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

Diagnosis: Dental Problems (overjet, overbite, Class I malocclusion, maxillary and mandibular crowding)

Treatment: Braces

The insurer denied coverage for braces.

The denial is upheld. 

This patient is a male child who presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite, Class I malocclusion, maxillary and mandibular crowding and has recommended orthodontics.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 26 total points to support orthodontic care. 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 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 does not claim an automatic qualifying condition and completes the HLD index, arriving at 26 points to justify orthodontic care. However, this reviewer concurs with the index completed by the insurer, attaining a total of 21 points on the HLD index (5 overjet, 3 overbite, 10 anterior crowding, 3 labiolingual spread). 

The coverage for braces is not considered medically necessary for this patient

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

Based on the above, the medical necessity for braces is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

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

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

Yes, the Braces are medically necessary.

The patient has an extreme overjet, meaning her upper from teeth are very much in front of her lower front teeth. "Overjet greater than 9mm [millimeters] with incompetent lips with reported masticatory/speech difficulties," is an automatic qualifying condition according to the handicapping index scale. The braces in this case are medically necessary due to this problem.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive System/Gastrointestinal. 
Treatment:  Inpatient Hospital. 

The insurer denied inpatient stay.  The denial is upheld in whole.

The patient is a female with a history of central abdominal pain, nausea, vomiting, and diarrhea beginning approximately 14 hours prior to presentation.  She had some right lower quadrant tenderness on examination and a reassuring white blood cell (WBC) count.  Ultrasound did not visualize the appendix, but also did not show any other features or signs supportive of a diagnosis of appendicitis.  Review of her chart also reveals that she has had multiple prior visits to the emergency department for abdominal pain and has been evaluated by the pediatric gastroenterology service in the past with no unifying diagnosis for all of these episodes.  This time, she was admitted to the pediatric surgery service for serial exams and observation.  Her hospital stay was uneventful.  She displayed no signs of sepsis, and indeed her pain and vomiting resolved, and she was discharged after a 2-day stay.  The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

An acute inpatient stay was not medically necessary.  The patient could have been safely and appropriately managed at a lower level of care status.  An inpatient stay might be justified if there was a serious medical or surgical condition identified, which required more complex management.  However, this patient was simply observed with symptomatic treatment for abdominal pain.  There were no complications of this pain, no physiologic derangements, hemodynamic instability, acute or chronic organ dysfunction, persistent altered mental status, fever or other signs of sepsis, management of complex comorbid medical condition or a finding of an occult or new medical condition.

Even if surgery were needed for treatment of an otherwise healthy adolescent with acute appendicitis, it is routinely provided at a lower level of care status.  No evidence was presented in the appeal documentation or in the primary medical records that would indicate that the patient had a serious medical condition requiring an acute care inpatient admission.

According to Pant et al., cited below, nearly one million children present to the ED annually in the U.S. with a primary diagnosis of functional abdominal pain, with the highest incidence of ED visits for this diagnosis in the 10-14-year age group.  For such patients, only 1% to 1.5% require admission to the hospital, thus the overwhelming majority of patients without a clear-cut medical or surgical diagnosis are treated and released without admission.
Appeal type: Medical necessity
Decision: Upheld

Digestive System
Inpatient hospital

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

The patient is a previously healthy man who presented to the hospital with a history of progressively worsening abdominal pain of several days duration. His evaluation included physical exam, labs, and computed tomography (CT) scan. He was without fever at the time of presentation. Lab data identified an elevated white blood cell (WBC) count of 18.4 K. A computed tomography (CT) scan yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was obtained.
The patient underwent laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy with findings of acute gangrenous appendicitis without abscess. 

The Inpatient stay was not medically necessary for this patient. The care and treatment provided could have appropriately been rendered at a lower level of care. The patient was clinically stable at the time of presentation and remained so during the course of care. An ambulatory designation would have provided for presurgical assessment, serial examination, operative treatment and post-surgical monitoring. This lower level of care would have also allowed for overnight monitoring.
According to Milliman Care Guidelines (MCG) inpatient and surgical care 24th edition, Appendectomy by laparoscopy, the goal length of stay is ambulatory or 1 day postoperative. These criteria indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications the procedure may be performed with an ambulatory level of care. In this case, the patient tolerated oral hydration, diet and medication and pain was well controlled. A lower level of care would have appropriately provided for presurgical assessment, laparoscopic appendectomy, and post-surgical monitoring. Inpatient care was not required or medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Advanced chronic obstructive pulmonary disease (COPD) requiring supplemental oxygen therapy, associated chronic fatigue, dyspnea.
Treatment:  Consumer directed personal assistance program (CDPAP) services: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week.

The insurer denied the Consumer directed personal assistance program (CDPAP) services: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week.  The denial is overturned. 

The patient is a female with a history of advanced chronic obstructive pulmonary disease (COPD) requiring supplemental oxygen therapy, associated chronic fatigue, dyspnea rendering her chronically bedbound with stage II decubitus ulcers.  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 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) Consumer directed personal assistance program (CDPAP) services to offer increased activities of daily living (ADLs) support.

