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

Diagnosis: Hyponatremia, Gastroenteritis

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.  

This is a female patient who presented to the hospital with complaints of fever 101.5 at the time of presentation, coughing, dyspnea, nausea, vomiting and diarrhea.  Cardiology consulted on the patient and a laboratory work up was performed revealing no elevations in her cardiac enzymes and B type natriuretic peptide.  A computed tomography (CT) chest was performed which was negative for a pulmonary embolism. An echocardiogram was done which showed an ejection fraction of 55%.  She was consulted by Nephrology and Endocrinology.  The patient was noted to have hyponatremia with gastroenteritis.  Intravenous (IV) fluids were given and antibiotics; her diuretics were held.  The patient's sodium normalized and she was discharged. 
The health plan did not act reasonably and with sound medical judgment and did not act in the best interest of the patient.  This patient did not have any active cardiac issues and based on physical examination, serum blood testing and imaging studies there was no evidence of acute congestive heart failure. (1)  However, this patient was febrile, was complaining of diarrhea, nausea and vomiting and was hyponatremic.  Simple fluid restriction was not sufficient treatment.  Inpatient management with follow up blood testing and normal saline infusion was required.  In a Danish study of almost 300,000 patients presenting to the hospital with hyponatremia, 30 day mortality was 10% in patients presenting with serum sodium levels of 125-129mmol/L. (2)  Other investigators noted that hyponatremia was associated with increased morbidity, mortality and an increased length of stay. (3)  In conclusion, it was medically necessary to manage this patient at a higher level of care.

The carrier's denial of coverage for the inpatient hospital admission is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
 
Treatment: D8080 Braces and D8670 monthly visit.

The insurer denied the D8080 braces and D8670 monthly visit. The denial was upheld. 

This patient presented for an evaluation for orthodontic treatment. The patient had a lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical imaging performed. Upon evaluation the patient was noted to have an overjet, overbite, ectopic eruption and crowding. An HLD index was performed attaining 26 total points to support orthodontic care.

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 26 points to justify orthodontic care.  This reviewer concurs with the index completed by the insurer attaining a total of 19 points on the HLD index (3 overjet, 2 overbite, 6 ectopic eruption, 5 anterior crowding and 3 labiolingual spread) which is below the threshold of 26 points to support 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.  

In this case the HLD index total score of 19 points remains below the threshold of 26 points to justify orthodontic care. 
The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for D8080 braces and D8670 monthly visit is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ehler's-Danlos Syndrome with associated symptoms of dysautonomia, hyperflexible joints and vascular fragility
Treatment: Increase Personal Care Aide Level II Basic per 15 minutes; seven days per week, 12 hours a day (84 hours per week)
The insurer denied the Increase Personal Care Aide Level II Basic per 15 minutes; seven days per week, 12 hours a day (84 hours per week).
The denial is overturned. 

The patient is a female with a history of Ehler's-Danlos Syndrome with associated symptoms of dysautonomia, hyperflexible joints and vascular fragility. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 84 hours/week Personal Assistance Services to offer increased ADL support.

Yes, the proposed treatment of 84 hours/week Personal Assistance Services is deemed medically necessary. 

