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

Dental
Dental/Orthodontic Procedure

Diagnosis: Class I malocclusion
Treatment: Braces/Monthly visits
The insurer denied the Braces/Monthly visits. The health plan's determination is upheld. 

The patient in question is a male with a diagnosis of Class I malocclusion, appropriate overjet and overbite. The upper and lower arches are both mildly crowded. Posterior teeth 12 and 13 are in crossbite but the molars are not. He is treatment planned for 24-30 months of orthodontics to correct his malocclusion. Under review is the medical necessity of Braces and Monthly Visit. 

Braces and Monthly Visit are not medically necessary.
The patient has appropriate overbite and overjet. There is mild crowding, but that alone does not rise to the threshold of medically necessary. The photos do not support a diagnosis of a crossbite of tooth 22 with tooth 10, and the gingival margin of 22 appears to be the same as tooth 27. There does not appear to be attachment loss. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. The diagnosis states the patient is has a skeletal Class I relationship which is the most efficient jaw relationship for mastication. If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate adenocarcinoma. 

Treatment: Oncotype DX- Prostate Cancer Assay, code 0047U. 

The insurer denied coverage for the Oncotype DX- Prostate Cancer Assay, code 0047U. 

The denial is upheld. 

This is a male patient with no significant past medical history found to have a prostate specific antigen (PSA) of 5.9. The patient then underwent prostate ultrasound biopsy which revealed Gleason 3 + 3 prostate adenocarcinoma in 2 of 13 biopsy cores. All treatment options were discussed with the patient. For further evaluation, the patient agreed to a period of surveillance due to COVID-19 concern. Genomic testing was then ordered. 

The insurer has denied coverage for the Oncotype DX PCA [Prostate Cancer Assay] test, code 0047U as not medically necessary. The insurer stated that there is not enough evidence in the literature to show that this testing is effective for managing the patient's condition. 

While it is true that current National Comprehensive Cancer Network (NCCN) guidelines state that men with low risk and or favorable intermediate risk prostate cancer who have at least a 10-15 year life expectancy consider the usage of tissue based genomic biomarker such as Oncotype DX PCA, they also note the absence of randomized prospective trials. In contrast, American Urological Association (AUA) guidelines state that "tissue based genomic biomarker such as Oncotype DX PCA, have not shown a clean role in active surveillance for localized prostate cancer and are not necessary for follow up." 

Currently, the impact of tissue based genomic biomarker tests such as Oncotype DX PCA on clinical practice and long term patient outcomes remains to be empirically demonstrated. Prospective studies of tissue based genomic biomarkers yielding a true clinical benefit when implemented in clinical practice are still lacking. 

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

The Oncotype DX PCA, code 0047U was not medically necessary for this patient. 

The medical necessity for the Oncotype DX- Prostate Cancer Assay, code 0047U is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain.
Treatment:  Full hospital admission.

The insurer denied coverage for the full hospital admission.  The denial is upheld. 

This is a female patient with a past medical history of asthma, gastroesophageal reflux disease (GERD), and a history of COVID-19.  The patient presented to the Emergency Department (ED) with subjective complaints of abdominal pain, cough, and shortness of breath.  The patient had undergone an appendectomy the morning of the presentation.  Her temperature was 99.8, and her heart rate was 119 beats per minute.  Her blood pressure was 142/82.  Her pain was rated 10/10.  The physical examination revealed there was no tachypnea, stridor, or accessory muscle use.  The patient's abdomen was soft and non-distended.  There was no rebound or guarding.  The patient's vital signs were within normal limits after 2-3 hours.  She was ambulating and conversing normally.  The patient's electrocardiogram (EKG) revealed normal sinus rhythm.  The patient was to be placed on observation for overnight monitoring and serial abdominal examinations and hemoglobin.  The hemoglobin level was roughly stable.  The serial examinations were benign.  The patient underwent a surgery consultation.  The ultrasound, of the right/left upper/lower quadrant, revealed sludge cholelithiasis and regions of slight gallbladder wall thickening.  A computed tomography (CT) chest angiography revealed no evidence of pulmonary emboli or thoracic aortic dissection.  There was bilateral lobe and discoid atelectasis and a small amount of perihepatic and perisplenic ascites.  Gallbladder sludge or stones were present.  Otherwise it was an unremarkable chest CT angiogram.  The X-ray of the abdomen revealed a nonspecific bowel gas pattern.  The working differential diagnoses included acute cholecystitis versus gallstone pancreatitis versus pancreatitis versus gastritis.  A hepatobiliary iminodiacetic acid (HIDA) scan was performed, and acute cholecystitis was noted to be unlikely.  The patient was discharged after a period of medical stability.

