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

Diagnosis: Class 1 malocclusion, maxillary and mandibular crowding, and anterior crossbite with gingival attachment loss (central incisor and canine)

Treatment: Braces (Comprehensive orthodontic treatment) and adjustments to braces (periodic orthodontic treatment)

The insurer denied coverage for Braces (Comprehensive orthodontic treatment) and adjustments to braces (periodic orthodontic treatment). The denial was reversed.

This patient is a male with Class 1 malocclusion, maxillary and mandibular crowding, and anterior crossbite with gingival attachment loss (central incisor and canine). The orthodontist has completed the Handicapping Labiolingual (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  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 only 17 points on review by internal reviewers.  

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

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care.  In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies

The healthcare plan did not act reasonably and with sound medical judgment in the best interest of the patient.  Braces (Comprehensive orthodontic treatment) and adjustments to braces (periodic orthodontic treatment) are considered medically necessary for this patient.

The carrier's denial of coverage for Braces (Comprehensive orthodontic treatment) and adjustments to braces (periodic orthodontic treatment) is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep bite and crossbite
Treatment: Braces and adjustments for braces
The proposed braces and adjustments are medically necessary. 

The patient has a deep impinging overbite with severe soft tissue impingement of the palatal tissues. This is an "automatic qualifier" on the handicapping scale. Also, she has a posterior crossbite on the upper right posterior section. This will, over time cause trauma to these teeth as they will bang into each other traumatically during the chewing cycle because the upper teeth are inside of the lower teeth, which is backwards. This could also lead to temporomandibular joint (TMJ) issues in the future. Both the deep bite and the crossbite need to be corrected with orthodontic treatment. Orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alzheimer's dementia
Treatment:  Personal care services 24 hours/day, 7 days/week (Split-Shift), 168 hours total

The proposed treatment of an increase in Personal care services to 24 hours/day, 7 days/week (Split-Shift), 168 hours total is deemed medically necessary. 

The patient is a male with a history of Alzheimer's dementia, frequent wandering, CHF, atrial fibrillation, legal blindness and insomnia.  For these reasons, he requires assistance with the majority of his activities of daily living (ADLs).  Recent documentation from the patient's Physician, indicates that the patient's overall clinical and functional status has substantially deteriorated over the last few months.  Specifically, the patient is not currently oriented in time or place, is chronically confused and periodically agitated.  He is unable to remember basic daily information or perform any of his activities of daily living without assistance or help.  Hence, the currently approved plan of 24 hours/day, 3 days/week, 39 hours total is not sufficient to meet the patient's current needs.  For these reasons, the proposed treatment of an increase in Personal care services to 24 hours/day, 7 days/week (Split-Shift), 168 hours total is deemed medically necessary for improved assistance with the patient's ADLs.
Appeal type: Medical necessity
Decision: Upheld

The patient  requesting Stelara every five weeks for the treatment of Crohn's disease. The patient  developed psoriasis while on Remicade. The patient tried and failed Entyvio, budesonide, Mercaptopurine, and prednisone. The patient was on every six weeks of Stelara a colonoscopy was with mild inflammation in the descending colon and the hepatic flexure.
The health plans determination of medical necessity is upheld in whole.The stelara injections every five (5) weeks is not medically necessary for this patient.There was no objective documentation of failing the every six week dosing of Stelara, the colonoscopy had mild changes and was improved from the past. The patient's oral intake was improved with a tolerance of salad that she could not do in the past. The patient is maintaining  weight , and has normal inflammatory markers.  The scientific literature has not established the safety and effectiveness of every 5 week dosing of Stelara to treat Crohn's disease. There are a lack of randomized controlled studies or well-designed cohort studies that show an improvement in health outcome, safety, and effectiveness with this approach.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Opioid dependence
 
Treatment: Suboxone 8 mg-2 mg film

The insurer denied the Suboxone 8 mg-2mg film. The denial was upheld.

This female had a diagnosis of opioid dependence and was taking brand name Suboxone 8 mg-2 mg film.  She had taken generic Buprenorphine tablets and had side effects including nausea, constipation, and jitteriness. She tried the Hikma and Sandoz brand tablets and had side effects.  The request was for brand name Suboxone 8 mg-2 mg film for treatment of opioid dependence.

The medical records supported that she did not tolerate the generic Buprenorphine tablets and had side effects, and she tried the Hikma and Sandoz brand tablets and had side effects as well.  However, there was no documentation that she took generic Buprenorphine Naloxone dissolvable tablets or generic Buprenorphine Naloxone films and had lack of efficacy or side effects, as these medications were on formulary. Suboxone brand name was recommended; however, she did not try the alternative formulary generic Buprenorphine Naloxone dissolvable tablets or generic Buprenorphine Naloxone films.  There was no evidence that these formulary medications were contraindicated or tried without efficacy or with side effects.  