Yes, the proposed treatment of 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) Consumer directed personal assistance program (CDPAP) services is deemed medically necessary. 

This is a female with a history of advanced chronic obstructive pulmonary disease (COPD) requiring supplemental oxygen therapy, associated chronic fatigue, dyspnea rendering her chronically bedbound with stage II decubitus ulcers.  Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).  Recent documentation from the patient's medical provider indicates that due to worsening dyspnea, fatigue and hypoxemia related to the patient's advanced chronic obstructive pulmonary disease (COPD), her generalized weakness and fatigue have become progressively worse.  She now requires extensive assistance with all activities of daily living (ADLs) including turning and repositioning. For these reasons, the currently approved plan of Live in diem: 24 hours per day - 7 days per week Consumer directed personal assistance program (CDPAP) services is insufficient to meet the patient's current needs due to the need for the live in aid to have time allocated for sleeping.  For these reasons, the proposed treatment 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) Consumer directed personal assistance program (CDPAP) services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain - acute coronary syndrome (ACS).
Treatment:  Inpatient admission.

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

The patient is a female, who presented with chest pressure, and dizziness times one week.  The patient had history of coronary artery disease (CAD) with stent, hypertension, diabetes, and remote brain tumor.  Electrocardiogram (EKG) did not show acute changes, cardiac enzymes were negative, and there was elevation of glucose and lipase.  The patient was admitted to telemetry, and intake declared no chest pain.  Chest pain was atypical and reproducible.  The patient received intravenous (IV) fluids, Pepcid, and Tums with relief of chest pressure.  The patient's computed tomography (CT) was negative, and chest x-ray (CXR) was negative.  The patient's symptoms resolved, and she was discharged.

No, inpatient level of care was not medically necessary.

Determination of level of care is primarily dependent on the actual care a patient receives and whether a higher level of acuity is needed to give this care.  This is best reflected in the presentation, physical exam findings, and laboratory orders and their results and highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome (ACS).  Exam (blood pressure normalized) and cardiac findings were normal.  Biomarkers and electrocardiogram (EKG) showed no evidence of acute ischemia ("abnormal EKG" was borderline).  Chest x-ray (CXR) was normal.  The physicians' treatment did not reflect any serious concern about the patient's cardiac condition.  Orders did not include medical therapy for acute coronary syndrome (ACS) such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or intravenous (IV) nitroglycerin (NTG).   

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care.  The only cardiac care provided was telemetry, frequently performed in a lower level of care.  The patient was admitted for monitoring; and subsequent tests and therapy did not require an inpatient level of care.  There was no complex care that required inpatient care.  This patient had no evidence of acute coronary artery disease (CAD). All tests showed absence of ischemia. 

The appeal noted that the care given could not be provided at a lower level of care, but no care actually given required inpatient level of care.  While there is always a potential for an adverse event, one did not happen, and no actual treatment was added.  The patient was discharged on normal home medications.

Milliman criteria requirements were not fulfilled as there was never any evidence of acute coronary syndrome (ACS) present.  The patient did not meet criteria for unstable angina.

All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care.  Thus, inpatient level of care was medically unnecessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Achalasia.
Treatment:  Pharmacy/Prescription Drugs (Botox).

The health plan denied the requested prescription drug (Botox).  The health plan's determination is upheld.

The patient is a male with dysphagia.  He has underlying cirrhosis secondary to hepatitis C.  He underwent an esophagogastroduodenoscopy (EGD) and barium esophagram that were possibly consistent with achalasia.  The EGD showed an esophageal diverticulum along with a tight lower esophageal sphincter (LES).  Careful review of all files did not reveal the upper gastrointestinal (GI) series report.  Prior to this he was seen for episodic nausea and vomiting.  Also was also seen later for the same which also included abdominal pain.  At neither visit did he endorse dysphagia.

The patient's provider has requested treatment of achalasia with botulinum toxin injection into the LES.  This request was denied by the plan; the preferred first line treatment modalities are pneumatic dilation and surgical myotomy.

The health plan's determination of medical necessity is upheld, in whole.

No.  This denial is based on the fact that this patient's diagnosis of achalasia has not been confirmed.  There are two main issues.  First, he has not had dysphagia documented as a prominent GI symptom.  All patients with achalasia have difficulty swallowing and this is the reason they undergo testing.  The purpose of treatment is to improve dysphagia.  Secondly, although supportive evidence for achalasia can be made on EGD and barium esophagram, definitive diagnosis is made on high resolution esophageal manometry, which the patient has not undergone.  Achalasia can be identified and other disorders of the lower esophageal sphincter, such as hypertensive LES and Esophagogastric Junction Outflow Obstruction (EGJOO) can be ruled out.
Appeal type: Medical necessity
Decision: Upheld

Mental Health
Inpatient hospital

Diagnosis: Suicidal Ideation
Treatment: Mental Health Inpatient Hospitalization 
The insurer denied the Mental Health Inpatient Hospitalization. The health plan's determination is upheld. 

