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

Diagnosis: Stroke/CVA
Treatment: Home Health Care
The health plan denied the requested increase in personal care services
The health plan's determination is overturned

The patient is a female with a past medical history of dementia, cerebrovascular accident (CVA), atrial fibrillation on anticoagulation, urinary incontinence, stool incontinence, hypertension, hyperlipidemia, osteoporosis, unsteady gait, depression, frequent falls, Dupruytren's contractures with deformity and macular degeneration with impaired vision who had been assigned 7 hours/day, 7 days/week to total 49 hours/week of personal care assistance (PCA) services based on assessment tool. The patient had a fall with subsequent admission to the hospital then a Skilled Nursing Facility (SNF) stay and discharge to home. At the assessment it was noted that the patient was moderately cognitively impaired, and she had symptoms of delusions and hallucinations. The patient is anticoagulated on Eliquis making her risk for injury with fall increased.

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

The patient has the medical diagnosis of dementia, which is a progressive disease. The patient has documented worsening of her dementia but the patient's frequent falls with injury and hospitalization caused her to require more assistance with ADL's and instrumental activities of daily living (IADLs). The patient had a telephonic assessment performed which underestimated her assistance with tasks of bathing, personal hygiene, dressing upper/lower body, transfer toilet, toilet use, bed mobility and eating. The patient's PCP and daughter provided documentation of the patient's assistance needs with ADL's and IADL's. There is also documentation that the patient is up at night at least 5 times to use the bathroom and/or commode requiring assistance with these tasks (bed mobility, walking, locomotion, transfer toilet, toilet use and incontinence cares). PCA service hours are not for supervision and safety but to assist the patient with unscheduled tasks overnight. The patient previously had an informal helper and no longer does. Due to the patient's overnight unscheduled assistance needs a PCA would not be able to obtain 5 hours of uninterrupted sleep. Personal care services are medically necessary under Medicaid when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
Treatment: D8080 Braces and D8670 monthly visit x12
The insurer denied D8080 Braces and D8670 monthly visit x12.
The denial was upheld.

This is a patient who consulted an orthodontist for orthodontic care. Diagnostic studies were performed that included lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite and impacted permanent anteriors. The orthodontist has completed the HLD index as required and has chosen the automatically qualifying conditions of deep impinging overbite with severe soft tissue damage and impacted permanent anteriors where extraction is not indicated. 

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion 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 deep impinging overbite with severe soft tissue damage and impacted permanent anteriors where extraction is not indicated. However based on the review of the medical record, the automatically qualifying condition criteria are not met and do not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the insurer attaining a score of 23 points on the HLD index (3 overjet, 6 overbite, 10 anterior crowding, 4 labiolingual spread) which is below the threshold of 26 points 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. The peer reviewed articles reviewed for this case conclude 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 this patient's orthodontic need.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for D8080 braces and D8670 monthly visit x12 is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders
Treatment: Surgical Services
The insurer denied: Abdominoplasty
The denial is: Upheld in whole

The patient is a female who has lost almost 100 pounds following bariatric surgery. She complains of rashes in the fold under her panis. Steroid creams and powders have not improved her rashes. She has been treated by a dermatologist for at least four months with no improvement in her rashes. Her surgeon recommends abdominoplasty and panniculectomy.
The subject under review is the medical necessity for the abdominoplasty.

The health plan's determination is upheld in whole.

An abdominoplasty is not medically necessary. According to the American Society of Plastic Surgeons (ASPS) Position Paper "Treatment of Skin Redundancy For Obese and Massive Weight Loss Patients", "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic. Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically, these procedures are performed to improve appearance and are therefore cosmetic in nature."
An abdominoplasty is a cosmetic body contouring procedure that will not confer any additional functional benefit for this patient, therefore the procedure is not considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Coronary Syndrome.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was upheld.    