This is a female with a history of Ehler's-Danlos Syndrome with associated symptoms of dysautonomia, hyperflexible joints and vascular fragility. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent correspondence from the patient's physician indicates that due to progressively worsening functional decline; the patient has been experiencing worsening hypotension, orthostasis, palpitations and syncopal episodes. Hence, the currently approved plan of 70 hours/week Personal Assistance Services is no longer sufficient to meet the patient's current needs. For these reasons, the proposed treatment 84 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This male patient has a history of diabetes mellitus, hypertension, hyperlipidemia, obesity, and ureteral calculus.  The patient presented to the Emergency Room (ER) via Emergency Medical Services (EMS) with complaints of intermittent left-sided chest pain radiating to the right.  The patient reported that the symptoms resolved after taking aspirin and sublingual nitroglycerin.  The patient's vital signs in the ER were stable.  The patient had recently been seen by his cardiologist and had a stress test the week prior. The patient's troponin in the ER was negative.  The patient's chest x-ray showed no acute abnormality.  The patient's electrocardiogram (EKG) showed normal sinus rhythm.  The patient was admitted to the Telemetry unit with a diagnosis of acute coronary syndrome and was evaluated by cardiology consult.  The patient's repeat troponin levels were negative and his D-dimer was less than 150.  No arrhythmias were noted on telemetry.  The patient's outpatient stress test came back, showing normal perfusion.  After a period of medical stability, the patient was then discharged.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient presented to the ER with chest pain and  the initial evaluation in the ER was unremarkable, including an unremarkable EKG and negative cardiac biomarkers.  There were no other high-risk symptoms suggestive of acute coronary syndrome. Though it was appropriate and medically indicated for the patient's symptoms to be evaluated, inpatient admission was not medically necessary in this instance.  The patient's care could have been provided under the observational setting, allowing for additional diagnostic testing, which was done here. There were no high-risk or concerning findings on diagnostic testing to necessitate further inpatient evaluation.  During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care.  Thus, the acute inpatient admission was not medically necessary.

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

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

Respiratory
Inpatient hospital

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

The patient is a girl with a history of intermittent wheezing who presented with status asthmaticus. She was well until 3 days prior to admission when she developed difficulty breathing. She then began to have difficulty speaking in full sentences. She had no medications at home at that time. On the day of presentation, her breathlessness was worsening, so she went to the emergency department for care. She was admitted to the hospital for status asthmaticus. She was initially treated with every two-hour albuterol therapy along with chest physical therapy and close monitoring. By the following day, she had improved and was able to wean to every 4 hour albuterol treatments. She was felt to be stable for discharge to home with continued treatment and follow-up as an outpatient.

The inpatient hospital admission was medically necessary for this patient.
This is a young girl who presented with status asthmaticus. She was in moderate distress upon presentation with retractions and nasal flaring. She received appropriate treatment with several nebulized bronchodilator treatments as well as prednisone and magnesium sulfate. However, she continued to have significant symptoms. She required hospital admission for continuation of frequent nebulized bronchodilator treatments, initially every 2 hours, along with close monitoring with additional treatments as needed. This frequency of treatment requires an inpatient setting.
The decision-making at the time of admission for this patient was consistent with her young age, the presence of status asthmaticus with continued symptoms despite appropriate and aggressive treatment in the emergency department setting, and the need for continued intensive treatments with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/ Neuromuscular Disorder. 
Treatment: Inpatient hospital stay. 

Diagnosis: Headache. 
Treatment: Inpatient hospital stay. 

Health plan denied the inpatient stay as not medically necessary. The reviewer overturns the health plan determination. Inpatient stay was medically necessary. 

The patient has a history of cluster headaches, migraines, and hypertension who was admitted to the hospital on the day after presenting to the emergency department. He presented with headache. The patient reported having a severe headache that was sharp, right sided, and non-radiating, rated the headache as a 10 out of 10 in severity. The patient denied fevers, chills, and weakness. The patient typically experienced headache flares for three months at a time, and had been treated with Topamax and Imitrex as an outpatient. Vital signs showed temperature 98.6 Fahrenheit heart rate 72 blood pressure 136/76. On physical examination, heart was regular, breath sounds were normal, and they were no cranial nerve deficits. Labs showed WBC 9.19, hemoglobin 16.2, platelets 302, sodium 139, potassium 4.0, and creatinine 1.1. A head computed tomography (CT) was negative for acute intracranial pathology. The patient was admitted for intractable headache. The plan of care included neurology consult, steroids, Reglan, neuro checks, and continue Topamax. The patient was given intravenous (IV) Decadron and Toradol in the emergency room (ER) but HA persisted. Neurology saw the patient and their impression was that steroid should be continued for five additional days, and that the patient should be started on a calcium channel blocker. The patient was also given supplemental oxygen for abortive therapy. The headache resolved after treatment and the patient was discharged the following day. 

Inpatient care was medically necessary. The patient presented with severe headache/migraine and required intravenous (IV)IV steroids, high flow supplemental oxygen, and subcutaneous triptans for resolution. Because of the severity of the pain and the need for involvement of neurology acutely for interventions, it was reasonable to manage the patient at the inpatient level of care. 

