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

The patient with alcohol use disorder, bipolar disorder, and a history of traumatic brain injury (TBI) was admitted to inpatient rehabilitation following inpatient detox at an affiliated facility.  The patient reported a serious TBI  for which alcohol intoxication was a contributing factor.  Patient reported that this accident was motivating him to get clean from alcohol.  Patient had no withdrawal symptoms on arrival.  Urine was positive for benzodiazepines, presumably from recent withdrawal management.  Patient was not on medication assisted treatment (MAT), and there is no documentation that this was discussed or offered.  Patient reported taking Prozac and olanzapine regularly but was not in outpatient mental health treatment for the last year; patient indicated these medications were helpful for him and denied any acute psychiatric complaints. He denied pain.  The course on the rehab unit appears uncomplicated.  Patient requested to meet with psychiatry to request an increase in olanzapine back to a previously helpful dose.  The patient reported having labile moods to the psychiatrist. Fluoxetine and olanzapine were increased as a result of this evaluation.  However, this evaluation does not coincide with any notes from staff citing labile mood or any psychiatric concerns.  Patient was assigned to attend groups and individual therapy and weekly progress notes from Credentialed Alcoholism and Substance Abuse Counselor (CASAC), and nursing indicated the patient was attending treatment without issue.  Patient worked with the team to arrange appropriate outpatient follow-up appointments/linkages for psychiatric, SUD and medical needs.  For the period in question, nursing notes do not indicate any clinical change or concern.  Vital signs were normal.  Patient was being discharged to a stable residence.  There is no discussion of MAT during this time period. The CASAC discharge note indicates the patient denied cravings for the last few days of the admission.  The health plan's determination of medical necessity is upheld in whole.  There is no documented discussion of MAT for alcohol use disorder in the chart and no rationale documented for why this was not done.  MAT is part of the standard of care for treatment of alcohol use disorders.  The presence of strong supports in the community was not clear; however, the treatment plan had addressed the building of supports and outpatient follow-up.  There is no documentation that the patient has been using in hazardous situations.  A completed concurrent review LOCADTR resulted in a recommendation for a lower level of care.  This was not updated by the facility during the admission to evaluate the ongoing stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
 
Treatment: Dupixent Inj. 200

The insurer denied the Dupixent Inj. 200. The denial was reversed.  

This is a young male patient who presented to his doctor with complaints of severe atopic dermatitis that is generalized. He was recently hospitalized due to the severity of the atopic dermatitis.  The patient has tried and failed topical corticosteroids, calcineurin inhibitors, oral prednisone, Bactrim, Benadryl, hydrocortisone ointment, triamcinolone topical, valacyclovir, cetirizine, and gentamicin ointment. 

Dupixent inj 200 is considered medically necessary for this patient.  He has severe atopic dermatitis that is generalized.  The severity has caused infection necessitating hospitalization.  The patient has tried and failed, topical corticosteroids, oral corticosteroids, oral and topical antibiotics, and oral antihistamine, without benefits.     

The medical literature supports the use of Dupixent inj 200 in the pediatric population. Due to the severity of the atopic dermatitis, and the fact that the patient has tried and failed conservative topical and systemic therapy, the use of oral immunosuppressive medications could have the possibility of organ and bone marrow toxicity which could lead to lifelong adversity. The drug Dupixent has been found to be safe, effective endurable in its therapeutic efficacy in the pediatric population. Therefore, the request for Dupixent should be approved. 

Based on the above, the medical necessity for Dupixent inj 200 is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic short stature
Issue under review: Nutropin

Determination:
The Nutropin is medically necessary.

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4-9]. FDA approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient has a pretreatment height less than or equal to -2.25 SD. The height velocity would not allow a height in the normal range. The patient therefore met idiopathic short stature criteria. The patient has been on treatment and has benefited from treatment, as her height SD has improved. 

Therefore, given the above, the request is consistent with generally accepted standards of medical practice, and it is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a skeletal Class III malocclusion, severe maxillary crowding, severe mandibular crowding, mild overbite and mild overjet. The proposed treatment is braces for 24-30 months. The issue under review is the medical necessity for braces.
The health plan's determination is upheld.
Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 6 with no auto qualifiers. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe periodontal bone loss/defect issues and apical pathology-Tooth #19

Treatment: Bone graft and guided tissue regeneration Tooth #19

The insurer denied coverage for Bone graft and guided tissue regeneration Tooth #19. The denial was reversed.

This patient is a male who presented for evaluation and treatment in the area of #19 which was deemed non-maintainable due to periodontal concerns and significant bone loss/defect and recurring infections.  The dentist recommended extraction of #19 and placement of a graft for ridge preservation prior to placement of an endosteal implant.  

The insurer has denied this service, stating that the extraction site should heal normally without graft placement.

