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

Diagnosis: Abdominal Pain. 
Treatment: Emergency Department (ED) visit. 

The insurer is denied coverage for Emergency Department (ED) visit. 

The denial is upheld. 

This male patient has a no past medical history. 

This case does not meet the definition of an emergency condition as defined by the New York State Insurance Law as judged by the clinical evidence submitted. It is not sudden onset as the pain had been present for 10 days. The pain was described as minor in severity. The patient was eating and drinking normally and having normal bowel function. This case could have been managed at a lower level of care. 

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

The carrier's denial of coverage for the Emergency Department (ED) visit is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe Overbite with Lower Incisors Impinging on Palatal Tissue.

Treatment: Full Braces.

The insurer is denied coverage for full braces.

The denial is upheld. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The Orthodontist recommended comprehensive orthodontics due to excessive overjet. The orthodontist has presumably completed the Handicapping Labio-Lingual Deviation (HLD) Index as required and although not submitted for review, the narrative letter state the patient exhibits the automatically qualifying conditions of overjet greater than 9 mm (millimeters) with incompetent lips or reverse overjet greater that 3.5 mm with reported masticatory/speech difficulties, and deep impinging overbite with severe soft tissue damage to support orthodontic necessity. 

It is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, 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 overjet
greater than 9mm with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties and deep impinging overbite with severe soft tissue damage. This reviewer finds that these automatically qualifying conditions 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.

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 cited below. 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 healthcare plan did act reasonably and with sound medical judgment in the best interest of the patient.

The coverage of full braces is not considered medically necessary for this patient.

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

Diagnosis: Postpartum Preeclampsia. 
Treatment: Inpatient Hospital Admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

The patient is a female with a past medical history of gestational hypertension, gestational diabetes, and status post Cesarian-section, who presented to the Emergency Department (ED) for evaluation of elevated blood pressure. In the ED, the patient initially had two blood pressure (BP) readings with systolic in the 160s and Labetalol was administered.  Urinary protein was negative. Laboratory evaluation was normal. 

The patient was admitted for postpartum preeclampsia superimposed on gestational hypertension without severe features. She was started on magnesium sulfate for post-partum seizure prophylaxis. The patient decided to leave against medical advice (AMA). 
 
This patient presented few days after delivery with elevated blood pressure. Delayed postpartum preeclampsia can be defined as signs and symptoms of the disease leading to readmission more than two days but less than six weeks after delivery. 

The diagnosis of preeclampsia is based on the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman: 
Systolic blood pressure >=140  or diastolic blood pressure >=90, and 
Proteinuria >=0.3 grams in a 24-hour urine specimen or protein: creatinine ratio >=0.3, or 
Signs of end-organ dysfunction (platelet count <100,000/microliter, serum creatinine >1/1 or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration). 

This patient had elevated blood pressure, no protein in the urine was documented and no elevated liver function tests (LFT) and no end organ dysfunction. This patient did not have a diagnosis of preeclampsia. She had significant elevation in her blood pressure. 

Ideally this patient would have been observed in the ED. Once her blood pressure was controlled, the patient could have been discharged home on home blood pressure monitoring and to return if any worsening of her blood pressure. Admission to the hospital was not medically necessary. 

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

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

Diagnosis: Becker Duchenne Muscular Dystrophy. 
Treatment: Emflaza. 

The insurer denied the Emflaza. 
The denial is overturned. 

The patient is a male with diagnosed Becker/Duchenne muscular dystrophy. His diagnosis was confirmed with genetic testing. He began treatment with deflazacort (Emflaza) at the time of diagnosis, consistent with the standard of care. While still ambulatory, he requires assistance to stand and has an elevator in his home. He falls on average once a month but has so far suffered no head or other serious injuries. He has undergone surgery for cataracts, has dyspnea walking a block, and has chronic dry cough. He recently has been diagnosed with gastroesophageal reflux disease and started on PPI (proton pump inhibitor) therapy. He continues on Emflaza therapy. 

Yes, the requested treatment with Emflaza is medically necessary. 

Corticosteroid use is standard of care for patients with Duchenne muscular dystrophy. Studies have shown that corticosteroids yield short-term improvement in both muscle strength and function (up to twelve months) and strength up to two years. Deflazacort, an oxazolone derivative of prednisolone, has been associated with less side effects that prednisone. This young man has history of abdominal pain and GERD (gastroesophageal reflux disease), and he is not a good candidate for prednisone therapy.  Deflazacort is not without side effects, but in the interest of providing this young man with standard of care treatment and a chance at prolonged muscle strength and function, deflazacort has a better side effect profile than prednisone and is therefore medically necessary and appropriate for him.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: left breast cancer

Treatment: genetic test (BRCA)

The insurer is denied coverage for genetic test (BRCA)

The denial is upheld. 

