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

Diagnosis: Secundum Atrial Septal Defect.

Treatment: inpatient emergency admission.

The insurer is denied coverage for inpatient emergency admission.

The denial is upheld. 

This female patient has a history of moderate secundum atrial septal defect (ASD).
In a large series involving over 1300 children undergoing percutaneous closure of an ASD, major complications peri-procedurally was seen in 1.8% (percent). Device embolization occurred either immediately (7/10 cases) or within 24 hour. Similarly, other major complications were seen early.

Review of Milliman Care Guidelines (MCG) Health Guideline: "Cardiac Septal Defect: Atrial, Transcatheter Closure" notes that based on large databases, this is in general an ambulatory procedure. As noted above, if complications occur this will result in need for inpatient stay.  However, these remain rare.

Therefore, acute inpatient admission was not necessary. Rather this child could have been observed for an appropriate time period including 24 hours and when no complications were noted discharged without the need for acute inpatient admission.

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 emergency admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Melanoma.
Treatment: PET Scan (78816).
The insurer denied the PET Scan (78816).
The denial is upheld.

The patient is a male. He has pT3N0M0 (measuring more than 2.0 and equal to or less than 4.0 millimeters in thickness) stage 2b right temple melanoma. The request is for a PET/CT (positron emission tomography/computed tomography).

No, the requested health service was not medically necessary.
The patient has stage 2b right temple melanoma. The NCCN (National Comprehensive Cancer Network) Guidelines for Melanoma: Cutaneous, version 2, does not list a PET/CT (positron emission tomography/computed tomography) as recommended follow-up imaging for stage 2b melanoma.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pancreatic Cancer, Hypertension, Hypertensive Heart Disease, Coronary Artery Disease, Diabetes Mellitus. 

Treatment: Home care/personal care HHC (Home Health Care)- level 2 personal care services, per 15 minutes 24 hour(s) per day (live-in). 

The insurer denied coverage for home care/personal care HHC - level 2 personal care services, per 15 minutes 24 hour(s) per day (live-in). 

The denial is overturned. 

The patient is an elderly female with a history of pancreatic cancer, hypertension, hypertensive heart disease, coronary artery disease, diabetes mellitus, retinopathy and osteoporosis. She was hospitalized with biliary obstruction. Per letter of medical necessity submitted the patient has had a steep and rapid deterioration in cognition, physical and functional status. The patient has full incontinence and requires multiple day and night changes. She requires continuous supervision and physical assistance with activities of daily living (ADLs), including turning and positioning (T&P). A letter from Hospice and Palliative Care notes that the patient has stage 4 pancreatic cancer and was admitted to home hospice. She is totally dependent with ADLs and personal care needs, has a sacral pressure injury, poorly controlled cancer pain and has lost over 60 pounds within the past few months. 

Uniform Assessment System (UAS) was done. Dependence was noted in instrumental (i) ADLs and extensive assistance was noted in some ADLs including toilet use and transfers and limited assistance in bed mobility. Urinary incontinence is noted. She is able to walk but needs assistance. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 

"(a) Definitions and scope of services. 

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph 

(b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse." 

The patient needs assistance across all ADLs. She is incontinent and has shown a tendency to get pressure sores. The request for more hours is not based solely on safety and supervision considerations. She cannot handle her incontinence supplies independently and needs assistance with toileting. Her needs are 24-hour, with unscheduled nighttime needs. 

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 home care/personal care HHC - level 2 personal care services, per 15 minutes 24 hour(s) per day (live-in) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Glaucoma
Treatment: Rocklatan 0.02-0.005% ophthalmic solution
The insurer denied the Rocklatan 0.02-0.005% ophthalmic solution.
The denial is upheld.

The patient is a female with primary open angle glaucoma for whom coverage of branded Rocklatan (netarsudil/latanoprost ophthalmic solution) 0.02%/0.005% is the subject of review. Coverage was previously denied as it was not identified that the patient had taken or had a poor response to preferred drugs including bimatoprost 0.03%, travoprost, dorzolamide, brimonidine, dorzolamice/timolol, carteolol, levobunolol, and betaxolol. 

