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

Diagnosis: Cellulitis
Treatment: Inpatient admission 
The insurer denied coverage for: Inpatient admission
The denial is: Overturned
This is an adult patient with left leg swelling for one week. The patient had several underlying comorbidities. The patient was treated by a Podiatrist with oral Clindamycin. The patient was evaluated in Emergency Department (ED) and noted to have swelling, redness and was febrile (39.5 degrees Celsius). The patient previously reported temperature of 101. The patient was evaluated by Orthopedics and Infectious Disease. The patient received several intravenous (IV) antibiotics and had blood cultures taken. The patient was found to have presence of Cardiobacterium hominid. The patient received ongoing treatment for cellulitis which gradually improved. 

The medical records show a medical condition which was not improving despite outpatient treatment. The patient has several underlying comorbidities. The patient has an infection which has systemic effects. The patient was found to have bacteremia with positive blood cultures. The patient required several consultations and ongoing intravenous (IV) antibiotic therapy. There would be need for direct observation of cellulitis (increasing or decreasing), change in IV antibiotic and monitoring of temperature which would support the necessity of acute level services.  

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080-Braces
The insurer denied: D8080-Braces
The denial is overturned.

The patient is a teenage female. The request is for orthodontic treatment. The patient has Class III malocclusion with moderate upper and lower jaw crowding. She has traumatic occlusion of the anterior teeth with excessive wear. The health plan denied coverage of the request due to the patient scoring 14 on the handicapping index scale. The denial is being appealed.

The requested braces are medically necessary.

The patient has a crossbite of anterior teeth with attachment (gum) loss and recession of the gingival margin. This is an automatic qualifier according to the handicapping index scale. 
Orthodontic treatment is needed to correct this this problem. This case has medical necessity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Elevated blood pressure
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is overturned.

This is a male patient who presented with a worsening headache. He had been under the care of his primary doctor for blood pressure management, but on the day of admission, his blood pressure was severely elevated at 225/120, and he was experiencing a severe headache and some chest pressure. Upon arrival at the emergency room (ER), his blood pressure was recorded at 210/140. In the emergency department, the patient received medications labetalol, clonidine, and lorazepam, which led to a slight improvement in blood pressure, and the patient reported an amelioration of his headache and chest pressure. He had been progressively increasing his lisinopril dose at home to 40 milligrams (mg) and affirmed compliance with his medications, though his blood pressure remained elevated. An electrocardiogram (EKG) performed in the ER revealed no abnormalities, and a computed tomography (CT) scan of the head showed no acute intracranial issues. When evaluated by the admitting physician, the patient denied chest pain, a headache, shortness of breath, abdominal pain, nausea, or vomiting.

The patient disclosed daily alcohol consumption. 

The patient was admitted to the hospital, and his home dose of lisinopril was continued. Hydralazine was initiated on an as-needed basis. During his hospital stay, the patient was diagnosed with alcohol withdrawal, which presented with symptoms of nausea, vomiting, tachycardia, and tremulousness. Over the course of his hospitalization, the symptoms of alcohol withdrawal improved, and his blood pressure came under much better control. He was able to tolerate oral intake, and he was discharged from the hospital, given his improved clinical condition. At issue is the medical necessity of an inpatient stay.

The admission at the acute inpatient level of care was medically necessary/justified. The hypertension in this case was a symptom of severe alcohol withdrawal. The patient experienced multiple symptoms of alcohol withdrawal including hypertension, tachycardia, nausea, vomiting, and tremor. It was clearly documented that the patient's Clinical Institute Withdrawal Assessment (CIWA) score was 18. At the time of the initial evaluation, the patient did not experience all of these symptoms. His withdrawal symptoms started later during the hospitalization. Considering the severity of the patient's condition and the complexity of services provided, an acute inpatient level of care was justified. The hypertension was only a symptom of alcohol withdrawal.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted upper canine; front tooth in crossbite. 
Treatment: Full braces and monthly brace adjustment visits. 
The insurer denied full braces and monthly brace adjustment visits. 
The denial is overturned. 