This is a male patient with a medical history of hyperlipidemia.  He presented to Emergency Room with complaints of mid-sternal chest pain and dyspnea on exertion, dry cough and generalized weakness.  His initial ER vital signs noted a blood pressure 131/85, pulse 95, respirations 16, temperature 97.7F, and blood oxygen level 97% on room air.  The patient stated his symptoms began several days ago and that they are notable on exertion and subsided at rest.  An electrocardiogram (EKG) showed normal sinus rhythm with no ST elevations or other ischemic changes.  Bloodwork revealed a troponin less than 0.015.  Chest radiography was negative.  He was given aspirin in the ER and was admitted to telemetry with dyspnea on exertion to rule out acute coronary syndrome (ACS).  Repeat cardiac enzymes were also normal.  Cardiology was consulted.  An echocardiogram showed normal left ventricular systolic function, mild diastolic dysfunction, and trace mitral regurgitation.  A nuclear stress test was negative for significant reversible ischemia.   The patient was medically stable and discharged to home.  

The patient presented with chest pain and dyspnea on exertion.  His initial evaluation in the ER was unremarkable, including a non-diagnostic EKG and negative cardiac biomarkers. There were no high-risk symptoms suggestive of acute coronary syndrome, rather that of stable symptomatology. As medically essential as it was to evaluate his symptoms, inpatient admission was not medically necessary for this patient. The patient's care could have been provided under the observational setting, allowing for additional diagnostic testing, which was done here, yielding no high-risk or concerning findings necessitating further inpatient evaluation. Further evaluation was warranted, however inpatient admission criteria was not met.  During the patient's initial evaluation and subsequent hospitalization, he exhibited no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. For all of these reasons, the observational level of care would have been appropriate.

The health plan acted reasonably with sound medical judgment 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: Abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male who presented to the emergency room (ER) for further evaluation/management of left lower quadrant abdominal pain. Intake vitals were afebrile, hemodynamically stable. Examination was notable for abdominal distention and left lower quadrant tenderness. Electrocardiogram (EKG) and laboratory testing was within normal limits. The medical records indicate that the patient was admitted to the inpatient medical service in stable condition where he received supportive care measures of intravenous (IV) fluids, continuous cardiac telemetry monitoring and serial cardiac biomarker testing. He was started on IV proton pump inhibitor (PPI) therapy and improved with the prescribed therapy. He was subsequently discharged in stable condition.  

No, the proposed treatment of inpatient admission is not deemed medically necessary. 

There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. Therefore, the proposed treatment inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with a past medical history of marijuana use who presented to the hospital with complaints of severe abdominal pain that she described as squeezing and burning, which was primarily located in the upper abdomen and radiated throughout the abdomen. It was associated with nausea and vomiting. Reportedly, the patient had been seen in the hospital on multiple occasions for similar symptoms, and on previous occasions was diagnosed with marijuana-induced hyperemesis.

The inpatient stay was not medically necessary. In this particular case, the diagnosis of CHS was pretty evident based on the patient's past medical history, results of the physical exam, laboratory studies, and diagnostic tests. Even though the patient had abdominal pain, nausea, and vomiting, there was no evidence of profound dehydration or severe electrolyte abnormalities. There was no need for any interventions or surgeries. Therefore, observation to treat the patient's symptoms and to ensure adequate hydration and hemodynamic stability was reasonable. This could have been provided at a lower level of care. According to the medical records, the patient's symptoms improved very quickly, and the patient tolerated her diet. Taking into consideration all these facts, neither the severity of the patient's condition or the complexity of the services provided justified admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Dx: Respiratory System
Tx: Inpatient Hospital
Denied: Inpatient Stay
Denial OVERTURNED in whole