It was not identified why the patent could not use the individual components of this medication (brimonidine 0.2% and timolol 0.5%) which are on the preferred drug list. Upon appeal, it is identified that the patient previously tried and failed latanoprost, timolol 0.25% and Rhopressa. Intraocular pressures were adequately reduced when the patient was switched to Combigan 0.2%-0.5% and Rocklatan. Pharmacy claims are identified for timolol 0.5% and brimonidine 0.2%.

No, the proposed Rocklatan 0.02-0.005% ophthalmic solution is not medically necessary.
In this case, fixed dose Rocklatan (netarsudil/latanoprost ophthalmic solution) 0.02%/0.005% is requested. The patient was previously using Rhopressa (netarsudil) in combination with latanoprost and timolol. Intraocular pressures reportedly became controlled when timolol was switched to fixed combination brimonidine/timolol. There are no paid claims identified for Rhopressa or documentation that the patient could not effectively be controlled with continued use of latanoprost or other formulary alternatives identified as being more effective than latanoprost at lowering intraocular pressures (e.g., bimatoprost). Lastly, while Rocklatan may be more convenient than using individual components alone, it is not established as more effective that the use of the individual components. Therefore, the medical necessity of Rocklatan is not established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior Crossbite with Gingival Attachment Loss

Treatment: Braces

The insurer denied coverage for braces.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to an anterior crossbite with gingival attachment loss along other clinical findings. The orthodontist has completed the Handicapping Labio-lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present, 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 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 as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 9 points (2 overjet, 2 overbite, 3 ectopic eruption, 2 labiolingual spread).  

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. Braces are not considered medically necessary for this patient.

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

Diagnosis: Congestive Heart Failure (CHF)

Treatment inpatient hospital stay

The insurer denied coverage for inpatient hospital stay

The denial is overturned.

The patient has a history of hypertension (HTN), heart failure and polysubstance abuse. The patient presented to the emergency department (ED) with complaint of weakness and progressive shortness of breath (SOB) for three days. The patient admitted to using Cocaine the previous night.  Past medical history (PMH) includes congestive heart failure (CHF) with ejection fraction (EF) 10-15% (percent). Status post automatic implantable cardioverter-defibrillator (AICD).

The patient was extremely short of breath when emergency medical services (EMS) came and so he was placed on continuous positive airway pressure (CPAP)/ bilevel positive airway pressure (BIPAP) immediately and transported to ED. The patient was also complaining of some chest pain. Vital signs at presentation: Temperature 98.4 Heart Rate 87 Respiratory Rate 22 Blood Pressure 121/92 oxygen (O2) saturations 95 % on CPAP. The patient was in severe Respiratory distress. Lung exam revealed bilateral (B/L) rales at bases.  The patient was given intravenous (IV) Lasix 80 mg (milligrams).  Labs revealed white blood cell count (WBC) 9.9K (thousand), blood urea nitrogen (BUN)/Creatinine 32/1.7 B-type natriuretic peptide (BNP) 7871, Troponins and Creatine Phosphokinase (CPK) were elevated. Urine toxicology was positive for Cocaine.   
Chest x-rays revealed (CXR) possible right lower lobe opacity, rule out Pneumonia.

The patient was admitted to Telemetry to rule out acute coronary syndrome (ACS) and decompensated heart failure (HF). The patient was treated with intravenous (IV) Lasix for Heart failure. Serial Cardiac enzymes and electrocardiogram (EKG) done to rule out myocardial infarction (MI). The patient was seen by cardiology who recommended IV Lasix and close monitoring.

The patient was treated with IV Rocephin and Azithromycin for possible community acquired pneumonia (CAP). The patient was continued on HF Medications.

Given the patient's tenuous cardiac status with ejection fraction (EF) 10-15 % and presentation with Chest Pain and decompensated HF requiring BIPAP (non invasive ventilation) it was appropriate to admit this the patient to rule out ACS and treat congestive heart failure (CHF) in a monitored setting. The patient had chronic renal failure (CRF) and on diuresis Creatinine (Cr) further went up.

The patient was treated appropriately in consultation with Cardiology. Labs closely monitored and MI was ruled out. Once stable the patient was discharged home with Cardiology follow up in outpatient setting.