The patient is a teenage female. The request is for orthodontic treatment and monthly visits. The patient has an impacted upper canine and a front tooth in crossbite. The health plan denied coverage of the request, citing that the patient, "did not need braces to fix a serious head or facial medical problem." The denial is being appealed. 

The requested braces and monthly visits are medically necessary. 

The patient has a crossbite of an anterior tooth with clinical attachment loss and recession of the gingival tissue. She also has an impacted permanent anterior tooth where extraction is not indicated. Both of these things are automatic qualifiers for treatment according to the handicapping index scale. This patient needs orthodontic treatment to correct these problems and needs monthly visits to make sure treatment is progressing properly. This case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left upper extremity amputation 
Treatment: Durable Medical Equipment (Myoelectric prosthesis)
The insurer denied Durable Medical Equipment (Myoelectric prosthesis).
The determination is upheld.

The patient is a male with a history of left forequarter left upper extremity amputation (amputation of the entire left upper extremity including the shoulder girdle) due to infection. At issue is the medical necessity of the requested health service/treatment of Durable Medical Equipment (Myoelectric prosthesis) for this patient.

The requested health service/treatment of Durable Medical Equipment (Myoelectric prosthesis) is not medically necessary for this patient.
The patient did not meet the Milliman Care Guidelines (MCG) Criteria for myoelectric prosthesis for the following reasons: 1. There was no documentation that the patient was able and willing to participate in myoelectric prosthesis training. 2. There was no documentation that the patient was able to tolerate the weight of the prosthesis. 3. There was no documentation that the patient has adequate cognitive ability to operate the myoelectric prosthesis. 4. There was no documentation that the surrounding environment did not preclude the use of a myoelectric prosthesis, ie there was no documentation that the environment was not excessively moist or dusty. 5. There was no documentation that the remaining proximal arm musculature contains a minimum microvolt threshold to operate myoelectric prosthesis. In this case, the patient underwent left forequarter left upper extremity amputation (amputation of the entire left upper extremity including the shoulder girdle) and therefore, there is no remaining proximal arm musculature to operate the myoelectric prosthesis. The occupational therapy note stated that right upper extremity strength, sensation, and coordination were normal. He had left upper extremity phantom limb pain to "fingers" of left upper extremity. He was treated with physical therapy. There was improved scapular range of motion. The therapy was working on scapular mobility with intention to use a left upper extremity prosthesis. There are many standard treatments for the diagnosis of left forequarter upper extremity amputation including a conventional passive prosthesis or a switch controlled externally powered prosthesis. The use of the myoelectric prosthesis is not considered medically necessary, is not supported by the peer-reviewed medical literature, and is not considered the standard of care in the United States at this time.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a morbidly obese male with a medical history of diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, asthma, and anxiety, as well as bilateral lower extremity lymphedema who presented to the hospital from the wound care center with a worsening wound over the right anterior aspect of the ankle that had been ongoing for one week. On the day of admission, an incision and drainage (I&D) procedure was performed at the wound care center to address necrotic fat and necrotic infected muscle. Subsequently, the patient was referred to the hospital for intravenous antibiotics.

The inpatient hospital admission was medically necessary.
This patient presented to the hospital after having incision and drainage (I&D) of the right anterior aspect of the ankle. Even though the patient was afebrile and hemodynamically stable, there were certain circumstances that increased the probability of adverse outcomes.
First of all, the patient had bilateral lower extremity lymphedema, which definitely complicated the healing process and treatment of infection. Second, it was indicated in the note that the patient underwent I&D of necrotic fat and muscle.
Based on the Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 26th Edition criteria for cellulitis, admission at the acute inpatient level of care is indicated for patients with suspected necrotizing soft tissue infection.
Furthermore, there was another criterion that was applicable in this clinical case. The clinical presentation was judged to require the intensity of patient monitoring that could not be provided at other than inpatient level of care.
In addition, the patient and his family needed time to learn wound care techniques to ensure safe discharge. Taking into consideration these facts, inpatient hospital admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: polymyositis/dermatomyositis, scleroderma/systemic sclerosis and Sjogren's syndrome
Treatment: Rituximab
The insurer denied Ritiximab.
The determination is overturned.