The severity of the patient's migraine, in combination with his need for intravenous and subcutaneous therapies and neurology consultation, made inpatient level of care appropriate. He rated the headache with a severity level of 10 out of 10 and required aggressive therapy for resolution. Given the acuity, it was reasonable to manage him at the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite.
Treatment: Braces.
The insurer denied the braces. 
The denial is overturned. 

The patient is a female. The request is for orthodontic benefits.

Yes, the proposed treatment with braces is medically necessary. 

The patient has a crossbite (reverse bite) between teeth #'s 7 and 26. If there is a crossbite of an anterior tooth with gingival (gum) attachment loss, this is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem as teeth can be fractured as a result.
Appeal type: Medical necessity
Decision: Upheld

Skin Disease
Pharmacy/Prescription Drugs

Diagnosis: Plantar warts 
Treatment: Cidofovir Cream Compound 
The insurer denied the Cidofovir Cream Compound. The health plan's determination is upheld. 

The patient is a female with a history of acute myeloid leukemia (AML) and is status-post allogeneic stem-cell transplant (and therefore immunosuppressed). The patient has large, bothersome, virus-mediated plantar warts that have not responded to first-line treatment. 

Cidofovir Cream Compound is not medically necessary for this patient. The requested Cidofovir cream is not proven to be of any benefit over standard therapies after years of only anecdotal studies. Retrospective and other analyses do not show any significant and reliable benefit of Cidofovir cream over standard therapies (such as imiquimod and cryotherapy). This is particularly true for the plantar skin, where hyperkeratosis and an inability to access actively-infected and responsive keratinocytes is more difficult than virtually any other skin surface (for both Cidofovir cream and any other topical agent).
Despite the patient's history of immunosuppression, standard treatment would be to use even more keratolytic agents and possible peels to flatten (if true removal is not possible) the warts to allow more comfortable walking and less discomfort caused by the warts.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Throat pain; diarrhea; fever; abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male with history of schizophrenia, vocal cord mass, daily smoking, restless leg syndrome and polysubstance abuse. Medical records indicated that he was diagnosed with a vocal cord mass after a soft tissue neck computed tomography (CT) revealed a supraglottic versus glottic lesion. He presented to the hospital with complaints of subjective fevers, cough, abdominal pain, chronic throat pain and diarrhea. He denied nausea, vomiting, chest pain, and shortness of breath (SOB). 

The patient's vital signs included blood pressure 157/91, heart rate 67, respiratory rate 20, oxygen saturation 90% on room air, and temperature was 97.5 degrees Fahrenheit. Laboratory studies included hemoglobin 12.5, hematocrit 39.8, platelet count 277, white blood count (WBC) 7.68, Potassium 5.7, blood urea nitrogen (BUN) 13, creatinine 1.1, sodium 137, aspartate aminotransferase (AST) 42, and alanine aminotransferase (ALT) 114. 

The patient's examination noted badly visualized right/white/yellow exophytic lesion near the epiglottis, suspicious for throat malignancy. Abdominal examination was non-focal. Rectal exam did not show evidence of hemorrhoids.

The patient was seen by otolaryngology (ENT), assessment was supraglottic versus glottic lesion, unclear if malignancy versus granuloma; no threatened airway at this time. Electrocardiogram (ECG) shows normal sinus rhythm. Maxillofacial imaging was unremarkable.

Maxillofacial CT did not show any acute findings. CT of the cervical spine was unremarkable. Management included heparin, Protonix, and supportive care.

The patient underwent direct laryngoscopy with biopsy; diagnosis was glottic mass, and he was discharged.

No, the inpatient admission was not medically necessary.

The patient was admitted to the hospital for supraglottic versus glottic lesion, unclear if malignancy versus granuloma. He has history of vocal cord mass. Examination by ENT on the day of admission does not support acute respiratory compromise. The patient underwent direct laryngoscopy with biopsy; diagnosis was glottic mass and he was discharged home same day of the procedure. 