The records indicate that prior to admission, the patient was ambulating and conversing normally, and she did not have rebound or guarding.  Her vital signs were normal at the time of admission.  She had presented to the ED late in the evening and was admitted in the morning hours the following day.  The patient was appropriate for observation.  The records do not indicate the patient had failed observation to support the need for full hospital admission. 

The full hospital admission is not considered medically necessary for this patient. 

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

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

Diagnosis: Unintentional drug overdose. 

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This is a male patient who was admitted due to an unintentional overdose of Trazodone, Clonidine, and Baclofen. It was reported that he wanted to sleep and was not getting much sleep due to his child's needs. He indicated he had a history of hypertension and anxiety. He was dizzy and lethargic. He denied suicidal intent or plan or suicidal thoughts and denied that this was a suicide attempt. He had bradycardia with a heart rate of 46-50. He had intravenous (IV) fluids. It was reported by the psychiatric consultant that this patient denied that this was a suicide attempt, had no suicidal ideation, plan, or intent, severe depression, homicidal ideation, or hallucinations. He was discharged on day 2 of admission.
  
The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment. They stated that he was not unstable, had no unstable vital signs, no dangerous heart rhythm, persistent seizures, infections, or other medical reasons for inpatient hospitalization. They recommended a less restrictive level of care.
  
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk for suicide, and that patients with suicidal plan or intent are in need of hospital treatment. In this case this patient denied that this was a suicide attempt and also denied suicidal ideation, plan, intent, or depression according to the psychiatric consultant note. It was also reported that he denied hallucinations or homicidal ideation. He also denied current drug use though he had a past reported history of substance use. There were no reports of withdrawal symptoms or acute medical instability requiring only 24 hour hospital treatment. He had reports of bradycardia, lethargy, and dizziness but after one day he reportedly improved and was discharged. There were no reports of altered mental status or severe medical issues requiring 24 hour hospital treatment. There were no reports of serious metabolic disturbances. Also, there were no reports of physical aggression, severe agitation, inability to care for his basic needs, manic episodes, severe depressive symptoms, crippling anxiety, or inability to function. There were no specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a hospital setting for psychiatric reasons or detoxification reasons.  

Inpatient hospital treatment for psychiatric reasons or detoxification reasons was not medically necessary. It appeared that the health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.

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

Diagnosis: Dental problem (crossbite of individual anterior teeth when clinical attachment loss and recession the gingival margin are present).

Treatment: Insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit). 

The insurer denied coverage for the insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit). 

The denial is overturned. 

This is a female patient who was evaluated for orthodontic treatment.  This is a request to review Handicapping Labio-Lingual Deviations (HLD) scoring on a patient who is undergoing orthodontic evaluation.  The appeal specifically requests to evaluate tooth 22 and its position in the arch as well as the attached gingival tissues facially.

"Early diagnosis and treatment of anterior crossbite cases are recommended to prevent tooth wear, anterior tooth fractures, gum problems, and temporomandibular joint disorders and to achieve a better functional occlusion and esthetics.  Therefore, to diagnose and treat the malocclusion early and to supervise the patient properly are important for healthy physiological and psychological development" (Ceyhan et al. 2017).