Based on the radiographic images, it is noted that #19 is non-maintainable due to severe periodontal bone loss/defect issues and apical pathology.  To maintain ridge height for future prosthetic rehabilitation with an endosteal implant in the area, the dentist has recommended the aforementioned grafting procedure.  Ridge preservation procedures with bone grafting are an accepted standard of care service in dental practice and substantiated by peer reviewed literature as documented below. As this is a standard treatment, the graft procedure for ridge preservation is deemed dentally/medically necessary.

Reverse the denial and approve bone graft and guided tissue regeneration tooth #19 as dentally necessary as it would be a standard of care service in preparation of an extraction site for endosteal implant placement.

The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

Based on the above, the medical necessity for Bone graft and guided tissue regeneration Tooth #19 is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

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

Treatment:  Comprehensive orthodontic treatment services 

The insurer denied coverage for comprehensive orthodontic treatment services.  The denial was reversed.

This patient is a male who patient presented for evaluation for orthodontic care.  The orthodontist has recommended comprehensive orthodontics due to Class III malocclusion, maxillary and mandibular crowding, and anterior crossbite with gingival attachment loss (canine).  The orthodontist has completed the Handicapping Labio-Lingual Deviation (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 23 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, 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 applied, 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.

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.  

Reverse the denial, as the clinical circumstance presented does substantiate medical/dental necessity of orthodontic care.

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

Based on the above, the medical necessity for comprehensive orthodontic treatment services is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Skeletal Class I malocclusion, maxillary and mandibular crowding and excessive overjet and deep impinging overbite

Treatment:  D8080- Comprehensive Orthodontic Treatment

The insurer denied coverage for D8080- Comprehensive Orthodontic Treatment.  The denial was reversed.

This patient is a female with skeletal Class I malocclusion, maxillary and mandibular crowding and excessive overjet and deep impinging overbite.  The orthodontist recommended comprehensive orthodontics.  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, having attained only 19 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, 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 claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage.  This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. 

Reverse the denial and approve coverage for braces, as the clinical circumstance presented does substantiate medical/dental necessity of orthodontic care.

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

Based on the above, the medical necessity for D8080- Comprehensive Orthodontic Treatment is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Joint problem, pain
Treatment:  Surgical Services

This case describes a patient with a complaint of left knee pain that began two years earlier as a result of a fall down some stairs.  The patient's plain x-rays and a magnetic resonance imaging (MRI) of the affected right knee confirmed osteoarthritis of the medial and patellofemoral compartments, as well as a complex medial meniscus tear.  The patient attempted oral medications and a steroid injection, which failed to provide lasting pain relief.  The patient subsequently underwent right knee arthroscopic surgery.  The health plan's determination of medical necessity is upheld in whole. 
The requested health treatment of Knee Arthroscopy was not medically necessary for this patient.  The rationale for this determination is based upon a review of the current, peer-reviewed orthopedic literature on this topic, which has proven that arthroscopic knee surgery in knees with osteoarthritis is not an effective treatment.
This conclusion was drawn in recent studies published in the peer-reviewed literature by Katz and colleagues in the New England Journal of Medicine and by Steadman and associates in the Arthroscopy Journal.
The rationale for this determination is based upon the provided medical and radiological records which document significant osteoarthritis in this patient's right knee along with a degenerative medial meniscal tear.  This determination was based on the provided medical records, which clearly document osteoarthritic changes in this patient's right knee, as well as an associated degenerative medial meniscal tear for which arthroscopic knee surgery was eventually performed.  The current, peer-reviewed orthopedic literature does not support the efficacy of this procedure.  It has been found to be less effective than more conservative treatment options, such as physical therapy, in a study published by Katz and associates in the New England Journal of Medicine in 2013. Therefore, the right knee arthroscopic surgery was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a medical history of intussusception with three prior laparotomies  intestinal migraine, anxiety, opiate dependence, and cannabis use.  He presented to the emergency department with severe left lower quadrant abdominal pain (sudden onset of 10/10 non-radiating twisting pain), forceful hematemesis, diaphoresis, and lightheadedness.  Lab results were notable for hypokalemia with a potassium of 3.4 millimoles per liter (mmol/L), anemia with a hemoglobin of 12.3 grams per deciliter (g/dL), elevated neutrophil fraction of 79.1%, elevated lymphocyte percentage of 14.6%, and hyperchloremia with chloride of 111 mmol/L.  A urine drug screen was positive for opiates, methadone, and tetrahydrocannabinol.  A computed tomography scan of the abdomen and pelvis showed no acute pathology.  He was treated with intravenous fluids, ondansetron, and ketorolac.  He was admitted as an inpatient.  A computed tomography scan of the abdomen and pelvis on showed a trace of free pelvic fluid but no obstruction, appendicitis, diverticulitis, or colitis.  He had 8/10 left lower quadrant abdominal pain, and a formed non-bloody bowel movement; he later vomited some contrast, and was later noted to be sleeping comfortably, with improved abdominal pain; he did not have nausea, vomiting, diarrhea, or any other complaints.  A Gastroenterology consultation concluded that the symptoms were suggestive of cyclic vomiting syndrome and recommended benzodiazepines and ondansetron as needed, and follow-up with Gastroenterology and possibly Psychiatry or therapy.  A General Surgery consultation concluded that there was no intra-abdominal pathology requiring surgical intervention.  He was treated with intravenous methadone, Dilaudid, lorazepam, and oral dicyclomine. 

