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

Diagnosis:  Malocclusion 

Treatment:  Comprehensive orthodontic treatment

The insurer denied coverage for comprehensive orthodontic treatment of the adolescent dentition.  The denial was upheld.

This patient is a male who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to Class I malocclusion, anterior crossbite with gingival attachment loss, Class II molars and maxillary and mandibular crowding.  The orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and gingival recession are present.  The insurer has denied coverage for orthodontic treatment as not medically necessary attaining only 15 points on review by internal reviewers. 
It is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and, therefore, medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are employed, 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 not met 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 insurer, attaining a score of 15 points on the HLD index (4 overjet, 2 overbite, 6 ectopic eruption, 3 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.  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 healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient.  Based on the above, the medical necessity for the comprehensive orthodontic treatment of the adolescent dentition is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Other
Home Health Care

The patient requests personal care services, and an increase to 24 hours a day 7 days a week split shift for a total of 168 hours per week. Patient requests additional services for nocturnal needs.  Currently the patient is approved for 12 hours a day 7 days a week.  These services are performed during daytime hours.  Patient is asking for additional services to help with  nighttime needs including confusion, arthritic pain and dementia.  Currently the daughter has been helping with nocturnal needs. The health plan's determination is upheld in whole. The amount of service hours which are noted and approved, 84 hours a week, is sufficient to meet the patient's health care needs including Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). It was noted that the patient was dependent on care for all IADLs. Patient was also dependent on care for ADLs with the exception of eating which was noted to be independent. Patient is also independent in bowel continence. The services in regard to the ADLs and IADLs required a total of 37 hours per week over 7 days for an average of 5-1/2 hours a day. According to the assessment, the patient required a total of 37 hours per week of care in regard to her ADLs and IADLs.  Patient is currently approved for 84 hours a week which exceeds the number of hours noted to be necessary for her care.  This would include bathing, grooming, toileting, feeding and light housework.  There are no specific nighttime needs such as frequent turning or positioning for an underlying medical problem such as decubitus ulcers.  Observation of the patient to prevent falls or companionship typically is not a medically necessary service unless other services are medically necessary during that same time.  Additional service hours for this care alone would not be considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Venous insufficiency
Issue under review: 36478 - Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser, first vein treated

Determination:
The 36478 - Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser, first vein treated, was medically necessary.

The patient is an adult female. The provider performed ablation of the residual right greater saphenous vein (GSV) for this patient who had previously underdone stripping of the upper GSV segment. 

The AP performed ablation of the residual right greater saphenous vein (GSV) for this patient who had previously underdone stripping of the upper GSV segment. 
Widely accepted criteria will be applied to assess the medical necessity of the procedures.  

Under widely accepted criteria [1-8], endovenous ablation of axial saphenous veins is medically necessary when:
1) The patient has venous insufficiency symptoms severe enough to affect normal function. 2) The patient has failed a trial of prescription compression stockings. 3) The patient has duplex-proven reflux that correlate with the patient's symptoms.

Requirement 1 has been met. The submitted records show that the patient has symptoms of varicose vein disease, and that the symptoms are severe enough to adversely affect her normal function.
 
Requirement 2 has been met. The records indicate that the patient had been using compression stockings for several months without relief of her symptoms.

Requirement 3 has been met. The reflux study showed severe reflux in the residual GSV from the mid-thigh to the ankle. The GSV was also enlarged to a size of 7.2 mm.

Therefore, the patient meets published, well-accepted criteria for right GSV ablation

Note: The previous denial was based on the fact that the patient does not have junctional reflux. However, the presence of junctional reflux is not accepted as an essential element of clinically significant varicose vein disease [8]. Moreover, in this particular case, the patient's saphenofemoral junction is absent due to prior stripping and ligation of the greater saphenous vein. It is not possible for the patient to have junctional reflux. The decision about treatment must be made based on the patient's symptoms and the presence of axial reflux.
Appeal type: Medical necessity
Decision: Overturned

