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

Diagnosis: Coronary artery disease
Treatment: Home health care
The insurer denied Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week. 
The health plan's determination is upheld. 

The patient is a male with past medical history of coronary artery disease, congestive heart failure, hypertension, chronic kidney disease, osteoarthritis, dementia, benign prostatic hyperplasia (BPH), deep vein thrombosis (DVT) on chronic anticoagulation, depression, glaucoma, urinary incontinence, bowel incontinence, and gout who had been assigned PCA (personal care aide) services based on assessment tool performed assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, stairs, transportation, bathing, dressing lower body, walking, locomotion, and transfer toilet. With tasks of personal hygiene, dressing upper body, toilet use, bed mobility, and eating the patient was assessed at extensive assistance while supervision with task of phone use. 

Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week is not medically necessary for this patient.

While the patient does require assistance with all activities of daily living (ADL) and Instrumental activities of daily living (IADL) there is insufficient documentation of the patient's overnight care needs that would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. Although the patient's health care advocate noted the patient had a sore on his back and lower extremity this is not documented in the patient's rehabilitation notes. There is no medical order for turning and repositioning overnight. The provided rehabilitation notes indicated the patient was not bed bound contrary to the health care advocates letter. The health care advocate noted the patient was up at night talking and yelling and needed assistance overnight and this assistance would be for safety and supervision which is not a covered benefit under the insurance plan. The rehabilitation provider note stated the patient required around the clock care as the patient was high risk for aspiration and fall without further documentation of how these conditions would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. On the final adverse determination notice, the plan indicated there would be a new assessment at rehabilitation discharge to determine appropriate PCA hours to meet the patient's ADL/IADL needs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 x 12 hours/day, split shift, 7 days/week, to total 168 hours/week are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Opzelura cream. 
The denial is upheld.

The patient is a male with atopic dermatitis, treated with topical steroids, topical calcineurin inhibitors, Eucrisa and Protopic. The provider is requesting Opzelura cream. The denial reason states that the medication is covered when it is being used on a body surface area of 20% or less.

The health plan's determination is upheld in whole.

The requested Opzelura is not medically necessary for this patient. The phase 3 randomized controlled trials included patients with 3-20% body surface area (BSA). According to the dosing requirements, the medication should not be applied to exceed 20% BSA. Therefore, the medication as requested for a body surface area greater than 20% is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis.
Treatment: Cimzia Prefilled 2 x 200MG/ML SC KIT.
The insurer denied the Cimzia Prefilled 2 x 200MG/ML SC KIT.
The denial is upheld.

The patient is a female with psoriasis, treated with topicals and Cosentyx. Patient is currently breastfeeding. She was well controlled on Cosentyx, but stopped due to pregnancy. Patient also has arthritis. The health plan denied the request as Enbrel and Humira are preferred.

No, the requested Cimzia is not medically necessary.
While Cimzia would be not be an inappropriate therapy, all of the anti-TNF (tumor necrosis factor) agents are considered safe in lactation. Cimzia is the most appropriate in pregnancy, but all are acceptable in lactation.

According to the review by Owczarek et al, TNF (tumor necrosis factor) inhibitors are evidenced to be the safest and most researched biological drugs used in psoriasis treatment of patients planning to conceive, during pregnancy or lactation.  Cimizia, Enbrel and Humira are all appropriate therapies for this patient, and the medical necessity of one of these over another is not firmly established.

Therefore, given the health plan's preferred alternatives, the requested Cimzia is not medically necessary.

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

Diagnosis: Cervical radiculopathy. 
Treatment: Inpatient admission. 

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

The patient is a male who had a hospital admission.  The patient had the pre-admission diagnosis of cervical radiculopathy.  The patient was admitted to the hospital for an elective procedure for treatment of neck pain with bilateral arm pain complaints.  The patient had failed all conservative care prior to surgery. 

The patient has a past medical history of diabetes mellitus, hyperlipidemia, and obesity.  The patient had a previous covered infection. The patient had surgery under general anesthesia for anterior cervical discectomy and fusion of C4-5.  Postoperative treatment included intravenous analgesics, neurovascular checks, and intravenous (IV) fluids.  The patient was cleared for discharge the following day.  There was no documentation of any complications and the patient had a routine postoperative course.  This is a review for the inpatient level of care. 

No, the inpatient level of care was not medically necessary. 

The need for this treatment has not been established.  The patient had an anterior cervical discectomy and fusion of a single level which is considered an outpatient procedure.  The patient did not have any associated diagnoses that require treatment during the hospital stay or complications from surgery that would support the need for the inpatient level of care.  Based upon the postoperative course of the patient, the preoperative medical condition, as well as the surgical procedure, the inpatient level of care was not medically necessary. 

