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

Diagnosis: Transient Ischemic Attack (TIA). 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is overturned. 

The patient is an adult female who presented to the emergency room with near syncope associated with paresthesia in the right arm and shortness of breath. The paresthesia was persistent for the last few days. There was also slurred speech. Computed tomography (CT) angiogram of the chest showed filling defects within the periphery of multiple right lower lobe pulmonary arteries. Due to concern for transient ischemic attack (TIA) versus pulmonary embolus, the patient was admitted, and workup was ultimately negative. The patient was stabilized. The inpatient admission was previously denied as it did not meet level of care. 

Inpatient admission was medically necessary. 

According to the Milliman Care Guidelines (MCG) on Syncope, inpatient admission is indicated with suspicion of imminently dangerous cause. Suspicion of pulmonary embolus falls within this given the risk for significant morbidity and mortality. Furthermore, transient ischemia attack can be a precursor to a stroke which in itself can cause significant morbidity and mortality.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: Full braces

The insurer denied coverage for full braces

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, and overbite, and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation Index Report (HLD) index attaining 17 total points to support orthodontic care. 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. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 17 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining a total of 17 points on the Handicapping Labio-Lingual Deviation Index Report (HLD) index (2 overjet, 3 overbite, 10 anterior crowding, 2 labiolingual spread) which is below the threshold of 26 points to support orthodontic care. Of note is in this case, the patient's own orthodontist does not attain 26 points on the Handicapping Labio-Lingual Deviation Index Report (HLD) index as required for orthodontic approval. 

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 full braces services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic neck pain. 
Treatment: Outpatient procedures 64490 x 1 and 64491 x 1 (facet joint injections). 
The insurer denied coverage for outpatient procedures 64490 x 1 and 64491 x 1 (facet joint injections). 
The denial is overturned. 

This is an adult female with chronic neck pain. She has had prior radio frequency ablation (RFA) of her facet joints 2 years ago with good results, as well as repeat diagnostic blocks. She has had physical therapy (PT) and Home Exercise Program. She has had trials of non-steroidal anti-inflammatory drugs (NSAIDs), Tylenol, Topamax and Gabapentin. Imaging report documents "moderate spondylosis". 

The patient has tried several medications for more than 3 weeks. The patient meets ALL of the criteria for these injections. Clinical practice guidelines (1,2) support the performance of facet blocks in this patient. 

The requested procedure is medically reasonable and 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 outpatient procedures 64490 x 1 and 64491 x 1 services is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Mild Persistent Asthma.
Treatment:  Flovent HFA (Hydrofluoroalkane).

The insurer denied Flovent HFA.  The denial is upheld.

The patient is a school age male with a diagnosis of persistent asthma. The prior denial reason was formulary requirements are not met. The reason the physician is appealing the determination is to provide further documentation.

The health plan should not cover the proposed treatment.

The patient has used Flovent for asthma with improvement of symptoms. The patient also has sensitization to aero allergens. However, there is no high-quality study demonstrating that the requested medication is more effective and safer than all formulary medications. The formulary medications include Pulmicort Flexhaler.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cardiac/Heart Problem.
Treatment:  Transthoracic Echocardiography (TTE).
The health plan denied the Transthoracic Echocardiography (TTE).  The determination is overturned.

The patient is a female with a past medical history significant for chronic right bundle branch block (RBBB) and hyperlipidemia who was seen by her medical provider for an annual evaluation. The patient reported feeling well and denied cardiac symptoms. She exercises twice weekly on the Peloton bike. For evaluation of structural heart disease, the treating provider ordered a transthoracic echocardiogram (TTE).
At issue is the medical necessity of the transthoracic echocardiogram (TTE).
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of transthoracic echocardiogram is medically necessary for this patient. The patient was diagnosed with RBBB. The electrocardiogram (ECG) performed was abnormal demonstrating normal sinus rhythm, RBBB with possible right ventricular hypertrophy (RVH) and rightward axis. Based upon the eviCore version 2.0 2023 cardiac imaging guidelines and the 2011 appropriate use criteria for echocardiography, obtaining a transthoracic echocardiogram would be medically appropriate in this case for evaluation of structural heart disease, including myocardial and right ventricle (RV) abnormalities. [1]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Anemia.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