This is a male patient with polymyositis (PM) and dermatomyositis (DM), systemic sclerosis, inflammatory arthritis and Sjogren's. Prior treatment included Remicade, intravenous immunoglobulin (IVIG) and steroids. Rituximab was started with improvement. Rituximab (week 0 and 2 every 6 months) is being denied by the health plan; the health plan will only approve rituximab if the patient has one of certain conditions, including but not limited to rheumatoid arthritis (RA), multiple sclerosis and myasthenia gravis. At issue is the medical necessity of rituximab.
Rituximab (RTX) is medically necessary for this patient. This patient is very complicated from a rheumatologic standpoint and is stable on rituximab. He has tried and failed other therapies and there is ample data showing rituximab is beneficial in many of his conditions.
This patient has multiple overlapping rheumatologic conditions, including PM/DM, systemic sclerosis, inflammatory arthritis and Sjogren's. Prior treatment included remicade, IVIG and steroids. Rituximab was started with improvement. There is evidence demonstrating rituximab is beneficial in patients with scleroderma, PM/DM as well as inflammatory arthritis. For example, as published in Ann Rheum Dis in 2015, 'the comparison of RTX treated versus untreated matched-control SSc patients from the European Scleroderma Trials and Research (EUSTAR) cohort demonstrated improvement of skin fibrosis and prevention of worsening lung fibrosis, supporting the therapeutic concept of B cell inhibition in systemic sclerosis (SSc)'. Another study published in Arthritis Rheum in 2009 found that 'sequential parotid biopsy specimens obtained from patients with primary Sjogren's syndrome (SS) before and after rituximab treatment demonstrated histopathologic evidence of reduced glandular inflammation and redifferentiation of lymphoepithelial duct lesions to regular striated ducts as a putative morphologic correlate of increased parotid flow and normalization of the salivary sodium content. These histopathologic findings in a few patients underline the efficacy of B cell depletion and indicate the potential for glandular restoration in SS'. Lastly, another study in Adv Rheumatol 2018 reported 'this study provides convincing evidence that rituximab is an effective and safe therapy for refractory Idiopathic inflammatory myopathies (IIM)'.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Gastroparesis
Treatment: Motegrity (prucalopride) 
The health plan denied: Motegrity (prucalopride) 
The determination is: Overturned 
The patient is a female with gastroparesis, chronic idiopathic constipation, biliary dyskinesia status post cholecystectomy, Ehlers-Danlos syndrome, and postural orthostatic tachycardia syndrome. She has had severe nausea, vomiting, oral intolerance, constipation, and unintentional weight loss of 30-40 pounds. A gastric emptying study confirmed gastroparesis. A nasojejunal tube was placed with subsequent weight gain noted. She has failed metoclopramide, domperidone, and scopolamine.
At issue is the use of the non-formulary drug Motegrity for the treatment of gastroparesis.

The health plan's determination is overturned in whole.
The formulary drugs may be effective for the treatment of constipation, but are not supported for the treatment of gastroparesis. The request for Motegrity is supported. The patient has had chronic constipation symptoms. Motegrity has shown efficacy for the treatment of constipation and associated symptoms including bloating and abdominal pain [1-3]. Additionally, Motegrity has demonstrated greater efficacy than placebo for the treatment of gastroparesis in a crossover study [4,5]. The patient has previously attempted first-line therapy (according to the most recent American College of Gastroenterology guidelines) for the treatment of gastroparesis with metoclopramide [6]. For these reasons, the continuation of Motegrity is supported in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental issues - severe crowding. 
Treatment: Braces and monthly visits. 
The insurer denied braces and monthly visits. 
The health plan's determination is overturned. 