This is the case of a child at the time of presentation, previously healthy, Spanish-speaking, with a history of dental caries who presented to the emergency department (ED) with a 4 day history of refusing to eat and drink. Mother had been giving small doses of liquids via an oral syringe. Additional symptoms include a pruritic maculopapular rash that spares the hands and feet. There was no fever, vomiting, diarrhea, respiratory illness, known ill contacts, or recent travel. Admission vital signs included afebrile, heart rate (HR) 128, respiratory rate (RR) 26, blood pressure (BP) 100/74, and oxygen (O2) saturation 99% on room air. Physical exam was notable for an uncooperative child with tacky mucus membranes, macular skin rash, and severe frontal dental caries. Labs showed a white blood cell count (WBC)=9.4, hematocrit (Hct)=36, platelet count (Plt)=419. Bicarb was low at 13 with otherwise normal electrolytes. The patient was treated with intravenous fluids (IVF) bolus and admitted to the floor to continue IVF hydration to treat dehydration. Patient was also given a probable diagnosis of coxsackievirus infection.
The health plan's determination of medical necessity is overturned in whole. This is a young child with moderate dehydration by both physical exam and laboratory findings. Paitent has failed oral rehydration as an outpatient, and also presented with tachycardia. According to the medical documentation provided, this child fit criteria for moderate dehydration (tacky mucus membranes, tachycardia, serum bicarb=13).  In studies, serum bicarbonate level has correlated well with the degree of dehydration.  Thus, this child with both metabolic derangement and vital sign abnormalities required additional treatment and monitoring at the inpatient level of care. As a primarily non-English speaking family, this child is at higher likelihood of poor health outcomes, delayed follow-up in care, and receipt of fewer preventive services compared to English-speaking counterparts.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System
Inpatient hospital

The patient is a male infant with medical history significant for perinatal E. coli meningitis, chronic respiratory failure status post tracheostomy tube placement hydrocephalus status post ventriculoperitoneal (VP) shunt placement seizure disorder, dysphagia status post gastrostomy tube placement, hypothyroidism, hypocomplementemia, and hypertension. He was hospitalized when he developed acute respiratory symptoms and fever. Because of suspicion for VP shunt infection and/or sepsis, he was transferred for acute admission. 

The health plan's determination is overturned. The Acute Inpatient Rehabilitation Facility Admission was medically necessary for this patient.
This male infant with his complex and complicated medical problems and extremely fragile state was appropriately re-admitted to Blythedale where he could continue to receive comprehensive medical care, family teaching could continue for the mother, and he could benefit from the skills and expertise of the rehabilitation staff to optimize his level of functioning. This male infant suffers from a number of complex acute and chronic medical problems as a result of and in addition to perinatal E. coli meningitis with subsequent neurologic devastation. He was transferred to Blythedale from acute care where he received comprehensive medical and rehabilitation services. He had to return to the acute hospital with complications from his meningitis. During the time period in question, the complexity of care that this infant required necessitated the skilled services that an institution such as Blythedale could provide, with round the clock skilled nursing services, physician oversight, aggressive ancillary services, rehabilitation services, and family support. The acute inpatient rehabilitation facility admission for the dates in question was medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient Hospital

The patient is a male with a history of coronary artery disease, atrial fibrillation, coronary artery bypass graft surgery, surgical pulmonary vein isolation, hypertension, chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea. He presented to the hospital for transcatheter ablation of recurrent atrial fibrillation. The procedure was uncomplicated. He was discharged the following day. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld.

An inpatient stay was not medically necessary. This patient underwent a transcatheter pulmonary vein isolation (PVI) procedure for recurrent atrial fibrillation. Given the complexity of the procedure, with transseptal punctures, catheter manipulation and ablation within the left atrium, full dose anticoagulation, and the proximity of the ablation lines to the esophagus, the complication rate is higher than that of catheter ablations for other supraventricular arrhythmias. Accordingly, despite at least two reports demonstrating the safety of same day discharge after PVI, most electrophysiologists admit patients for overnight monitoring post-procedure. This patient's procedure was uncomplicated, and he was hemodynamically stable. Accordingly, while monitoring at a lower level of care status was reasonable and prudent, the records provided do not indicate that an inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Joint Problem/Pain
Inpatient hospital

The patient is a female. She was admitted to the hospital. She has a past medical history of acute myelogenous leukemia status post allogenic transplant, breast cancer status post mastectomy, hypertension and atrial fibrillation. She presented with right lower leg pain for 3 days. She also had poor oral intake. Vital signs showed a blood pressure of 109/63, pulse 82, respiratory rate 16 and oxygen saturation 100%. Labs showed a hemoglobin of 7.7, platelets 49, potassium 5.8 and creatinine 1.8. She was given intravenous steroids, fluids and morphine. She was admitted for further management and evaluation.