The patient is a young female who presented to the emergency department (ED) with a 1 day history of cough, congestion, and wheezing. In addition, she vomited several times the day prior to admission. There was a history of fever to 102, rash, and exposure to brother with similar illness. Past medical history was remarkable for 35 week gestation and eczema.
ED vitals showed temperature (T) 99 Fahrenheit (F), heart rate (HR) 148, respiratory rate (RR) 48, and oxygen (O2) saturation of 98% on room air. Physical exam was notable for rhinorrhea, increased work of breathing with wheezing, and facial rash. The patient received ibuprofen, intravenous fluid (IVF) bolus, and albuterol nebs x 3. Respiratory syncytial virus (RSV) and influenza testing was negative. Labs showed white blood cell (WBC) count=11.5 with 47% segs and 34% lymphs, hematocrit (Hct)=36, platelets (Plt)=535. Electrolytes were normal except for low bicarb=18. Chest x-ray was obtained, and findings were consistent with acute bronchiolitis. The patient was treated with oral prednisone and albuterol/Atrovent nebs; she was still wheezing and tachypneic, so the decision was made to admit to the hospital for further management.

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

The requested inpatient hospitalization is medically necessary for this patient. This patient presented to the ED with tachypnea (RR=48), wheezing, and respiratory distress, consistent with a diagnosis of bronchiolitis. The patient was treated with prednisone and nebulizers in the ED for acute wheezing, with continued tachypnea and respiratory findings. Thus, the decision to admit to the hospital was warranted based on the acute need for continued breathing treatments and inpatient monitoring. Inpatient hospitalization was medically necessary for frequent vital sign monitoring, nebulized treatments, and respiratory support.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fracture to neck of right humerus with shaft displacement
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission. 
The denial is reversed. 

This is a male struck by an auto while walking across street. He reported an injury to his right shoulder. He was evaluated in ED and diagnosed with fracture to neck of right humerus with shaft displacement. He was also found to have 7th and 8th rib fractures. He underwent several diagnostic studies. He required Orthopedic and Psychiatry consult. He was found to have alcohol withdrawal. He was admitted to hospital and discharged the next day.

This man has a complex clinical condition. He has a newly diagnosed displaced fracture to his proximal right humerus with new rib fractures. He was involved in a high energy type of trauma with associated mental status abnormality. The man is at high risk for complication. He required additional specialty testing and consultation. He required monitoring which could not be provided as an outpatient. There is concern as likely problems could arise from chest injury, extremity injury and possible head trauma. His alcoholism and new onset multi trauma substantiates the need for admission and all services provided. 

Observation status would not be applicable; the health care plan did not act 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 from is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Complaints of right sided pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient is a female who presented to the emergency department (ED), with complaints of right sided pain after a fall. The patient reported that she was walking, tripped and fell onto the concrete, and she immediately developed pain in the right upper quadrant area. The patient denied head trauma, loss of consciousness, change of vision, fever, chills, chest pain, shortness of breath, nausea, vomiting, diarrhea, urinary or fecal incontinence. She was given Motrin in the ED. Examination showed a soft abdomen but tenderness on palpation. She was seen by trauma surgery and cleared for discharge. An ultrasound revealed there was scant free fluid in Morrison's pouch and Pouch of Douglas. A computed tomography showed trace pelvic free fluid which was from a probable degenerating/ruptured right ovarian cyst, but there was otherwise no acute disease or evidence for a traumatic injury to the chest, abdominal organs or viscera. Her urinalysis showed trichomonas. Gynecology was consulted and noted the patient would need to be treated prophylactically for chlamydia and bacterial vaginitis with Flagyl, Zithromax and Doxycycline. 

Trauma Surgery was also consulted, and she was cleared from a trauma standpoint. 

The patient was admitted for serial abdominal exams and cardiac monitoring due to the right upper and lower quadrant pain. The patient's complete blood count lab work was stable, indicating there was no internal bleeding from the pelvis. She was discharged with outpatient instructions to follow up with her physician in 2 to 3 days and to return to the ED if the pain worsened. 

The patient had a fall. She was evaluated and cleared by trauma surgery. Because of trichomonas in the urine, she was seen by gynecology and prescribed antibiotics. Treatment of trichomonas infection does not require admission.