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that Methadone, LAAM, Buprenorphine, and Buprenorphine/Naloxone (Suboxone) are all medications used for the maintenance treatment of opiate dependence or for opioid withdrawal.  Although the brand name Suboxone 8 mg-2 mg film was considered standard treatment for opioid dependence or withdrawal, this patient did not try other FDA approved standard medications for opioid dependence and withdrawal, including the alternative formulary generic Buprenorphine Naloxone dissolvable tablets or generic Buprenorphine Naloxone films.  

Based on the above, the medical necessity for Suboxone 8mg-2mg film is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left renal colic
Treatment: Inpatient stay

Summary:

The patient is a male. He was admitted with left renal colic. The patient was treated with a left ureteroscopic stone extraction, laser lithotripsy, stent placement and bladder biopsy.   

An acute inpatient level of care was not medically necessary.  Care could have been provided at a lower level of care.  The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  He did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, severe vomiting.  Pain control, IV antibiotics and IVF followed by ureteroscopic stone removal in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain 

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a female admitted for worsening back pain.  Physical exam was negative for focal neurologic deficit. She was treated with oral and intravenous pain medication, with muscle relaxants, and systemic steroids but the pain remained poorly controlled. The Anesthesia/Pain Management team administered an epidural steroid injection for pain control and she was discharged in stable condition. The patient was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolytes disturbance or change in kidney function, did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration, no new focal neurologic deficit and did not require frequent neurologic monitoring. On a specified date she reported that she no longer had numbness in her left leg, but she continued to have pain. However, she was able to ambulate post-injection. The patient was evaluated by physical therapy (PT) and was recommended for subacute rehabilitation. There is no evidence-based literature that this condition could not be treated safely under lower level of care; therefore, inpatient admission was not medically necessary.

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

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Epigastric and right-upper-quadrant abdominal pain and nausea
Treatment:  Inpatient stay 
The Inpatient admission was not medically necessary.

The patient is a female.  Her medical history includes symptomatic gallstones, liver cysts, renal cysts, and syncope. 

The patient presented to an emergency department with a 48-hour history of epigastric and right-upper-quadrant abdominal pain and nausea.  Her vitals were temperature 36.6, pulse 60, blood pressure 107/69, respirations 16, oxygenation 99%.  Her physical examination demonstrated tenderness to palpation in the epigastrium and right-upper-quadrant.  Serum laboratories demonstrated a normal white-blood-cell count of 7.1. 

The patient was admitted at an acute inpatient level of care with a diagnosis of symptomatic gallstones.  She was made nil per os [NPO]; and provided with intravenous fluids and antibiotics.  She underwent laparoscopic cholecystectomy.  Surgery and recovery were uncomplicated. 

Having returned to her baseline health and function, the patient was discharged home in good and stable condition with outpatient surgical follow-up, and prescriptions for oral analgesics and stool softeners. 

According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), "patients undergoing uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged home on the day of surgery" [SAGES]. Indeed, insofar as the patient did not demonstrate significant co-morbidities or physiologic derangements, and insofar as surgery and recovery were uncomplicated, the patent could have been treated at a lower level of care, precluding the need for admission at an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Stomach pain 
Inpatient Hospital 

The patient presented to the emergency department with abdominal pain and vomiting.
The patient was well until the day prior to admission when the patient developed abdominal pain and had 5-7 episodes of emesis at home. The patient had a prior admission for dehydration and a parent brought her to the emergency department. There was no recent travel or ill contacts.
In the emergency department the patient was initially treated with intravenous Reglan and a normal saline bolus, as well as Zofran orally. Laboratory values were obtained which revealed a bicarbonate of 20 and an elevated white blood count of 22,000 with 80% neutrophils. An abdominal ultrasound revealed no evidence of intussusception.The  health plans determination of medical necessity is overturned in whole .
Yes, the requested health service/treatment of inpatient hospital stay was medically necessary for this patient.
 The patient who presented with abdominal pain and vomiting continued to vomit despite appropriate treatment in the emergency department, and failed an oral challenge. The patient was also found to have an elevated white blood count and developed a high fever and tachycardia. The patient required inpatient admission for management of dehydration with intravenous fluids along with close monitoring and additional diagnostic evaluation and intervention as needed.
The decision-making at the time of admission for this patient was consistent with  young age, the presence of persistent vomiting along with leukocytosis and fever, and the need for prompt initiation of intravenous fluids with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion, Class II maxillary and mandibular spacing
 
Treatment: Orthodontic treatment (braces)

The insurer denied the orthodontic treatment. The denial was upheld.

This patient presented with history of pain for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to skeletal Class II maxillary and mandibular spacing, deep bite, narrow upper arch and ectopic eruption. 

It is evident that the patient exhibits a malocclusion. To assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  

The treating orthodontist claims automatic qualifying conditions of impacted permanent anteriors (and also posteriors) where extraction is not indicated, as well as deep impinging overbite (with and without severe soft tissue damage).  This reviewer finds that neither of these automatically qualifying condition criteria are met and the submitted documentation does not support the need for comprehensive orthodontic care. 

The Handicapping Labiolingual Index methodology has been shown through scientific scrutiny in peer reviewed journals to be a valid approach for assessing orthodontic need.   As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

Braces (D8080) are not considered medically necessary for this patient. The carrier's denial of coverage for Braces (D8080) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient hospital stay

The insurer denied coverage inpatient hospital stay. The denial was upheld.