This is a female patient with a past medical history (PMH) of diabetes mellitus type 2 (DM2), who was admitted with complaints of (c/o) weakness without overt evidence of an acute gastrointestinal (GI) bleed. Her vital signs were unremarkable. The physical exam was unremarkable. Lab work was notable for a hemoglobin of 5 and glucose 610. The patient was diagnosed with severe anemia and hyperglycemia and was treated with intravenous fluids (IVF), transfusion of 3 units of packed red blood cells (PRBCs), insulin, and a GI consultation. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) weakness associated with anemia. The patient was found to have a low hemoglobin but had no history of hematochezia or hematemesis. She received three units of PRBCs, symptomatically improved, and was discharged home in stable condition. The patient did not have hemodynamic instability, persistent orthostasis, evidence of active bleeding in the ED (such as frequent episodes of hematemesis, or bright red blood per rectum (BRBPR)), coagulopathy, or known esophageal varices. For the hyperglycemia, the patient was hemodynamically stable, responded to insulin therapy, and there was no diabetic ketoacidosis (DKA), acute mental status change, end stage renal disease (ESRD), sepsis, acute cerebrovascular accident (CVA), acute myocardial infarction (MI) or significant complications, and she did not have any evidence of acidosis, as the patient had a normal serum bicarbonate without a significant increase in the anion gap. GI evaluated the patient and determined there were no overt signs of an acute GI bleed and recommended an outpatient work-up. This patient could have been safely observed and received a diagnostic work-up, consultation and transfusion at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fall
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld. 

The patient is a female who initially presented to the emergency department with concerns of falling down a flight of stairs with loss of consciousness. Pertinent history included pulmonary embolism (7 years prior) on Eliquis, complex regional pain syndrome, oxygen dependence, hypertension, and prior cerebrovascular accident (CVA). Initial vital signs noted the patient to be afebrile, hemodynamically stable, and without hypoxia. Initial examination documented the patient as alert, oriented, Glasgow Coma Scale (GCS) 15, without focal neurologic deficits, and with left 1st toe discoloration and 2 posterior scalp hematomas. 

The inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care. The patient had a history of complex regional pain syndrome with opioid dependence and remote pulmonary embolism on Eliquis who presented with concerns for a syncopal event. Initial examination documented the patient as alert, oriented, hemodynamically stable, and with a GCS 15. Initial evaluation revealed a left 1st non-displaced phalangeal base fracture, but otherwise unremarkable laboratory testing, electrocardiography, and extensive computed tomography (CT) imaging. Orthostatic vital signs unremarkable. Podiatry recommended a surgical shoe and weight bearing as tolerated. Treatment plan included telemetry and supportive care. Following observation, no other issues or complications were documented and the patient was discharged.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chest pain and shortness of breath

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient is an adult female who presented to the emergency department (ED)  with complaints of chest pain and shortness of breath (SOB).  Vital signs: Temperature 99.4 degrees Fahrenheit, Pulse 95 beats per minute, Respirations 18 breathes per minute, Blood Pressure 123/81 mmHg (millimeters of mercury), oxygen (O2) saturation 98 % (percent) on room air. The patient was in no acute distress with clear lungs, normal heart sounds, soft abdomen and no edema.

White blood cell (WBC) count was 9.1. Hematocrit 33. Electrocardiogram (EKG) was normal. Computed tomography angiography (CTA) revealed bilateral pulmonary emboli, no evidence of right heart strain or pneumonia.  Studies were negative for deep vein thrombosis (DVT). 
Echocardiogram was done which revealed normal left ventricular function and no evidence of right heart strain.

The patient was seen by Pulmonary and Hematology and was recommended to start Lovenox.
2 doses of Lovenox were given. The patient remained stable after admission, was afebrile and hemodynamically stable, tolerating oral (PO) intake, not hypoxic. Patient was switched to oral Eliquis and was subsequently discharged home on oral medications.

This  patient did not need acute inpatient hospitalization. She could have been placed in Observation status while diagnostic testing and treatment were initiated. Observation period could be for up to 48 hours.

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

Dental Problems/dental issues
Dental/Orthodontic Procedure/adjustment and insertion of braces
The health plan denied the requested health service of adjustment and insertion of braces as not medically necessary. The health plan's determination is upheld.

The patient in question is a male with a Class I occlusion. He has 5 millimeter (mm) overbite and a 3 mm overjet. He has minor maxillary and severe mandibular crowing. He is treatment planned for 24-30 months of orthodontics to correct his malocclusion.
At issue is the medical necessity for the requested health service/treatment of adjustment and insertion of braces.

I uphold, in whole, the health plan's determination of medical necessity.

