Care Guidelines (MCG) criteria for admission, and do not find that he had elements that required admission. He did not have chest syndrome or priapism and Dilaudid and Benadryl could have been given by mouth. There was no evidence of infection. He did not require exchange transfusions, oxygen, or narcotics that could not be given by mouth. 

On review of the available documentation, it was found that the vital signs were stable and the exam was negative. He was capable to hydrate by mouth. He refused placement of an intravenous (IV) line and IV hydration, and signed out against medical advice (AMA). Clinical indications were not present for the inpatient admission. Therefore, the inpatient admission in question was not medically necessary for this patient. 

The health care plan did act reasonably and 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: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female. She presented with chest pain, SOB (shortness of breath), and heart racing. She had risk factors of hypertension, and prediabetes. 

The patient underwent stress testing and dobutamine. Her dizziness prevented completion. Her Calcium score was 109, and outpatient work up was recommended. Her lab was normal. Her EKG (electrocardiogram) revealed no acute changes, and echocardiogram showed no wall motion abnormalities. She had no chest pain in hospital. The patient was discharged on ASA (aspirin) and statin. 

No, the Inpatient admission was not medically necessary. 

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. 

In this patient's case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome. Her exam, including vital signs and cardiac findings, were normal. Biomarkers and EKG (electrocardiogram) showed no evidence of acute ischemia. CXR (chest x-ray) was normal. Echocardiogram showed no wall motion abnormality.  Dobutamine was negative for CAD (coronary artery disease). 

The physicians' treatment did not reflect any serious concern about the patient's cardiac condition.  Orders did not include medical therapy for ACS (acute coronary syndrome), such as IV (intravenous) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV (intravenous) NTG (nitroglycerin). 

The letter of appeal was carefully considered, but it offered no evidence to support an inpatient level of care. The only cardiac care that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. 

There was no "complex" care provided that required inpatient level of care in this patient's care. While there was always a potential for an adverse event, one did not happen, and no actual treatment was added. 

Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS (acute coronary syndrome) present. 

All of the testing and therapy that were provided would have been appropriate, safe and guidelines consistent in a lower level of care. Thus, inpatient level of care was not medically necessary. 

The denial explanation was consistent with guidelines and usual community care. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld.

This female was hospitalized for chest pain. She presented to the hospital emergency department (ED) for evaluation of intermittent chest pain of two days. Treatment included aspirin. Her past medical history is pertinent for multiple abdominal procedures. There was no history of hypertension (HTN), hyperlipidemia (HLP) or diabetes mellitus (DM). 

The patient's vital signs were stable. Her heart rate was 65 to 70. Electrocardiogram (EKG) showed normal sinus rhythm (NSR) and no acute changes. Her troponin panel was negative. Chest x-ray showed no abnormality detected (NAD). Echocardiogram with doppler was normal. Telemetry monitor showed ST/AT with correlation of her chest discomfort. Electrophysiology (EP) cardiology recommended using a beta-blocker. The patient was started on metoprolol and discharged to home. This is an appeal of the denied claim that the requested acute inpatient hospital stay was medically necessary for this patient.

No, the proposed treatment was not medically necessary.

According to the Milliman Care Guidelines (MCG) for Chest Pain, #M-89, there was not a medical need for the acute inpatient hospital stay because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the guideline, criteria for inpatient admission is not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome (ACS) or chest pain that is indicative of a serious cardiac condition, such as acute myocardial infarction (AMI), pulmonary embolism (PE), aortic dissection, pneumonia, cardiac arrhythmias requiring immediate attention or any other medical condition that warranted inpatient hospitalization. The care the patient received, including treatment of uncomplicated supraventricular tachycardia (SVT) with an oral beta-blocker is routinely provided safely and effectively at a lower level of care, such as at the observation level of care. Therefore, based on the submitted information and the current standard of care, there was not a medical need for the acute inpatient hospital stay for this patient.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right foot pain.
Treatment: Inpatient admission.

The insurer denied inpatient admission.  The denial is overturned.

The patient is a male with a history of insulin-dependent diabetes, osteomyelitis times 2, diabetic neuropathy, splenectomy, partial pancreatectomy and polysubstance abuse on methadone. He presented to emergency department with right foot pain, wound, odor and pus.

On initial examination the patient's vital signs were stable. He was found to have a right heel ulcer, tenderness, erythema, and drainage. His labs were significant for an elevated white count as well as elevated inflammatory markers. These are typically indicative of osteomyelitis. He was started on IV (intravenous) clindamycin and Zosyn. He was monitored for worsening signs of infection. X-ray was negative and an MRI (magnetic resonance imaging) was ordered. Unfortunately an MRI (magnetic resonance imaging) was not performed, as it was noncompatible with his implants.

Infectious disease and podiatry were consulted. A local debridement was performed. A bone scan was recommended which showed cellulitis and osteomyelitis. This showed osteomyelitis of the distal fibula. In was decided at that point to discharge the patient home, so that a bone biopsy could be performed after the antibiotic had been given. It was felt that a more accurate culture could be obtained from bone once the antibiotics had been discontinued. Patient was then discharged.

Yes, the Inpatient admission was medically necessary.

The admission was medically necessary. The patient is a diabetic with previous history of osteomyelitis who had a malodorous wound. The standard of care is to refer to the emergency room for possible surgical treatment and certainly IV (intravenous) antibiotics. That is exactly what was done in this case. The patient did not undergo surgery, as the infectious disease specialist and podiatrist felt the best course of treatment at that time would be to delay operative care, and that is why the patient was discharged rather than keep the patient in-house. This was done because it was felt a more accurate bone biopsy could be performed while the patient is off antibiotics. This initial antibiotic was necessary to prevent sepsis. The ordering of labs, the monitoring of the patient for worsening symptoms, the ordering of a bone scan, the administration of IV (intravenous) antibiotics to prevent sepsis and evaluation by multi specialists are all in keeping with standard of care for this condition.

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

This was a medically very admission. All actions and interventions are in keeping with standard of care. Failure to have treated this way could have led to limb loss and death. Treating the patient at a lower level of care than acute inpatient admission would not have been consistent with the standard of care.