The denial of the inpatient level of care was appropriate and medically necessary.  The patient could have been treated in a lower level of hospital care and received the same services.  This was provided in the best medical judgment for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient has a medical history of Ulcerative Colitis, diabetes mellitus type 1, and tobacco use. He presented to the emergency department with 3 days of diarrhea, bloody bowel movements, cramping abdominal pain, nausea, body ache, malaise, and fatigue. He had not been taking mesalamine until 3 days prior. Vital signs were notable for elevated blood pressure of 157/84 millimeters of mercury (mm Hg). Physical examination was notable for a soft, nondistended abdomen with normal bowel sounds. Labs showed elevated hemoglobin of 17.2 and hematocrit of 49.8%, and unremarkable comprehensive metabolic panel. Chest x-ray was unremarkable. Computed tomography scan of the abdomen and pelvis showed no acute intra-abdominal or pelvic inflammatory process, no acute colitis, and borderline dilated appendix without peri appendiceal inflammatory change. He was treated with intravenous fluids and ondansetron. He was made nil per os. Gastroenterology consultation concluded that he had acute decompensation of Ulcerative Colitis, or less likely infection given absence of fever; the recommendation was to continue oral mesalamine, start mesalamine suppository, start prednisone if no suspicion for appendicitis, establish long-term care of ulcerative colitis, and the patient was clinically stable for discharge from a Gastroenterology viewpoint, with a plan for outpatient follow-up within 1 week. He left the hospital against medical advice, on mesalamine. 

The inpatient level of care is not supported. 

The patient presented with diarrhea, hematochezia, abdominal pain, nausea, and fatigue, and was assessed to have an Ulcerative Colitis flare. The standard of care for the evaluation and treatment of Ulcerative Colitis was appropriately performed, including intravenous fluids and supportive care, as well as mesalamine and a recommendation for corticosteroids [1-5]. Imaging did not show colitis or associated complications such as toxic megacolon, and the patient did not have protracted hypotension, peritonitis, bowel obstruction, sepsis, abscess, significant gastrointestinal bleeding or anemia, or perforation to support the inpatient level of care [1-5]. The measures which were undertaken, including observation, monitoring, labs, imaging, Gastroenterology consultation, and mesalamine therapy, could have been performed without the inpatient level of care, at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with a history of menorrhagia, pelvic pain, and pelvic organ prolapse who underwent a laparoscopic assisted vaginal hysterectomy with bilateral salpingectomy, perineoplasty, posterior vaginal repair, and mid-urethral sling placement. The procedure was performed without reported complication. She was discharged the following day on and assessed as an inpatient level of care.

An inpatient hospital admission was not medically necessary. 

The laparoscopic-assisted procedure was reported to have been performed as planned without intraoperative complication. This procedure has generally been considered an outpatient procedure, though many surgeons utilize a night of observation after such a procedure. The records showed the procedure to have been conducted without any unexpected events. Her vitals were normal, and pain was described as controlled by the physician and nursing notes. She tolerated a regular diet on postop day 1, and voided spontaneously after the catheter was removed on postop day 1. There was no documentation in the physician notes of any complications or unexpected events during her stay. Her postoperative day 1 progress note describes her pain as well controlled, and that she was ambulating and tolerating a regular diet. Her blood pressure and other vitals were normal the entire hospital stay (other than a couple mild systolic elevations). Urine output was documented to be adequate. No blood products or extra fluids were administered. Her postoperative hematocrit was 39. Her physician ordered her discharge less than 24hrs after the surgery, as would be typical in an observation case. A lower level of care was appropriate for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8080 comprehensive orthodontic treatment, D8670 periodic orthodontic treatment visits 

The insurer denied coverage for D8080 comprehensive orthodontic treatment, D8670 periodic orthodontic treatment visits

The denial is overturned

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified maxillary crowding, mandibular spacing and anterior crossbite (mandibular right canine/maxillary incisor). The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of cross bite 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 requirements of the HLD index attaining 8 points by internal reviewers when 26 points are required for approval. The orthodontist is appealing on behalf of the patient. 

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, and HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used to utilize 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. 

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.

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

The insurer's denial of coverage for D8080 comprehensive orthodontic treatment, D8670 periodic orthodontic treatment visits is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I skeletal occlusion.
Treatment: D8080 - Comprehensive Orthodontic Treatment of the Adolescent Dentition; 
D8670 - Periodic Orthodontic Treatment visits.

The insurer denied the D8080 - Comprehensive Orthodontic Treatment of the Adolescent Dentition; D8670 - Periodic Orthodontic Treatment visits.  The denial is overturned.

The patient is a female requesting orthodontic benefits. The prior denial was due to a Handicapping index score of 16 which is shy of the 26 threshold. The patient has a Class I skeletal occlusion with moderate upper and lower crowding.

Yes, the proposed treatment is medically necessary.

The patient has a deep, impinging overbite with soft tissue damage on her palate. This is an automatic qualifier according to the Handicapping Index scale. This case has medical necessity and needs orthodontic treatment to correct the problem.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: inpatient hospital admission
The insurer denied coverage for inpatient hospital admission
The denial is upheld

This is a female with a history of mild autism spectrum disorder and mild intermittent asthma. The patient presented to the emergency department (ED) for cough, runny nose, fast breathing, and wheezing. She was given 3 albuterol nebulizer treatments at home without much improvement. The patient had 2 ED visits for asthma in the last few months. A physical exam showed she was tachycardic and tachypneic. She received intravenous (IV) normal saline bolus, Decadron and magnesium sulfate and was admitted to the pediatric inpatient unit for asthma exacerbation where she was further treated with IV steroids.