The health plan's determination is overturned. The inpatient stay was medically necessary. The patient has a complicated past medical history of acute myelogenous leukemia resulting in pancytopenia and immunosuppression. She presented with right lower extremity pain which was due to increased disc protrusion at L3-L4 level. Labs showed acute kidney injury and hyperkalemia. She required continuous intravenous, steroids and frequent doses of intravenous pain medications. There was also a concern for upper gastrointestinal graft versus (vs). host disease. She was evaluated by cardiology and neurology during the stay. She slowly improved and was discharged.
The Inpatient stay was medically necessary due to the patient's complicated medical history, immunosuppression, pancytopenia, acute kidney injury with persistent hyperkalemia and length of stay of over 48 hours.
Appeal type: Experimental/Investigational
Decision: Upheld

Asthma
Lab Work/Blood Tests

The patient is a female who requests retrospective coverage for routine vaccination with Gardasil 9, human papilloma virus vaccination. This review is for the use of the HPV vaccination services.

The health plan's determination is upheld. The Human Papilloma Virus (HPV) Vaccination Services is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
At the time the services were provided, this vaccination was not a recommended vaccination based upon guidelines as represented through the ACIP/CDC in regards to vaccination of adults, specifically adult females ages 26 through 45. The ACIP approved HPV vaccination by majority vote at its meeting in June 2019 for patients ages 26 through 45 who are not adequately vaccinated. The patient received this vaccination prior to these recommendations at a time when it was not recommended for this age group. Therefore, it was not indicated at the time of service.
Appeal type: Experimental/Investigational
Decision: Upheld

Asthma
Lab Work/Blood Tests

The patient is a female with past medical history of mild intermittent asthma, herpes simplex virus (HSV) type 2 and prior PAP with human papilloma virus (HPV) changes in 2009. The patient was vaccinated with the HPV vaccine. The use of the HPV vaccine is under review.

The health plan's determination is upheld. The HPV vaccine would not be more beneficial than standard treatment for the insured's life threatening or disabling condition or disease. The patient has a past medical history of asthma and HSV type 2, but no other chronic conditions that would make her more prone to HPV. The patient does not have a life-threatening condition.
If a patient has previously been exposed to HPV prior to vaccination then there is no protection from those strains with vaccination. If the patient 27-45 years old has never had sexual contact and is vaccinated then they would be protected by the HPV vaccine. If a patient 27-45 years old has a new sexual partner and is fully vaccinated prior to sexual contact they would be protected from strains in HPV vaccine that they haven't been previously exposed to from prior sexual contact. There is no indication that the patient is immunocompromised and would strongly benefit from this vaccine.
Appeal type: Experimental/Investigational
Decision: Upheld

Asthma
Lab Work/Blood Tests

The patient is a woman with a history of asthma, herpes simplex, and a history of human papilloma virus (HPV) positive PAP (Papanicolaou) in 2009 with negative testing since then. She is requesting coverage for the HPV vaccine.

The health plan's determination is upheld. The Human Papilloma Virus (HPV) Vaccination Services is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has a past medical history of asthma and herpes simplex virus (HSV) type 2, but no other chronic conditions that would make her more prone to HPV. Treating her asthma with the HPV vaccine is not likely to be more beneficial than the standard treatments for asthma. There is no evidence that asthma is linked to infections with the human papilloma virus. There is no evidence that treating the patient with the HPV vaccine will help her asthma. There is no indication that the patient is immunocompromised and would strongly benefit from this vaccine.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Head/Neck Cancer
Treatment: Proton Beam Therapy
The Proton Beam Therapy is not medically necessary.