He has crowding but no teeth are impacted. His overbite is deep but there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows the lower incisors are contacting the upper incisors in occlusion, not the palate. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) on this patient. There are no anterior or posterior crossbites present.
There is no medical reason to correct his malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. [1] This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. [2] The patient has a slightly excessive overjet but this amount of overjet does not negatively affect oral health related quality of life. [3] If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis/sepsis. 
Treatment: Inpatient stay. 
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This case involves a man with multiple medical problems, including prior history of cellulitis of the legs, who presented to the emergency department (ED) with one day of right leg edema, erythema, and pain, with associated fevers and chills. Outpatient labs showed a leukocytosis of 20,000. He took one dose of Keflex and came to the emergency department to be evaluated. The temperature was 37.2, heart rate 79, respirations 22, and blood pressure 89/55. Laboratory studies were repeated, confirming leukocytosis of 23.1. Electrolytes and renal function were stable, and so were the LFTs (liver function tests). Lactic acid was 2.6. He was treated with ceftriaxone and doxycycline in the ED and admitted to the hospital. Examination showed no muscle tenderness to palpation, and the skin rash was described above. Admitting diagnosis was severe sepsis due to cellulitis. 

The inpatient hospital admission was not medically necessary. The patient had signs of sepsis, with mild lactic acidosis on admission; however, within 24 hours, there was a dramatic clinical improvement. On hospital day 1, the patient's vital signs are normal, leukocytosis has improved, and no rapidly progressive cellulitis or deep tissue infection is present. By hospital day 2, the white blood cell count had normalized, and the patient expressed a desire to be discharged. Inpatient admission was designed to treat severe infections that do not readily respond to appropriate antibiotic treatment. The patient did not fail outpatient antibiotics, as the documentation states he only took one dose of Keflex before being admitted to the hospital. There is no documentation of an inability to maintain adequate hydration. Beyond the initial vital signs, mild hypotension, and tachycardia, the rest of the vital signs remained stable. There is no concurrent end-organ damage. Finally, the blood cultures remain negative by the 48-hour mark.
Therefore, in summary, inpatient admission is not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Asthma.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

The patient is an adult female with a history of Asthma, Depression and Migraine. She was seen in Urgent Care where she was found to have wheezing and was given Prednisone and nebulizer treatment. The patient was subsequently sent to emergency department (ED).

Vital signs on presentation to the emergency department were: Temperature 97.8 degrees Fahrenheit, Respiratory Rate 20 breaths per minute, Heart Rate 79 beats per minute, Blood Pressure 119/79, oxygen saturation was 100 % (percent) on room air. The patient was speaking in full sentences and was alert and orientated to person, place and time and was in no apparent distress.

On examination she had bilateral wheezing in the lungs, the abdomen was soft and non-tender.  White blood cell (WBC) count was 6.2 and electrolytes were within normal limits.

The patient had upper respiratory infection (URI) symptoms and possible pneumonia (PNA). She was desaturating to oxygen level 80's % upon ambulating. She was started on intravenous (IV) steroids and IV antibiotics Rocephin and Azithromycin.

The plan was to do a computerized tomography (CT) of the chest to rule out pulmonary embolism; however, the patient signed out against medical advice (AMA). She was discharged on oral antibiotics and oral steroids.

It was appropriate to admit the patient for asthma exacerbation and to treat hypoxia of unknown etiology.

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 inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment:  D8080 Braces and D8670 monthly visit x (times) 12
The insurer denied coverage for D8080 Braces and D8670 monthly visit x 12.
The denial is overturned.

 
Upon review of the submitted documentation including lateral cephalometric radio graph, 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, and anterior crowding among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index attaining 28 total points. 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 attaining only 19 points on the HLD index by internal reviewers. The Provider is appealing the decision on behalf of the patient.

Upon review of the submitted documentation (study models were not provided for review) 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, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 
In this case, the treating orthodontist completes the second portion of the index arriving at 28 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist 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. 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.

D8080 braces and D8670 monthly visits x (times) 12 is considered medically necessary for this patient.

Based on the above, the insurer's denial must be reversed. 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 D8080 Braces and D8670 monthly visit x (times) 12 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine 
treatment: Vyepti
The insurer denied Vyepti.
The health plan's determination is upheld. 

The patient is a female with chronic migraines who is requesting treatment with Vyepti. The drug was denied because the patient is also using Qulipta, an oral CGRP (Calcitonin gene-related peptide) inhibitor, for prevention of migraine. 

Treatment with Vyepti is not medically necessary. While the patient does have a Food and Drug Administration (FDA) approved indication, the patient is concurrently receiving treatment with another (oral) CGRP inhibitor for prevention of chronic migraine. Studies are lacking to show that the combination of an oral and injectable CGRP inhibitor is safe and more effective than treatment with a single agent for prevention of migraine. The standard of care is to use either an oral or injectable CGRP inhibitor to prevent migraine. The provider has not submitted any literature to show that the use of Qulipta when added to Vyepti or vice versa leads to decrease migraine headache days or disability.