The patient is a female diagnosed with Major depressive disorder, recurrent, severe without psychotic features. And Anxiety disorder unspecified. The patient has history of alcohol, cabbies and opioid use, but had not used for 9 months prior to admission. It is noted that prior to admission the patient has attempted to harm herself by driving her car into a telephone pole at 70 mph. The patient has history of 9 hospitalizations. The patient was awaiting placement in the State based long term care. The patient was admitted to inpatient level of care due to the suicide attempt by motor vehicle accident.

The Mental Health Inpatient Hospitalization was not medically necessary on the days in question. From the denied date, as well as the several days leading up to it, the patient was stable. The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient had no significant medical instabilities. The patient had no required emergency medications, restraints or seclusions. The request for continued stay was to give the patient a safe, structured environment while awaiting placement. There is no indication the patient's care could not have been done in a less restrictive setting, which is the standard of care based on the principles of care for children and adolescents from AACAP (American Academy of Child and Adolescent Psychiatry) guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: History of stage IV breast cancer with metastasis to the lungs, spine and bone
Treatment: Personal Care Aide (PCA) Level II: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week; (split shift); a total of 168 hours per week

The insurer denied the Personal Care Aide (PCA) Level II: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week; (split shift); a total of 168 hours per week.
The denial is overturned. 

The patient is a female with a history of stage IV breast cancer with metastasis to the lungs, spine and bone. 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 168 hours per week personal care aide (PCA), level II services to offer increased activities of daily living (ADL) support.

Yes, the proposed treatment of 168 hours per week personal care aide (PCA) level II services to offer increased activities of daily living (ADL) support is deemed medically necessary. 

This is a female with a history of Stage IV breast cancer with metastasis to the lungs, spine and bone. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's medical provider indicates that due to worsening mental status, weakness, cachexia, cancer related pain and chronic respiratory failure; the currently approved plan of 42 hours per week personal care aide (PCA) level II is insufficient to meet the patient's current needs. Due to the patient's numerous serious comorbid conditions, she requires 168 hours/week  personal care aide (PCA) Level II services to better assist with activities of daily living (ADLs), home safety, bed mobility/repositioning, reminders, preparation and administration of meals and medication along with assistance in diaper changes, toileting needs and finally use of medical equipment and devices. For these reasons, the proposed treatment 168 hours per week personal care aide (PCA) level II Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes Mellitus
Treatment: Novolog (Brand)
The insurer denied the Novolog (Brand).
The denial is upheld. 

This is a male with type I diabetes on insulin pump therapy. His glycated hemoglobin (A1C) was greater than (>) 15.5% on insulin lispro. He has tried and failed Admelog and Humalog as well. The request for Novolog is under review. 

No, the proposed Novolog is not medically necessary.

The prior request for Novolog brand insulin was denied as the patient has not tried and failed insulin aspart manufactured by Novo Nordisk. Novolog insulin is a form of insulin aspart. Both Novolog and insulin aspart are marketed by Novo Nordisk. They are the same type of insulin and have the same glucose lowering effect. They are both equally safe and effective in this clinical situation and the American Diabetes Association clinical guidelines do not recommend brand Novolog over insulin aspart. Therefore, no, the proposed Novolog is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Recurrent pregnancy loss. 

Treatment: Tests for inherited thrombophilia disorders, described by codes 81241, 81240, 85306, 85303 and 85300. 

The insurer denied coverage for the tests for inherited thrombophilia disorders, described by codes 81241, 81240, 85306, 85303 and 85300. 

The denial is upheld. 

This is a female patient who has a history of recurrent pregnancy loss. The patient underwent laboratory testing for inherited thrombophilia disorders. A chart note where the patient was seen for a maternal-fetal medicine consultation states that a single gestation was noted. The patient also reported that noninvasive fetal testing had already been performed with low risk results. The patient had undergone multiple ultrasounds. 

Based on the review of the medical literature, there is no improvement in this patient's clinical outcomes with these test results. Testing for inherited thrombophilia should be considered in the following clinical scenarios: (1) a personal history of venous thromboembolism (VTE), with or without a recurrent risk factor, and no prior thrombophilia testing; (2) a first-degree relative (e.g., parent or sibling) with a history of high-risk inherited thrombophilia. In this case, there is no documentation of prior VTE reported, nor any relative that has a thrombophilia. In other situations, thrombophilia testing is not routinely recommended. 

Thus, the patient is not a good candidate for tests for inherited thrombophilia disorders, described by codes 81241, 81240, 85306, 85303 and 85300. The tests for inherited thrombophilia disorders, described by codes 81241, 81240, 85306, 85303 and 85300 are not the best available tests for this patient at this time. Therefore, the thrombophilia panel ordered on this patient is not likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of tests for inherited thrombophilia disorders, described by codes 81241, 81240, 85306, 85303 and 85300 should be upheld.