Per ENT, there was no threatened airway, severe airway obstruction, nor acute respiratory failure. The patient was hemodynamically stable on admission. There was no evidence of sepsis, abscess, change in mental status, active hemorrhage that required blood transfusion, cardiac arrhythmia, severe heart failure, acute renal failure, or severe electrolyte abnormalities.

Despite the concerns described in the appeal letter, this patient could have been cared for at a lower level of care. The interventions and work-up performed on this patient did not require acute hospital level of care to be completed.

The proposed treatment is not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer # 3:
This is a female patient with a history of chronic migraine headaches. It was reported that the patient tried and failed three other medications that included Topamax, nortriptyline, and propranolol.  
Peer-reviewed literature indicates that a migraine headache would be headaches that are present more than 4 days per month or headaches that last longer than 12 hours. The literature also supported that Botox is appropriate for prophylaxis of headaches in adult patients with chronic migraine. Onabotulinum toxin A injections have demonstrated safety and efficacy in chronic migraine patients in randomized, double blind, placebo-controlled studies.

The scientific and peer-reviewed literature supports a result of improvement in health outcomes.  The Botox injections for chronic migraines have final approval from the appropriate regulatory bodies for this diagnosis. The patient is a good candidate for the Botox injection for chronic migraines.  As the patient has failed Topamax, nortriptyline, and propranolol, the Botox injection for chronic migraines is the best available treatment for this patient at this time.  The requested Botox injection is likely to be more beneficial than any standard treatment/procedures for this patient due to a failure of prior treatments.

The carrier's denial of J0585 Injection, onabotulinum toxin A, 1 unit for chronic migraines should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Migraines
 
Treatment: J0585 Injection, Onabotulinum Toxin A

The insurer denied the J0585 Injection, Onabotulinum Toxin A. The denial was reversed. 

This is a female patient who has a two-decades history of bifrontal-temporal headaches. It was reported that she was treated by Ear, Nose and Throat several years ago for mild hearing loss in her right ear. Her treatment included a low salt diet and Dyazide with notable improvements.  She was seen again for recurrent headaches as a result of having to stop her Nortriptyline due to palpitations. It was reported that the medication helped her headaches. She again was evaluated for bilateral headaches as it was noted that she had failed medical therapy for her headaches.

The use of Botox for migraine prophylaxis is well established in the scientific literature and in current accepted medical practice. Therefore, the scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.

Per Frampton, J E; e tal. (2018), "In conclusion, the totality of evidence from clinical trials and real-world studies indicates that onabotA is an effective and generally well tolerated option for the prevention of chronic migraine [CM] that may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics."

Per Blumenfeld, A. M., Stark, R. J., Freeman, M. C., Orejudos, A., & Manack Adams, A. (2018), "The COMPEL Study provides additional clinical evidence for the consistency of the efficacy and for the long-term safety and tolerability of onabotulinumtoxinA for the prevention of headache in those with CM who have been treated with onabotulinumtoxinA every 12 weeks over 2 years (9 treatments) with the fixed-site, fixed-dose injection paradigm."

Per Matharu, M., Pascual, J., Nilsson Remahl, I., Straube, A., Lum, A., Davar, G., Johannes, C. (2017), "Utilization of onabotulinumtoxinA treatment for chronic migraine appears to be consistent with the Summary of Product Characteristics and published Phase III Research Evaluating Migraine Prophylaxis Therapy [PREEMPT] injection paradigm."

J0585 Injection, onabotulinum toxin A, 1 unit for chronic migraines has been Food and Drug Administration (FDA) certified for many years. The patient has failed maximum medical therapy; therefore, the patient is a good candidate for J0585 Injection, onabotulinum toxin A, 1 unit for chronic migraines and it is the best available treatment for this patient at this time.

A number of medications have failed to resolve the patient's symptoms. Nortriptyline had to be stopped because of palpitations. In this case, the request for J0585 Injection, onabotulinum toxin A, 1 unit is likely to be more beneficial than any of the standard treatments/procedures for this patient.                                                    

The carrier's denial of J0585 Injection, onabotulinum toxin A, 1 unit for chronic migraines should be reversed.