This patient is a man with a past medical history notable for coronary artery disease, myocardial infarction, three prior stents, diabetes mellitus, and hypertension. He presented to the Emergency Room (ER) with complaints of chest pain. He had negative EKGs and cardiac troponins. He was discharged home with instructions to follow-up with his outpatient Cardiologist for consideration of possible stress testing.

The patient presented with chest pain; however, the initial evaluation in the ER was unremarkable, including a nondiagnostic EKG. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional cardiac testing. Further evaluation was warranted; however, inpatient admission criteria were not met.  There was no evidence of other medical conditions warranting an inpatient level of admission. 

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

Based on the above, the medical necessity for the inpatient hospital stay is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain 
Treatment: Inpatient stay

Summary:
The patient is a female. She presented with chest pain and dyspnea. She had multiple other symptoms, including diaphoresis, palpitations, fatigue, weakness and slurred speech. She received heparin, IVF, ASA (aspirin) and NTG (nitroglycerin).

The patient presented with atypical symptoms and no direct evidence of ischemic heart disease. The EKG (electrocardiogram) was benign. Enzymes were negative. There was no WMA (wall motion abnormality). CT scan showed Calcium score of zero. The "stenosis" described with negative calcium is not considered diagnostic, nor did the treating physicians act on it. 

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 case, the patient's symptoms were atypical and unlikely to be representative of acute coronary syndrome (ACS). Her exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. CXR (chest x-ray) was normal. Echocardiogram showed no wall motion abnormality. Physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for ACS such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG.  

There was no acute intervention, nor was one indicated. The patient did not have evidence of unstable angina. CT angiography does not require inpatient level of care. While risk factors present are significant, the patient did not have actual clinical CAD that required intervention. Discharge diagnosis does not include ACS. All of the testing and therapy that were provided would have been appropriate, safe and guidelines consistent in lower level of care. Thus, inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Heart Problem
Inpatient Hospital

The patient has cardiac risk factors of diabetes and cigarette smoking. He underwent stress testing with myocardial perfusion imaging for complaints of fatigue. This showed a small, mild to moderate perfusion defect of the inferolateral wall. He presented to the hospital for elective cardiac catheterization. At the time of presentation, he was pain-free with a blood pressure of 135/60 mmHg and a heart rate of 62 beats/minute. He had no ischemic electrocardiographic changes. Cardiac catheterization showed proximal and mid-right coronary artery disease that was treated with drug-eluting stents. The procedure was uncomplicated. The patient was admitted to the hospital post-procedure. His overnight course was uneventful and he was discharged home the following day. The inpatient admission is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. While some period of observation immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document From the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. This patient met none of these criteria. Per the recommendations, patients with stable symptoms who receive more than one stent in the same vessel, such as this man, can be observed overnight for a period of less than 24 hours, and do not require an inpatient admission. Accordingly, the care this patient received could have been provided at a lower level of care and an inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Throat Infection
Inpatient Hospital

The patient is a female with presentation to the emergency room (ER) with sore throat (pain 3 of 10) and history of pink eye for two days. She had also tried Tylenol as an outpatient. The patient was a gravida (G) 3 para (P) 2 who had a 2 day history of sore throat. There was no fever or chills. She had no headache, nausea, vomiting or visual symptoms. She reported this to be of mild to moderate severity. She had no prior medical history. There was no history for smoking. At home, she had been on Augmentin 875/125 milligrams (mg) every 12 hours and Claritin 10 mg tablet daily. Her complete review of systems was otherwise negative. The patient was given a diagnosis of pharyngitis. The patient was transported to labor and delivery (L&D) for clearance after evaluation in the ER per hospital protocol. The patient had stable vitals and was afebrile. She was 133/85 by blood pressure which is normal. Her oxygen saturation was 100% on room air. Labs were completed and noted a normal urine and complete blood count. The white blood cell (WBC) count was 13.83 which is normal for pregnancy. Hemoglobin was 11.4 grams per deciliter (g/dL). A complete metabolic panel was normal. Vital signs remained stable without any evidence of sepsis. The patient was given a course of dexamethasone and Augmentin was continued. The patient was discharged to home with follow-up planned in the outpatient setting.

The health plan's determination is upheld. 

In this case, the patient had a sore throat and was under treatment with Augmentin at the time of presentation. There was no signs of sepsis or fever. She was noted to have been treated with dexamethasone in the hospital. The vitals remained normal. There were no pregnancy complications noted. In this case, the care rendered could have been performed at a lower level of care and would not have required admission to acute inpatient level of care. The administration of steroids (dexamethasone) would not require inpatient admission. Given the lack of signs of sepsis or serious infection, there would also not have been reason for admission to acute inpatient care. Under the Milliman Care Guidelines (MCG) Care Guideline entitled "General Criteria - Observation Care," the level of care appropriate for head and neck problems such as sore throat would be supported at a lower level of care status. There is no support for acute inpatient level of care in this case.