Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hyperlipidemia

Treatment: Livalo 4 mg (milligrams) tablet QD (per day)

The insurer denied coverage for Livalo 4 mg tablet QD.

The denial is overturned. 

This is a patient with a history of hypercholesterolemia, hypertension and atherosclerotic cardiovascular disease. Initial cholesterol panel revealed a total cholesterol of 349, low density lipoprotein (LDL) 252, high density lipoprotein (HDL) 39 and triglycerides (TG) 291. Treatment with atorvastatin, rosuvastatin and pravastatin all produced muscle pain and were not tolerated. The patient is currently tolerating pitavistatin (Lovalo) and ezetimibe and cholesterol panel demonstrates a 50% (percent) reduction in LDL-C (low density lipoprotein cholesterol) (LDL 96, Total cholesterol 192). 

Current American Heart Association and American College of Cardiology (AHA/ACC) guidelines clearly note that in patients with atherosclerotic cardiovascular disease (ASCVD) and statin associated muscle symptoms or recurrent muscle symptoms (despite appropriate re-challenge), non-statin therapy should be considered (Reference 1). In this case, two high intensity statin medications caused intolerable side effects. A third agent, pravastatin also was not tolerated. AHA/ACC guidelines recommend the use of PCSK9 (gene) inhibitors in patients with atherosclerotic coronary disease and LDL levels greater than 70mg/dl in patients intolerant to statin therapy (Reference 1).  

Medical records indicate that this patient suffered from statin induced muscle pain on multiple agents. Pitavastatin appears to be tolerated and resulted in a significant decrease in LDL levels. The patient has been treated with three out of six potential statin agents listed in the formulary along with ezetimibe. Given this alone, treatment with PCSK-9 inhibitor therapy is appropriate (Reference 1,2). Other options in the formulary are likely to cause symptoms consistent with statin induced myopathy. The requested drug appears to be more effective (based on tolerance) than three of the medications in the formulary, including pravastatin, which typically tends to cause fewer cases of myopathy (Reference 3). Treatment with additional agents from the formulary are likely to cause harm. In conclusion, Pitavastatin should be continued. 

The insurer's denial of Formulary Exception for Livalo 4 milligrams (mg) tablet a day (QD) to treat hyperlipidemia is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Physical Therapy. 
The insurer denied physical therapy 02 visits. 
The denial is upheld. 

The patient is a male with a right ankle disorder.  He underwent right ankle removal of open reduction internal fixation (ORIF) hardware. At issue is whether the requested health service/treatment of Physical Therapy, 02 visits is medically necessary for this patient. This was denied by the plan due to lack of progress with the right ankle disorder diagnosis.

The health plan's determination is upheld.

The requested Physical Therapy, 02 visits are not medically necessary for this patient. The patient has a right ankle disorder. The patient underwent right ankle removal of ORIF hardware. The physical therapy note stated that he had a previous course of physical therapy but continued to have strength and range of motion deficits. His pain level was 5-8/10. Right ankle active range of motion was -20 degrees () dorsiflexion, 25 plantar flexion, 10 inversion, and 10 eversion. Right ankle strength was 3/5. He ambulated on his toes with the right lower extremity with lack of heel strike or dorsiflexion.  He ambulated on the metatarsal heads of the right foot without heel strike.
The medical documentation indicates that the patient did not make significant progress in his previous physical therapy treatments and has continuing deficits in strength, range of motion, and function as well as moderate to severe pain. Due to a lack of progress in physical therapy, a home exercise program would be recommended as well as follow up treatment with his physician and surgeon. Physical therapy 02 visits are not medically necessary as there was no documentation in the medical records provided of significant improvement in pain levels, range of motion, strength, or function during the previous course of physical therapy. The peer-reviewed medical literature does not support physical therapy 02 visits. Further the medical standard of care in the United States at this time would not include additional physical therapy 02 visits.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lipomamatous neoplasm, head

Treatment: medical procedure

The insurer denied coverage for medical procedure

The denial is upheld.

This is the case of an adult male with history of a scalp mass. He presented to the hospital for excision of a scalp mass. The patient underwent the procedure. The mass was sent to pathology with the findings of a lipoma. He was discharged.   As per the operative note, the patient underwent excision of scalp mass under local anesthesia. The procedure was done as per the operative note in the ambulatory surgery area. Surgery started at 15:25 and was competed by 16:02. The face sheet notes that the procedure was done through ambulatory surgery and therefore no inpatient admission should be present.