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 inpatient hospital stay is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intermittent chest cramps. 
Treatment: Procedure code 71250, computed tomography (CT) of the chest without contrast. 

The insurer denied coverage for procedure code 71250, computed tomography (CT) of the chest without contrast. 

The denial is upheld. 

This is a patient who was being evaluated for history of intermittent chest cramps. The patient reported sharp pains. This has been going on for years. The patient denied any shortness of breath (SOB). The patient reports that these are sometimes triggered by a large meal. Improved with "stretching out the lung."  Past medical history (PMH) included pneumothorax (PTX). They were small and no intervention was needed. The patient has had multiple Tele Health Visits for same. Diagnostic testing includes chest x-ray (CXR) within normal limits (WNL) and echocardiogram (ECHO) WNL.  The patient had a genetic evaluation done to rule out connective tissue disorder and Marfan's Syndrome. Both were negative.  Last CXR was a normal exam.  There was no PTX, and no pleural effusion. The patient's physician ordered a CXR to rule out PTX. 

There is no indication for a chest CT for this patient. The patient's multiple CXR have been Normal. ECHO was Normal. 

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

Based on the above, the medical necessity for the procedure code 71250, computed tomography (CT) of the chest without contrast is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Attrition of the occlusal enamel
Treatment: Crown (D2740) Tooth and/or Quad #5
The insurer denied the Crown (D2740) Tooth and/or Quad #5.
The denial is upheld.

The patient is a male requesting a crown on tooth # (number) 5. Tooth #5 has significant wear which has caused attrition of the occlusal enamel.

No, the proposed treatment is not medically necessary.

The tooth does not have any fracturing or severe decay requiring a crown. The requested treatment is not medically necessary.

Tooth #5 is the same height as tooth #4, so the wear on this tooth has not caused a severe shortening of the tooth. Based on the documentation submitted, there is enough occlusal enamel to bond a composite restoration to, contrary to what has been stated by the provider. Placing a composite restoration first, a more conservative restoration than a crown, especially when only a one surface composite would be needed, would be standard of care. If the restoration fails before it's normal life, then a crown may be indicated at that time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever. 
Treatment: Inpatient admission. 

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

The patient is a female with a history of relapsed acute lymphoblastic leukemia who presented with a temperature of 102.8. 

The patient was not neutropenic. She had a chest x-ray, which showed pneumonia. She was positive for COVID-19 and RSV (respiratory syncytial virus). Her oxygen saturation was 95. She had no evidence of sepsis. She was admitted to the hospital and received a dose of cetrixaone. She was then discharged. 

No, the Inpatient admission was not medically necessary. 

The patient presented with fever. The patient was not neutropenic. She did not have hypoxia. She had a cough and positive chest ray and was positive for RSV (respiratory syncytial virus) or related to recent COVID-19 diagnosis. Her vital signs, physical examination and labs did not indicate evidence of sepsis. The care provided to the patient could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis

Treatment: Inpatient level of care

The insurer denied coverage for inpatient level of care.

The denial is upheld.

The patient has sickle cell disease and presented with abdominal pain and vomiting. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The platelet count was 1,291,000. The liver enzymes were elevated. Hepatitis serology was negative. An abdominal ultrasound revealed gallbladder sludge and a splenectomy. A Magnetic Resonance Cholangiopancreatography [MRCP] showed cholelithiasis without evidence of cholecystitis. There was no duct dilatation. He was referred to surgery clinic for an elective laparoscopic cholecystectomy. Aspirin was given for the high platelet count. The liver enzymes improved.

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Stone (MCG [Milliman Care Guidelines] M-555) include having acute cholecystitis or acute cholangitis. The patient did not have these conditions. A calculus of the gallbladder is also an indication for admission if it is associated with hemodynamic instability, severe vomiting, severe dehydration, severe pain not responding to analgesics, or bacteremia. The patient did not have these conditions.

This patient had sickle cell disease and gallstones. He did not have acute cholecystitis or acute cholangitis. Intravenous (IV) hydration, antiemetics, and monitoring the liver enzymes could have been done with observation status. He did not meet MCG criteria for admission for Gallbladder or Bile Duct Stone or Inflammation. The health care plan acted reasonably and with sound medical judgement. An inpatient level of care was not medically necessary.