Based on the documentation, it is clear that tooth 22 is labial in the arch with significant attachment loss.  There is gingival recession and the tooth is in crossbite.  This meets criteria by itself and follows generally accepted standards.  The HLD scoring provided in the documentation notes that there is a crossbite of individual anterior teeth when clinical attachment loss and recession the gingival margin are present.  This is a condition that automatically qualifies for treatment.      

The insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit) is considered medically necessary.

Treatment is needed, there are significant tissue changes already, if treatment is not done, there will be damage to the tissues, and the tooth in question will be more unstable.  Braces are needed to correct the issue, and prevent further damage/changes.

The health care plan did not act reasonably, with sound medical judgement, or in the best interest of the patient.

The carrier's denial of coverage for the insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit) is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems (skeletal Class I, maxillary and mandibular crowding, excessive overjet, and anterior crossbite with gingival attachment loss).

Treatment: D8080 braces and D8670 monthly visit x12.

The insurer denied coverage for D8080 braces and D8670 monthly visit x12.

The denial is overturned. 

This patient is a female child who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to skeletal Class I, maxillary and mandibular crowding, excessive overjet, and anterior crossbite with gingival attachment loss.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (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.  The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements.  

Upon review of the submitted documentation, (study models were not provided for review), 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, the HLD index is utilized.  This index provides 6 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 clearly met and does support comprehensive orthodontic care.  In this case, the clinical circumstance does meet the insurer and plan criteria to justify orthodontic care.

D8080 braces and D8670 monthly visit x 12 is considered medically necessary for this patient.  

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 D8080 braces and D8670 monthly visit x12 should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and Hiccups.
Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of marijuana abuse and hypertension (HTN) and was admitted with complaints of (c/o) intractable singultus (hiccups) associated with nausea and feeling of something stuck in throat/chest. Vital signs were remarkable for initial tachycardia. The physical exam was notable for no apparent distress (NAD), comfortable, no abdominal pain or tenderness. Lab work was notable for a white blood cell count (WBC) of 14.7, mild hypernatremia, and negative troponin. A chest x-ray (CXR) showed no acute disease, a computed tomography (CT) scan of the chest showed no acute abnormality. An electrocardiogram (EKG) showed sinus tachycardia and non-specific T-wave changes. The patient was diagnosed with intractable singultus and treated with intravenous fluids (IVF), Haldol, alprazolam, and metoclopramide. The admitting attending physician did not feel pancreatitis was likely. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.
The hospital stay was not medically necessary at an acute inpatient level of care.
This patient presented to the ED with c/o intractable singultus associated with nausea and feeling of something stuck in throat/chest. The patient did not have associated high-risk features, such as renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability. In addition, while the patient had electrolyte abnormalities, he responded to fluids. He did not have a bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable, his tachycardia responded to fluids, he did not have an acute kidney injury, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. The patient presented with intractable singultus, was treated, and responded to, IVF, anti-emetics, and benzodiazepines (BZDs). In addition, while the patient did have chest pain, the patient's HEART [History, Electrocardiogram, Age, Risk Factors, Troponin] score was 3, indicating a low risk of a major adverse cardiac events (MACE), and cardiology evaluated the patient and determined no need for acute intervention. Finally, the admitting physician did not feel that the patient had pancreatitis due to the benign presentation and treated the patient for intractable singultus. All these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Familial Mediterranean Fever (FMF).

Treatment: Colcrys (generic name cholchicine).

The insurer denied coverage for Colcrys.

The denial is overturned.  

This female patient has a medical history of familial Mediterranean fever (FMF)/Behcet's overlap, autoimmune hearing disorder, vertigo, hypercholesterolemia, psoriasis and thyroid disease. At the time of a tele-visit, her Rheumatologist increased Colcrys (generic name colchicine) to 0.9 mg (milligram) twice a day (BID). Colcrys 0.6 mg tabs were ordered. Office visit notes show documentation that Mitigare was given 7 and 8 months prior to the tele-visit. At that time she had a flare of aphthous ulcers, and there was question of abnormal liver function tests (LFT) on thrice daily (TID) dosing of Mitigare. The insurer has denied coverage for Colcrys as not medically necessary.  