Based upon the records submitted for review, the medical procedure was justified to be performed in the ambulatory setting of the hospital, not as an inpatient. According to the guidelines of MCG (Milliman Care Guideline) Health General Recovery Guidelines 25th edition General Surgery or Procedure GRG: SG-GS (ISC GRG), Operative Status Criteria is ambulatory for many procedures. Examples include: Endoscopic procedures; Embolization procedures; Most biopsy procedures; Many elective operations; including Stoma repair, Fistula repair, Lymph node surgery; Hernia repairs in the absence of ALL of the following: Emergency procedure (e.g. strangulated hernia), Severe co morbid disease (e.g., severe infection), Complex approach (e.g., morbid obesity, large chronic incarceration); Hemorrhoid or rectal surgery; Most breast procedures; Percutaneous and dilation procedures; Liver biopsy. Thus, in this case the patient should have been managed as an outpatient without inpatient status as this surgery is an ambulatory status. 

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

The insurer's denial of coverage for the medical procedure performed is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acidosis
Treatment: Custodial Care (long term care)
The insurer denied Custodial Care (long term care).
The determination is upheld.

The patient has a past medical history significant for acidosis, schizophrenia, vitamin deficiency, diarrhea, pressure ulcer of the sacral region of an unspecified stage, seizure disorder. He was initially admitted for skilled services with a diagnosis of acidosis. At the completion of the skilled services, the patient remained in the facility for custodial services. His insurance denied inpatient custodial services stating the following: We cannot approve your request for custodial care. Your request tells us that you have a feeding tube. We see that you are able to go to the bathroom without help. You do not have a serious mental illness or cognitive issue. We see that your needs can be met in a community setting. For this reason, we believe that permanent long-term care is not medically necessary. We used New York State (NYS) recommendations on long-term placement for this decision.
At issue is the medical necessity of custodial care (long term care).
Question(s):
The requested health service is not medically necessary for this patient.
Physician progress notes/psychiatric exam notes state that the patient is not particularly depressed/anxious, not psychotic. The patient has been diagnosed with a pressure ulcer and seizure disorder. There is a notation in the chart that the patient has a tracheostomy (trach) along with parental feedings through a gastrostomy (G)-tube. The etiology for these medical complications and the tracheostomy were not noted in the chart. There are limited medical progress notes available for review. Nursing notes, on multiple separate occasions. showed no significant distress, it was stated several times that the patient is resting comfortably in bed. There are several episodes where the patient was out of the facility with his sister.
There was a psychiatric exam noted on the patient's admission which stated the patient was not depressed and anxious or psychotic. None of the nursing notes state any ongoing concerns regarding cognitive impairment or psychological impairment in the medical record.
Therefore, ongoing inpatient custodial care is not medically necessary. The patient has no specific noted medical problems demonstrated in the medical record which would require inpatient custodial care. Tracheostomy care along with tube feedings can be provided in an alternate location. Similarly, there is no noted psychological reason that the patient could not be treated at an alternate location.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and monthly visits
The insurer denied Braces and monthly visits.
The determination is overturned.

The patient has a Class II malocclusion with moderate crowding and protrusive maxillary incisors. He has a 6 millimeter (mm) overjet and 5 millimeter (mm) overbite. He is treatment planned for orthodontics to correct the crowding and protrusion. At issue is the medical necessity of braces and monthly visits.

The orthodontic treatment is medically necessary.
Teeth # (number) 8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. Tooth #9, which is the most protrusive incisor, already has a history of trauma.
There is strong medical evidence that the correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. (1) Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. There is scientific evidence that oral health quality of life is reduced in patients with 6 plus (+) mm overjets, which this patient has. (2) For these reasons orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted teeth.
Treatment: Braces/monthly visits.
The insurer denied braces/monthly visits. 
The health plan's determination is overturned. 

The patient in question is a male with impacted teeth # (number) 20 and #29. Both teeth are completely blocked out and will be unable to erupt without orthodontic intervention. He presents with a skeletal Class I malocclusion and severe crowding. Teeth 3, 14 and 19 are unrestorable and will be lost. He is treatment planned for braces to address the crowding and impacted teeth.

Braces and monthly visits are medically necessary. There are changes in the bite including lingual tipping of the incisors and counterclockwise rotation of the occlusal plane which will deepen the bite and potentially lead to damage of the anterior teeth. Complications of impacted teeth include potential root resorption and devitalization of the adjacent teeth. As this patient has two impacted teeth braces are medically necessary to correct it.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer. 
Treatment: Nuclear medicine study positron emission tomography (PET) scan with computed tomography (CT) imaging. 