Based on the above, the medical necessity for the inpatient level of care is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: gastroenteritis

Treatment: inpatient level of care

The insurer is denied coverage for inpatient level of care.

The denial is upheld. 

This male patient has no significant medical history.

The documentation of this child's appearance, vitals, and modest increase in weight with fluids would indicate mild to moderate dehydration on presentation that could have been addressed while in the ED (emergency department). Unfortunately, his IV (intravenous) resuscitation began less than 2 hours before the decision to admit him to the acute care setting. He never received bolus fluids that undoubtedly lead to his continued tachycardia while awaiting admission. He should have been rapidly intravenously resuscitated followed by oral rehydration that failed to occur until after admission. Vomiting was never part of his presenting symptoms and shouldn't have prevented successful oral rehydration as suggested in the appeal. After an evaluation excluded dangerous conditions, he should have received bolus fluids followed by oral rehydration to permit safe and appropriate discharge with outpatient follow-up. He actually received no acute care after admission to merit that level of care. In regard to the acute inpatient admission the determination by the carrier that the admission was not medically necessary was correctly applied, objective, clinically valid, compatible with established principles of health care and flexible enough to permit justified variation. This decision was rendered based on review of the hospital record and the reviews from UpToDate summarizing the approach to diarrhea in child in resource rich countries and dehydration in children.

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 level of care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Leimyosarcoma.
Treatment:  Continued inpatient admission.
The insurer denied the  Continued inpatient admission.
The denial is overturned.

The patient is a male with a history of immunodeficiency complicated by EBV (Epstein Barr virus) viremia and leimyosarcoma diagnosed, with metastatic disease to the liver, lungs, CNS (central nervous system), oropharyngeal cavity, and airway. The patient has failed multiple treatments. The patient has recently had further tumor progression requiring tracheostomy.

The patient was transferred to another facility for palliative radiation therapy. He completed IV (intravenous) levofloxacin for tracheitis.  Since that time, he has been on IV (intravenous) PCA (patient controlled analgesia) morphine for intractable pain, as well as intravenous anti-emetics.

Yes, the continued stay was medically necessary.
On the inpatient days under review, the patient was on an intravenous morphine by PCA (patient controlled analgesia) with severe pain. The patient was transitioned to an oral pain medication. The patient then had infected impetigo, which required intravenous antibiotics. The patient was discharged when his IV (intravenous) antibiotics were completed and he was stable on oral pain medications. The hospital days were medically necessary, since the patient had multiple co-morbidities and could not be managed in an outpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decreased strength to the bilateral lower extremities.

Treatment: Personal Care Services - 24 hours a day, 7 days a week (split shift), for a total of 168 hours.

The insurer is denied coverage for Personal Care Services - 24 hours a day, 7 days a week (split shift), for a total of 168 hours.

The denial is overturned. 

This female patient has a history of atrial fibrillation, congestive heart failure, chronic kidney disease, hypertension, hypothyroidism, osteoarthritis, osteoporosis, and unstable gait.

The patient is living alone. The patient had atrial fibrillation, congestive heart failure, chronic kidney disease, cerebrovascular accident, glaucoma, chronic back pain and bilateral knee pain along with an unsteady gait and blindness. The patient had experienced extensive cognitive decline and lacked the ability to perceive the time of day. The patient is at risk for increased falls due to an unsteady gait and blindness. The patient required maximal assistance with walking in addition to transfers and toilet use. The patient was frequently incontinent of bladder and occasionally incontinent of bowel. The daughter was unable to help much as she had her own health issues. The requested service is an increase from the approved 24 hours a day 7 days a week live-in 9 hours a day 7 days a week. Given the patient's current extensive cognitive decline, unsteady gait, and blindness along with maximal assistance necessary for walking and transfers and toilet use, the requested for Personal Care Services - 24 hours a day, 7 days a week (split shift), for a total of 168 hours are medically necessary.

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

The carrier's denial of coverage for the Personal Care Services - 24 hours a day, 7 days a week (split shift), for a total of 168 hours is overturned.  The medical necessity is  substantiated.