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.

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:  Helicobacter Pylori.
Treatment:  Pylera 10 DAY PAK.

The insurer denied the Pylera 10 DAY PAK.  The denial is upheld. 

The patient is a male, who has a history of Helicobacter (H) pylori gastritis.  The patient failed a Prevpack course of treatment twice.  At this time, the provider requested treatment with Pylera. 

No, the brand Pylera treatment course is not medically necessary, as there are numerous generic alternatives available to the patient on the formulary.

There are numerous generic treatments for H. pylori.  This patient failed the same regimen twice.  H. pylori is never treated with a repeat regimen, as the bacteria becomes resistant to the failed regimen.  As such the patient failed exactly one regimen, and there are numerous alternatives.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteogenesis Imperfecta
Treatment: Zometa
The insurer denied the Zometa.
The determination is overturned.

The patient is diagnosed with osteogenesis imperfecta (OI). As reported, treatments with bisphosphonate have already been delayed for many months secondary to COVID, therefore, she is at increased risk of sustaining life threatening fractures. She has a history of severe OI, failure to thrive, developmental delay, seizures, obstructive sleep apnea (OSA). Her severe OI has caused her multiple lifetime fractures. She has had 12 biphosphonate infusions with pamidronate which have helped to reduce the number and severity of fractures. She has been unable to be hospitalized for the 3 day stay for pamidronate secondary to the inability to obtain a bed secondary to the global COVID pandemic. During a hospitalization for pamidronate infusion, she was noted to have breast budding consistent with a small amount of estrogenized breast tissue under bilateral areola.
Her C-terminal telopeptide (CTX) was 310; N-terminal telopeptide (NTX) (serum) was 37.6; NTX (urine) was 457; alkaline phosphatase (alk phos) was 56.9.
Her Vitamin D was 37.9; parathyroid hormone (PTH) was 56.1.
At issue is the medical necessity of Zometa.
Treatment of osteogenesis imperfecta with intravenous bisphosphonates (pamidronate or zoledronic acid) is standard of care(1-5). This indication is listed in Micromedex for pediatric patients with osteogenesis imperfecta. This patient has osteogenesis imperfecta with fractures. Non-treatment of this patient would be expected to cause ongoing fractures. The request is consistent with the standard of care based on the above cited studies. The request is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Dupixent
The insurer denied the Dupixent.
The denial is overturned.

The patient is a female with severe eosinophilic asthma who is being treated with inhaled corticosteroid-and-long-acting beta agonist (ICS/LABA) and Singulair with frequent asthma exacerbations requiring systemic steroids. The patient is prescribed Dupixent. 

Yes, the proposed treatment is medically necessary.

The clinical documentations provided describes the patient as having been compliant with ICS/LABA as well as other asthma maintenance medications. The patient has had recent asthma exacerbation requiring steroids and has had multiple cycles of prednisone use in the past 12 months. Since initiation of Dupixent, the patient's asthma symptoms have improved significantly, and the patient's quality of life has improved significantly. 

Dupilumab has been shown to increase lung function and reduced severe exacerbations in patients with uncontrolled persistent asthma irrespective of baseline eosinophil count. Thus, addition to inhaled corticosteroids plus long-acting 2-agonist therapy could improve the lives of patients with uncontrolled persistent asthma compared with standard therapy alone. To date, there is the strong need to compare the efficacy across the monoclonal antibodies (mAbs) approved to treat severe asthma. All the investigated mAbs were more effective than placebo in reducing the risk of exacerbation and improving lung function. Dupilumab showed a general superiority compared to the other mAbs, as it significantly reduced the risk of exacerbation versus omalizumab, and significantly improved forced expiratory volume in one second (FEV1) when compared to omalizumab, mepolizumab, and benralizumab. 

Since this patient's asthma is inadequately controlled with current treatments, the addition of Dupixent is medically necessary.