The insurer denied Nuclear medicine study positron emission tomography (PET) scan with computed tomography (CT) imaging. 

The determination is upheld. 

The patient has newly diagnosed Gleason 4 +(plus) 5 =(equals) 9 prostate cancer. His prostate-specific antigen (PSA) was 35.6 at diagnosis. An Axumin scan was obtained. At issue is whether the nuclear medicine study positron emission tomography (PET) scan with computed tomography (CT) imaging is medically necessary. 

Positron emission tomography (PET) scanning using one of the more sensitive radiotracers is recommended by the American Society of Clinical Oncology (ASCO) when conventional imaging is negative in a patient with clinically high- or very high-risk prostate cancer or when the results of conventional imaging are suspicious or equivocal, for clarification of disease extent or detection of additional sites of disease, if this could potentially alter management. The provider utilized PET/ computed tomography (CT) instead of conventional imaging as is documented. There is a paucity of support for the use of an Axumin scan at diagnosis in the literature and this approach is not supported by the authors of UpToDate nor by the National Comprehensive Cancer Network (NCCN). Evidence of an improvement in outcomes in this clinical scenario has not been established and, therefore, medical necessity cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crowding; Overjet; Crossbite. 
Treatment: Comprehensive Orthodontic Treatment. 

The insurer denied the Comprehensive Orthodontic Treatment. 
The denial is upheld. 

The patient is a female. The request is for comprehensive orthodontic treatment (braces). 

Per the dental clinical summary, the patient presents with skeletal class I relationship, moderate maxillary crowding, severe mandibular crowding, deep bite, moderate excessive overjet, left posterior crossbite, blacked out mandibular right 2nd molar. 

The health plan denied the coverage for the braces, because they felt that the patient did not score a 26 on the Handicapping Labio-lingual Deviation (HLD) Index Report, the score necessary for approval for orthodontic treatment. 

The provider appealed based on the diagnoses in the dental clinical summary. 

No, the proposed treatment of orthodontic treatment is not medically necessary. 
The photos and x-rays do not support some of the dental clinical diagnoses. In particular, the presence of a deep bite, moderately excessive overjet and left posterior crossbite is not supported in the photos and x-rays submitted. 

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

Based on the documentation presented, the deep bite, the posterior crossbite and the excessive overjet is not substantiated. Therefore, the braces are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain. 
Treatment: Inpatient Stay. 

The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a female with a past medical history remarkable for hypertension, chronic obstructive pulmonary disease (COPD), obesity, gastric sleeve bypass, and diabetes, who was admitted for upper abdominal cramping and vomiting. A review of system was negative for additional clinical symptoms. The patient was afebrile (Temperature of 36.8). Her blood pressure was 151/93, pulse rate of 72, respiratory rate of 16, and oxygen saturation of 97% on room air. Physical examination was remarkable for tenderness of the right and left upper quadrants. The patient was admitted for abdominal pain and emesis in the setting of recent pancreatitis and history of peptic ulcer disease. 

The inpatient hospital admission was medically necessary. The care could not have been safely rendered at the observation level of care. 

The patient was admitted for abdominal pain of unclear etiology. The patient was thought to have possible pancreatitis, but lipase was low, and the computerized tomography (CT) scan did not reveal clear evidence of pancreatitis. Therefore, the inpatient level of care was justified for a comprehensive workup that entailed magnetic resonance imaging (MRI), endoscopy and expert consultant with a gastroenterologist. Furthermore, the patient had risk factors for recurrence of abdominal pain and complications related to history of prior peptic ulcer and pancreatitis. Additionally, the findings of pancreatic fluid collection in the setting of abdominal pain warranted endoscopic intervention. The presence of vomiting, abdominal pain and poor oral intake along with comorbid conditions and risk factors warranted a full inpatient workup.
Appeal type: Medical necessity
Decision: Upheld

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

This was a male with history of anxiety, depression, post-traumatic stress disorder (PTSD) and intravenous drug use who presented to the hospital with complaint of left arm pain and swelling that began 1 day prior. Vital signs were temp 98.5 F (Fahrenheit), pulse 79, respirations 19, and blood pressure (BP) 137/83. Physical examination revealed diffuse swelling from the elbow down to the hand, tender to the touch around the left forearm as well as induration. Abnormal laboratory values included aspartate aminotransferase (AST) 44. Urine toxicology was positive for cannabis. Ultrasound of the left arm showed a superficial vein thrombosis and a well-defined structure concerning for a hematoma, mass or cyst. The patient was admitted and started on intravenous antibiotics. The patient decided to the leave the hospital against medical advice.