The inpatient stay was not medically necessary in this case.  Although the patient presented with abdominal pain and vomiting suggestive of cyclic vomiting syndrome, he did not have persistent hypotension, organ failure, or other stigmata of severe volume depletion.  Although protracted vomiting may have been present, he did not have evidence of bowel obstruction, ongoing gastrointestinal bleeding, peritonitis, abscess, fistula, sepsis, or other complications warranting inpatient level of care [1,2].  Hematemesis and gastrointestinal bleeding did not continue after presentation; there was no protracted tachycardia or hypotension to indicate volume depletion due to blood loss, and the hemoglobin remained stable [3].  The patient had close monitoring, which was warranted, as bleeding can be severe and sudden in onset, and appropriate transfusion [3-5].  However, the Gastroenterology consultation did not suggest an endoscopy or any other intervention for bleeding.  All of the measures that were undertaken, including observation, monitoring, labs, imaging, Gastroenterology and Surgery consultations, antiemetic therapy, analgesic therapy, and intravenous fluid administration, could have been performed without the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: juvenile dermatomyositis and juvenile idiopathic arthritis 
Treatment: Xeljanz

The proposed treatment of tofacitinib is medically necessary to treat this patient with severe, treatment resistant juvenile dermatomyositis and polyarticular Juvenile Idiopathic Arthritis.

Tofacitinib has been used in multiple different patient case series in both juvenile dermatomyositis and juvenile idiopathic arthritis (see references below).  Tofacitinib has been shown to be safe and effective in this patient population.  Therefore, this request should be approved.

The health plan denied coverage of Xeljanz for this patient on the basis that the patient's diagnosis is not approved by the FDA product labeling. While this may be the case, it would be within the standard of care in the pediatric rheumatology community to provide this treatment to this patient at this time. As such, it is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain
Treatment:  Inpatient hospital stay

The patient presented to the emergency department (ED) with crushing chest pain, 7 out of 10, and dyspnea.  The patient noted dyspnea for a few days, and had difficulty walking.  The patient has a history of hyperlipidemia, hypertension, myocardial infarction (MI), seizure disorder, diabetes mellitus (DM), pulmonary embolism (PE), obesity, and obstructive sleep apnea (OSA), and depression.  The patient has a history of coronary interventions, and the last stent was placed 11 days prior to this admission.
The patient was treated with aspirin and nitroglycerin (NTG), without a good response, the pain continued.  The pain was in the left side of the chest, radiating to the left arm.  The patient was given Morphine for his pain.  Cardiology felt that the chest pain was atypical for coronary artery disease.  The cardiac enzymes were normal, and ECG unchanged from baseline.  The chest pain was worse with deep inspiration, which was considered to be possible costochondritis.  The patient was given topical lidocaine.  The patient was given intravenous (IV) Hydralazine, as  BP was 184/80.  Carvedilol was increased.  The patient was continued on a cardiac monitor.  His serial cardiac enzymes were normal.  The health plan's determination of medical necessity is upheld in whole.  The concern about a cardiac event was appropriate, and the patient was evaluated and monitored.  However, chest pain was out of proportion of his ECG, cardiac enzymes, physical examination and CXR.  There were no objective supportive evidence of acute coronary syndrome.  ECG was unchanged from baseline.  Cardiac enzymes were normal. Therefore, acute coronary syndrome was ruled out, and inpatient level of care was not medically necessary.
The patient also had elevated blood pressure, which was provoked by the pain.  However, it was managed mostly by oral medications.  There was IV Hydralazine administered for elevated blood pressure, however, that does not justify an inpatient admission.  IV Hydralazine could be administered in a lower level of care setting.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Hematuria
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary, in part.

The patient is an adult male. He was admitted through the ER with gross hematuria. 

On the day of admission, the patient had gross hematuria that required admission for CBI.  However, by later in the day, the CBI was able to be discontinued.

The next day, the patient's catheter was removed.  Although he had large clots, he was medically stable and able to void spontaneously.   The primary service provided was observation for possible hematuria decompensation.  At this time, he was not in need for an acute level of care, because the same care could have been provided at a lesser degree.

The day of discharge, the patient was stable enough for discharge.  An acute level of care was not needed for this date.

Therefore, given the above, the inpatient admission was medically necessary the first night, though it was not medically necessary from the second day through the day of discharge.