The patient in question is a female with severe crowding. She presents with a skeletal Class I malocclusion and has 3 millimeter (mm) overjet and 5 mm overbite. Tooth (number) #6 is in anterior crossbite with #27 and #28.  She is treatment planned for Braces and Monthly Visits to address the crowding and crossbite. 

Braces and monthly visits are medically necessary. This patient presents with an anterior crossbite on tooth 6, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. 
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. If this crossbite is not resolved it is likely that tooth 27 will develop periodontal recession. Orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dysphagia

Treatment: Dupixent

The insurer denied coverage for Dupixent

The denial is overturned

The patient has a long history of severe dysphagia. The patient has had several endoscopies and dilatations. The esophagus showed concentric rings which were felt to be characteristic of eosinophilic esophagitis. The biopsies were full of eosinophils and the patient was diagnosed with eosinophilic esophagitis. A subsequent endoscopy later showed the concentric rings but had fewer eosinophils since the patient was already on treatment. The physician has documented that the patient has been treated with both a proton pump inhibitor (PPI) and topical steroids. 

UpToDate has an article titled "Treatment of Eosinophilic Esophagitis." The article discusses pharmacologic therapy. Both proton pump inhibitor (PPI) therapy and topical steroids such as budesonide are advised treatments. There are also options listed for non-responders. Dupixent (dupilumab) is an interleukin-4 receptor antagonist that has been approved for use in the treatment of eosinophilic esophagitis in patients over 12 years old. Studies have shown that dupilumab resulted in improvement in dysphagia scores as measured by the Dysphagia Symptom Questionnaire. Its best use is for patients who are refractory to other options. A study is reported in which 74-85% of patients with eosinophilic esophagitis achieved histologic remission on Dupixent based on the dose given. 

This patient has eosinophilic esophagitis and remains symptomatic on proton pump inhibitor (PPI) therapy and budesonide. The UpToDate article supports the use of Dupixent in patients with eosinophilic esophagitis who have failed standard therapy with a PPI and topical steroids. 
Dupixent is medically necessary to treat the patient's condition. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Dupixent is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Disease
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This is a school aged female patient. She has a history of sickle cell disease and had worsening epigastric abdominal pain. She was hospitalized for three days. The reason for the prior denial was that the hospital care did not meet acute care criteria for sickle cell disease. The reason for appeal is that the patient had severe abdominal pain and sickle cell disease and hospitalization was needed. A brief summary of hospital stays indicates that on the day of admission an emergency department note states the patient was seen in the emergency department for worsening epigastric pain for a day; likely gastritis flare up, rule out vaso-occlusive crisis (VOC). Plans were to admit for inpatient care, famotidine and pantoprazole, and intravenous fluids. On day #2, the progress note and discharge summary revealed the patient was on a regular diet and intravenous fluids; stable; moderate pain early in the morning; improved pain and tolerated by mouth intake in the afternoon. On day #3 the progress note stated the patient had no acute events overnight, was feeling well and had improving pain; tolerated by mouth intake. The patient was discharged home.

The requested health service is not medically necessary.

As documented in the clinical notes, this patient had acute abdominal pain and was suspected to have gastritis flare up versus rule out vaso-occlusive crisis. During the hospital stay the patient received intravenous fluids and oral intakes. The patient's 
pain improved after admission, and she tolerated by mouth intake. There was no documentation of any acute events. Thus, the acute inpatient care is not medically necessary. Acute gastritis or gastroenteritis may require intravenous fluids for dehydration and can be managed at observational level of care (1-3).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
Treatment: Orthodontic care: D8080 Braces
The insurer denied coverage for: Orthodontic care: D8080 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 impacted permanent anterior teeth among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 10 points on review by internal reviewers. Devika Shanna is appealing on behalf of the patient.
 
Upon review of the submitted documentation, (study models were not provided for review), 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, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labia-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated. This reviewer finds this criterion is not met and the HLD index attains 10 points which is below the threshold of 26 or more points which is necessary for approval of 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. 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. 

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

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for D8080 Braces is not substantiated.