The inpatient hospital admission was not medically necessary. This patient presented to the hospital with left arm pain and swelling. There was no evidence of hemodynamic instability. There was no evidence of a severe infection or sepsis. There was no evidence of failure of outpatient therapy with antibiotics. There was no evidence of severe pain requiring inpatient care. The patient did not require any surgical intervention. The patient was able to tolerate oral intake. Based on the available medical records, the patient did not have any clinical needs that warranted inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Missing teeth
Treatment: Implants for Teeth #s 2, 3, 5, 9, 15, 18, 19, 20, 30, and 31; Extraction for Tooth #9
The insurer denied the Implants for Teeth #s 2, 3, 5, 9, 15, 18, 19, 20, 30, and 31; Extraction for Tooth #9.
The denial is upheld.

The patient is a male who is under the care of a dentist. The dentist has filed a treatment plan to include placement of dental implants in the areas of 2, 3, 5, 9, 15, 18, 19, 30, 31  and the removal of tooth 9. The patient is already missing many teeth based on the Panorex provided.

No, at this time, the proposed treatment plan is not medically necessary.
The records provided do not support medical necessity. There is no evidence of any prior, more conservative, treatment plans, or their failures. This could include partial dentures or fixed bridges. Mainly, there is no evidence of any prior attempts at utilizing a partial denture in either arch.  Therefore, at this time, the proposed treatment plan is not medically necessary.

Yes, the health plan acted with good and sound judgement.
The plan language and review process was followed and was based on the information provided by the patient and/or dentist.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment:  D8080 Braces

The insurer denied the D8080 Braces.
The denial is overturned.

The patient is a female. She has a Class II malocclusion. She has severe upper arch crowding with blocked out upper right and left permanent canines. She has very deep bite. The health plan's reason for prior denial was a handicapping index score of 23.

Yes, the braces are medically necessary.
The patient has a deep, impinging overbite with soft tissue damage on her palate. This is an 'automatic qualifier' according to the handicapping index scale. Also, the patient's upper canines are out of their proper positions. They are outside of the rest of the upper teeth. This means that the lower canines do not touch them during the chewing cycle. With the canines not touching, there can be no 'canine guidance,' which means the rest of the teeth will not glide together smoothly during the chewing cycle, but rather bang into each other and cause damage and/or trauma over time. Loosening or breakage of teeth is possible over time. These two problems need to be corrected orthodontically. This case has medical necessity.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Appendicitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male. He was transferred from another facility for perforated appendicitis. The patient was COVID-positive as well. His CT (computed tomography) demonstrated perforated appendix with fluid collection. He was treated with IR (interventional radiology) drainage.

Yes, the Inpatient admission was medically necessary.
The patient was admitted for perforated appendicitis. Percutaneous drainage of abscess from appendicitis is part of normal treatment algorithm for this pathology. He responded well to percutaneous drainage and avoided a major surgery. Perforated appendicitis requires an inpatient stay depending on how well the patient responds to treatment.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The health plan denied an inpatient stay that met criteria for inpatient stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission

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

This male patient was hospitalized for chest pain. He was transferred from another facility for cardiac catheterization to evaluate chest pain that had been present for several days. His past medical history is pertinent for hypertension (HTN), hyperlipidemia (HLP), diabetes, paroxysmal atrial fibrillation, benign prostatic hyperplasia (BPH) and chronic eosinophilia. 

The patient's vital signs were stable. Electrocardiogram (EKG) showed sinus rhythm (SR) and right bundle branch block (RBBB). There were no arrhythmias or elevated troponin documented. Chest x-ray revealed calcification of the aortic arch. Echocardiogram showed left ventricular ejection fraction (LVEF) of 60%. Cardiac catheterization showed severe single-vessel coronary artery disease (CAD) and he underwent successful percutaneous coronary intervention (PCI) with stenting to the mid left anterior descending (LAD) coronary artery. There were no procedural complications and the patient was discharged to home the next day. This is an appeal of the denied claim that the requested acute inpatient hospital stay was medically necessary for this patient.

No, the proposed inpatient hospital admission was not medically necessary.
Based on the peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient admission is not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome (ACS), chest pain that is indicative of a serious cardiac condition like acute myocardial infarction (AMI), pulmonary embolism (PE) or aortic dissection, pneumonia, hypertension requiring inpatient hospitalization, significant procedural complication or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. The care the patient received, including an uncomplicated cardiac catheterization with percutaneous coronary intervention (PCI) like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, the proposed treatment is not medically necessary, based on the submitted information and the current published medical literature standards of care.

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