Regarding the dosage of colchicine, as noted in the UpToDate chapter "Management of familial Mediterranean fever" the maximum dose of colchicine/d (colchicine per day) in FMF is 3 mg/d (milligrams per day), above the 1.8 mg/d proposed here. Slow titration is advised, as has been done here.  Renal function is good. 
Regarding the benefit of Mitigare, the patient was on Mitigare for 2 months, and then has been on colchicine ever since. Mitigare comes only in 0.6 mg. As noted above there were questions about Mitigare efficacy and side-effects. Mitigare comes as capsules, mandating TID dosing here. Colcrys is a scored tablet, making BID dosing possible. As noted per a review of the literature, compliance is higher with BID than TID dosing. Dosing colchicine as Colcrys 0.9 mg BID is appropriate in this case. 
The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The medical necessity for Colcrys is substantiated. The carrier's denial of coverage for Colcrys is overturned.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic
Inpatient Hospital

Diagnosis: Lower limb length inequality
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a female child with idiopathic shortening of her left femur, resulting in a lower limb length inequality. She was admitted for a femoral lengthening procedure, which consists of an osteotomy of the femoral shaft and stabilization with an intramedullary nail, which will later be used to lengthen the femur. An ultrasound-guided nerve block was done to assist with pain control, and the patient was instructed in crutch-walking by physical therapy.

The inpatient admission was medically necessary. This procedure is one that should be considered to require inpatient admission. The femoral osteotomy basically creates a femur fracture, and the intramedullary nailing procedure is similar to that done for a fractured femur. There can be significant pain, and it may initially be difficult for a child to resume ambulation. The fact that a nerve block was done indicates the expectation that the patient may experience significant pain after the procedure, and some degree of monitoring is required after such a block. Pain may become greater after the block wears off and may need to be addressed. It would be risky and ill-advised to attempt this procedure in an outpatient setting, and significant resources are required to carry it out safely. The inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nonischemic cardiomyopathy
Treatment: LifeVest
The insurer denied the LifeVest.
The determination is upheld.

The patient was diagnosed with nonischemic cardiomyopathy. She underwent an echocardiogram which showed an ejection fraction (EF) of 25% with global hypokinesis. A LifeVest was ordered for 4 months. The indication was not listed on the form.
At issue is the medical necessity of the LifeVest.
The wearable defibrillator (LifeVest) is not medically necessary. The patient had a newly diagnosed nonischemic cardiomyopathy. Per the current American Heart Association (AHA) science advisory (reference 1 below), the LifeVest is a class IIB indication for patients with newly diagnosed nonischemic cardiomyopathy, which is the clinical situation for this patient. A IIB indication means that there is some divergence of opinion but the weight of evidence is not in favor of treatment with the wearable defibrillator. It has not been shown in randomized, controlled clinical trials to be more beneficial than standard medical treatment for patients with newly diagnosed nonischemic cardiomyopathy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Coronary Artery Disease.
Treatment:  Inpatient Hospital Stay.

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

The patient has a past history significant for hypertension, hyperlipidemia, diabetes, mild left ventricular dysfunction, prior coronavirus disease (COVID) infection and coronary artery disease with prior percutaneous coronary intervention (PCI) and presented for an elective staged percutaneous coronary intervention (PCI) of the obtuse marginal vessel. The procedure was unremarkable and a drug-eluting stent was placed without complication. The patient was admitted overnight and discharged the following day without complication.

At issue is the medical necessity of the inpatient stay.

An inpatient stay was not medically necessary in this case.

This was an elective procedure performed without complications, and the patient was discharged the following day without event. The care of this patient was most appropriate at a lower level of care. Although the patient had some risk factors that (on a population level) are associated with poorer outcomes, there were no issues related to this case that warranted an escalation of care. Specifically, there were no clinical, electrocardiogram (ECG), hemodynamic, procedural or post procedural issues that necessitated an inpatient level of care.

The care of this patient was most appropriate at a lower level than inpatient. There were no specific features related to this elective and uncomplicated PCI that warranted an inpatient level of service.