The patient is a male with stage T3N3M0 HPV + squamous cancer of left base of tongue. Proton beam therapy is being requested for definitive concurrent chemoradiation treatment.

Currently, there is no published long term clinical outcome evidence of combined IMRT (intensity-modulated radiation therapy) and proton beam RT (radiation therapy) relative to photon IMRT for head and neck cancer. It is, therefore, not possible to draw any conclusions on the benefits of proton beam RT as "promising" compared to photon IMRT, which has demonstrated high locoregional control rate for the base of tongue cancer, as in this patient's case. 

Proton radiation treatment for head and neck cancer such as base of tongue cancer, is currently under study in phase II/III  clinical trial (a. Phase II/III Randomized Trial of Intensity-Modulated Proton Beam Therapy (IMPT) Versus Intensity-Modulated Photon Therapy (IMRT) for the Treatment of Oropharyngeal Cancer of the Head and Neck Cancer (ClinicalTrials.gov Identifier:NCT01893307)). 

The 2017 ASTRO model policy for proton beam RT states that while PBT is not a new technology, there is a need for continued clinical evidence development and comparative effectiveness analyses for the appropriate use of PBT for various disease sites. All other indications not listed in Group 1 are suitable for Coverage with Evidence Development (CED). 
The policy recommends coverage for Group 2 indications if the patient is enrolled in either an Institutional Research Board (IRB)-approved study or in a multi-institutional registry adhering to Medicare requirements for Coverage with Evidence Development (CED). These indications also represent the disease sites for which evidence is accumulating and may support future Group 1 coverage. While the policy specifies that no indications are deemed inappropriate for CED, it also specifies several systems for Group 2 indications:
 Non-T4 and resectable head and neck cancers such a stage T3N3M0 the base of tongue cancer, as in this case.

However, medical documents do not indicate that proton beam RT was provided in clinical trial or in registry trial.

Thus, proton beam RT in this case is not consistent with the 2017 ASTRO model policy for proton beam therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower extremity paresthesia and chest pain
Treatment: Inpatient stay 

Summary:
The patient is a female with asthma, panic disorder, attention deficit hyperactivity disorder, Chiari malformation, fibromyalgia, bipolar disorder and anxiety. She presented to the hospital with lower extremity paresthesia and chest pain.  The patient had been seen the prior evening in the emergency department for anxiety and headaches and underwent computed tomography of the brain, which demonstrated no acute process.  

The patient did not have evidence of acute coronary syndrome; cardiac enzymes were negative and the electrocardiogram showed sinus rhythm without acute ischemic changes.  There was no evidence of pulmonary embolism, pulmonary edema, acute respiratory failure, or aortic dissection.  The patient did not have persistent vomiting, confusion, drowsiness, or documented muscle weakness related to lithium toxicity.  There was no evidence of severe psychosis or requirement for frequent or continuous administration of parenteral sedatives medications.  In summary, inpatient admission was not medically necessary. The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath
Issue under review: inpatient admission

Determination:
The inpatient admission was medically necessary.

The patient is an adult male with history of COPD (chronic obstructive pulmonary disease), CHF (congestive heart failure), and afib (atrial fibrillation). He presented to emergency room with worsening shortness of breath. The patient tried and failed outpatient therapy with prednisone and nebulization. 

At the time of admission, patient was in mild respiratory distress and was hypoxic on room air. The patient also had tried and failed emergency room treatment with IV steroids and nebulizations. The patient had decreased breath sound with labored breathing. The patient was started on IV steroids for COPD exacerbations. The patient received supplemental oxygen as well as frequent nebulization treatments. The patient's COPD exacerbation slowly improved with IV steroids. The patient was discharged home with prednisone taper, COPD home medications and pulmonary follow up.

The patient had tried and failed outpatient treatment as well as emergency room treatment. The observation level of care was also failed, since the patient's COPD exacerbation was not improving. The patient was symptomatic, requiring frequent nebulizations and IV steroids. The acute in-hospital level of care was therefore medically necessary