This female patient has a history of left breast cancer.

The National Comprehensive Cancer Network (NCCN) (2021) guidelines do not support the requested testing on this patient on the basis of age, no Ashkenazi ancestry, and no family history or personal history of breast cancer below age 45 or 46-50. Furthermore, the information provided for the BRCA test does not indicate it is for treatment planning, as NCCN recommends.

Casaubon, J. T. et al. (2021), "American Society of Breast Surgeons emphasizes the importance of thorough patient history and uses the following criteria (similar to the NCCN guidelines for genetic risk evaluation).

Criteria for testing in patients with a personal history of breast cancer and one or more of the following (from the NCCN and the American Society of Breast Surgeons Consensus Guideline on Hereditary Genetic Testing) [4][5]:
1)Age of onset less than or equal to 50
2)Triple negative tumor (ER-PR-HER2-) and age less than or equal to 60
3)Ashkenazi Jewish heritage and breast cancer at any age
4)Two or more primary breast cancer (either asynchronous, synchronous, bilateral, or multicentric)
5)A first-degree relative with breast cancer diagnosed at age less than or equal to 50
6)Two relatives on the same side of the family with breast cancer and/or pancreatic cancer
7)Family or personal history of ovarian cancer, fallopian cancer, or primary peritoneal cancer
8)Male breast cancer
9)Known mutation carrier in the family"

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

The carrier's denial of coverage for the genetic test (BRCA),  is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: malignant hypertensive urgency

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission

The denial is upheld. 

This male patient has a history of hypertension and congenital heart defect.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  Hypertensive emergency is defined as (Blood Pressure) BP >180/120 with target organ damage. (Reference 1) This patient complained of abdominal cramping and blood in his stool. He had no evidence of anemia or significant blood loss, a benign abdominal examination, and no acute pathology on CT abdomen. This patient had a hypertensive urgency without any target organ damage. Treatment goals for hypertensive urgency are to institute antihypertensive medications in an outpatient setting. American Heart Association/American College of Cardiology (AHA/ACC) guidelines state: "There is no indication for referral to the emergency department, immediate reduction in BP in the emergency department, or hospitalization for such patients." (Reference 1) Admission to the hospital for aggressive blood pressure management was not medically necessary. (Reference 1,2) In conclusion inpatient hospital admission was not medically necessary in this case.

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

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure. 
Treatment: Inpatient Hospital Stay. 

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

The patient was in his usual state of good health when he was found on the floor of his bedroom having a generalized tonic-clonic seizure. The seizure had a duration of about 20 minutes and stopped spontaneously. Postictally, he was sleepy. He was transported to the emergency room by Emergency Medical Services (EMS). By the time he arrived at the emergency room, he was back to normal. On physical examination in the emergency room, he was afebrile and had normal vital signs. His level of consciousness was normal, and all aspects of his neurological exam were normal. He was found to have some dental caries and some dark spots on his skin, but his general physical examination was otherwise normal. In the emergency room, blood tests, including a complete blood count and basic metabolic panel were normal. An electrocardiogram (EKG) was also normal. A magnetic resonance imaging (MRI) scan of the brain revealed a partially empty sella, but was otherwise normal. He received intravenous levetiracetam and was admitted to the hospital. In the hospital, he underwent an electroencephalogram (EEG), which was abnormal and revealed frequent multifocal sharp waves and spike-wave discharges. Throughout the hospitalization, he remained seizure-free and clinically stable and was discharged the following day. At issue is the medical necessity of an inpatient stay. 

The inpatient stay was not medically necessary. 

When a child has a single seizure that is self-limited and stops spontaneously, then it is reasonable for that child to be evaluated in the emergency room. If the child is found to have normal vital signs, normal electrolytes, and a normal neurologic exam, then that child can be safely discharged to home. It is not medically necessary to admit a child to the hospital after a single seizure. 

This patient had a single self-limited seizure that stopped spontaneously. In the emergency room, he had normal vital signs, was clinically stable, had a normal neurological examination, and had normal blood test results. He could have been safely discharged to home. It is customary and appropriate to discharge such patients. 
Therefore, the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease as well as depression, ataxia, cerebrovascular accident, dementia, gastroesophageal reflux disease. 

Treatment:  PCW (personal care worker) services of 8 hours per day, 7 days per week for a total of 56 hours. 

The insurer denied coverage for PCW services of 8 hours per day, 7 days per week for a total of 56 hours. 

The denial is overturned. 