The patient did not have predictors of severe asthma such as previous ICU (intensive care unit) admission, previous need for BiPAP (Bilevel Positive Airway Pressure) or previous need for ventilators, previous history (hx) of chronic lung disease. Also, the respiratory status improved as expected with scheduled albuterol. There was no need for escalation of therapy nor change in frequency of albuterol. There was no persistent hypoxia and no need for CPAP (Continuous Positive Airway Pressure) or HFNCBiPAP (high flow oxygen through nasal cannula bilevel positive airway pressure). There was no need for the second or multiple doses of MgSo4 (magnesium sulphate) nor Epinephrine nor terbutaline. There was no need for pressors nor multiple boluses.
There were no abnormal labs that persisted. The Bicarb in the BMP (basic metabolic panel) was 15, however the PaCo2 (partial pressure of carbon dioxide) 33 and Ph (potential hydrogen) 7.3. There was no respiratory acidosis. The metabolic acidosis could be from dehydration. If one were to take the PRAM (pediatric respiratory assessment measure) score to assess the pediatric asthma, it would be in the category of mild asthma. If one were to take the PEWS (pediatric early warning signs) score, it would have been desirable also indicating an expectant and stable course in hospital. Bronchiolitis is not a plausible diagnosis because of the child's age. Due to the above reasons, this child could have been treated in observational status

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

Diagnosis: Absence of leg below the knee.

Treatment: durable medical equipment prosthetic repair.

The insurer denied coverage for durable medical equipment prosthetic repair.

The denial is upheld.

The patient is a male with a left below knee amputation (Symes). His prosthetic components and supplies were in need of repair/replacement. Under review is the medical necessity for durable medical equipment prosthetic repair.

This physician agrees with the insurer. This physician also reviewed the medical literature and coding policies as established by the Centers for Medicare and Medicaid Services (CMS). The HCPCS (Healthcare Common Procedure Coding System) code L7520 (repair prosthesis per 15 minutes) labor code should be disallowed. The labor component for the approved liners and foot shell replacements are incorporated in the HCPCS codes L7510 (repair prosthetic device minor parts) and L5679 (addition to lower extremity, below the knee/above knee, custom fabricated from existing mold), which were approved by the insurer.

The health plan acted reasonably, with medical judgment and in the best interest of the patient in this particular case. Considerations included the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendations and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and/or associations. All decisions are evidence-based.

From a physical medicine & rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the durable medical equipment prosthetic repair (as coded) is not medically necessary for this patient.

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

The insurer's denial of coverage for durable medical equipment prosthetic repair is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Enteritis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient presented with abdominal pain, nausea, and vomiting. She was having the pain for 3 months and was found to have an enteritis during an emergency room (ER) visit a few months prior to the subject admission. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. An abdominal computed axial tomography (CAT) scan showed an enteritis. Intravenous (IV) hydration was given, and stool testing was ordered. She was treated with antibiotics and improved. 

Clinical indications for admission for Gastroenteritis according to Milliman Care Guideline (MCG) M-170 include having a suspected severe infection such as bloody diarrhea, severe abdominal pain, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient was diagnosed with an enteritis. IV hydration, antiemetics, and stool testing could have been done in the ER with observation care. If antibiotics were felt to be necessary, she could have been treated with a course of oral antibiotics, without the need for an acute inpatient hospitalization. She responded to the treatment that was given and her symptoms improved. She could have been treated with observation status.

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

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

Diagnosis: Genitourinary/Kidney Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male who was born to a Gravida 3 now Para 3 female by repeat scheduled Cesarean section. His birthweight was 3147 grams, and the one- and five-minute Apgar scores were both 9. He was noted to be admitted to the Neonatal Intensive Care Unit (NICU) secondary to prenatal ultrasounds showing bilateral hydronephrosis. The infant voided 3 times in the delivery room.
While in the NICU, he was hemodynamically stable, breathing unassisted room air, and orally feeding every 3 hours. Electrolytes were monitored and a renal ultrasound was performed. The electrolytes were stable, and the neonate continued to have good urine output. The renal ultrasound showed moderate left hydronephrosis and a voiding cystourethrogram showed no evidence of reflux. The case was discussed with nephrology and an advanced mercaptuacetyltriglycine (MAG-3) scan was ordered. The MAG-3 scan showed normal uptake and borderline excretory function in the right kidney without evidence of obstruction. There was mildly diminished excretory function in the left kidney with a dilated collecting system. Subtle low grade obstruction could not be excluded.
The neonate was discharged. Follow-up was arranged with Urology and with Nephrology.
The subject under review is the medical necessity for the inpatient stay. 

The neonate was hemodynamically stable, breathing unassisted room air, was feeding orally every 3 hours and underwent evaluation for prenatally diagnosed hydronephrosis. Because the neonate did not meet any of the criteria for admission to the NICU the infants care was not medically necessary in the NICU. Care could have been provided at a lower level of care status.