This case involves a male with a history of coronary artery disease as well as depression, ataxia, cerebrovascular accident, dementia, gastroesophageal reflux disease, abnormality of gait and mobility as well as polyosteoarthritis. The documentation indicated he has been receiving personal care worker (PCW) for approximately 42 hours a week. It has been recommended that his hours increase to 56. The submitted documentation does indicate the patient is able to ambulate and transfer with the assistance of a walker. The documentation indicated he has had multiple falls related to dementia and cerebellar ataxia. Due to his multiple medical problems, he requires assistance with all activities of daily living (ADLs) including but not limited to dressing, bathing, feeding, food preparation, and toileting. He will likely require assistance 24 hours a day according to the physician; however, as this is not possible the family was requesting an increase from 6 hours a day to 8 hours a day. 

This patient is said to suffer from multiple medical issues including polyarticular degenerative arthritis, ataxia leading to gait abnormalities and impaired mobility due to a previous cerebral vascular accident (CVA), both of which affect his mobility and make him susceptible to frequent falls and potential adverse events including fractures and intracranial bleeding. There is documentation that he has already suffered multiple falls in the past. He is also reported to have dementia, and this would make it difficult for him to call for help if he did fall. He is also reported to require help with all ADLs and his provider is recommending that he have 24/7 care. He currently receives 6 hours a day of PCW services, but this is not adequate for him in view of all the clinical conditions mentioned.

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 the requested Personal Care Worker (PCW) Services of 8 hours per day, 7 days per week for a total of 56 hours is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: GI (gastroenterology) Bleed. 
Treatment: Inpatient hospital stay. 

The insurer denied coverage for inpatient hospital stay. 

The denial is overturned. 

This patient with a history of hypertension, hyperlipidemia, osteoarthritis, and kidney stone presented to the emergency department (ED) for evaluation of bloody bowel movements 5 times. The admission was medically necessary at the acute inpatient level of care. The patient could not have been safely and effectively managed at an observational level of care or been directly discharged from the ED or ambulatory surgery unit based on the advanced age, comorbidity, and/or presenting complaints. Because of this patient's age and/or multiple comorbidities, acute bleeding, and/or recurrent chronic symptoms, the evaluation warranted the level of admission. 

Visible rectal bleeding occurring in adults warrants evaluation in all cases. The timing and setting of the evaluation depend upon the severity of bleeding and the patient's comorbid illnesses. A gastroenterology consultation should be obtained early in the hospital course of patients with acute lower GI bleeding. 

The initial management of a patient with suspected acute lower GI bleeding includes triage to the appropriate setting for management (outpatient, inpatient, intensive care unit), general supportive measures (e.g., oxygen, the establishment of adequate intravenous access), appropriate fluid and blood product resuscitation, and management of coagulopathies, anticoagulants, and antiplatelet agents. 

Patients with high-risk features including hemodynamic instability (shock, orthostatic hypotension), persistent bleeding, and/or significant comorbid illnesses should be admitted to an intensive care unit for resuscitation, close observation, and possible therapeutic interventions. 

This was not the case in this clinical setting, although in this case, it was not appropriate with only observation including automated blood pressure monitoring, electrocardiogram monitoring, and pulse oximetry. 

Most other patients without high-risk features such as hemodynamic instability can be admitted to a regular medical ward as in this case. 

Note that observation-level care was not appropriate in this clinical setting. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for the inpatient hospital stay is substantiated. The insurer's denial is overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine Headache.
Treatment: Ubrelvy.
The insurer denied Ubrelvy. 
The health plan's determination is upheld. 

The patient is a woman with a diagnosis of chronic migraine without aura. Treatment with Ubrelvy is the subject of this review.

A formulary exception is not indicated in this case. 
Formulary Alternatives:
Almotriptan, Eletriptan, Forvatriptan, Naratriptan, Rizatriptan, Sumatriptan Injection, Sumtraiptan Nasal Spray, Sumatriptan Tablet, Zolmiptriptan, Nurtec ODT, Zembrace ODT, Zomig nasal spray.
The documentation indicates that the patient has a relative contraindication to triptan medications due to reports of chest pain. This may be a relative but not absolute contraindication. There is also documentation that the patient has tried and failed Maxalt (rizatriptan).
Assuming that the patient has a contraindication to all triptans due to the relative contraindication of chest pain, the formulary drug is still not medically necessary because the formulary includes Nurtec ODT (orally disintegrating tablet). This drug is not a triptan. It is a gepant and has the same mechanism of action as Ubrelvy, the requested medication. There is no indication that this drug will not be as effective as the requested drug or would have adverse side effects.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Impinging Overbite. 
Treatment: D8080 braces and D8670 monthly visit x (times) 12. 

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12. 

The denial is upheld. 

The patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to the impinging overbite, among other findings. 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. 

It is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index (HLD) 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. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does 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 HLD index of the insurer attaining 21 points (3 points overjet, 5 points overbite, 3 points ectopic eruption, 5 points anterior crowding and 5 points labiolingual spread). 

Uphold denial as the clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care. 

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visit x 12 is upheld. Medical necessity is not substantiated.