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

Diagnosis: Weakness and dizziness (near syncope)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a history alcoholism, cirrhosis, and pseudo-seizures. He presented to the ED (emergency department) with near syncope.  The patient had dizziness, palpitations, chills, and two days of anorexia.  His BS (blood sugar) was 60 per EMS (emergency medical services).

The patient's ED vitals showed orthostatic hypotension.  His VS (vital signs) were as follows: Temperature 36.8 Celsius, heart rate 102, respiration rate 18, blood pressure 132/84, and pulse oximetry 94%.  The patient's exam was unremarkable.  His labs were remarkable for Na (sodium) 132, EtOH (alcohol) 210, lactic acid 2.8, WBC (white blood count) 4.0 and PLT (platelets) 71.  His head CT (computed tomography) revealed NAD (no active disease).  His CXR (chest x-ray) revealed NAD.

No, the inpatient admission was not medically necessary.

Medically necessary services are those which are the following:
1) safe 2) effective 3) generally accepted national standard of medical practice 4) not provided primarily for convenience of the patient or the practitioner 5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The requested inpatient admission was not medically necessary because it was not in accordance with generally accepted national standard of medical practice for this patient's scenario.

The patient was admitted.  Plan of care included IVF (intravenous fluids) and CIWA (clinical institute withdrawal assessment) protocol for alcohol withdrawal.  Lactic acidosis resolved after 2 liters LR (lactated ringers).  His dizziness improved.

The following day, the patient's vital signs were stable.  He complained of dizziness upon standing.  He had mild tremors on exam.  The plan was to continue IVF.  His hypoglycemia resolved.  The plan was to continue CIWA protocol and to follow up psychiatry.

This patient was admitted after presenting with presyncope in setting of alcohol intoxication.  The patient was found to have orthostatic hypotension and hypoglycemia.  He had mild tachycardia but no arrhythmia.  He did not have vomiting, delirium, seizures, or gross tremor.  Labs were remarkable for lactic acidosis.  The patient was admitted with plan for IVF and CIWA protocol.  Lactic acidosis and dizziness rapidly improved with IVF.  He did not have persistent hypoglycemia.  He did not have findings of severe alcohol withdrawal.  He did not have symptoms that required an acute inpatient level of care.  He had not failed management at a lesser level of care.  The inpatient hospital admission was therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (overjet, buccal crossbite and impacted canine). 

Treatment: D8080 braces and D8670 monthly visit.

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

The denial is upheld. 

This patient is a female child who presented for evaluation for orthodontic care. The Orthodontist recommended comprehensive orthodontics due to overjet, buccal crossbite and impacted canine. The Orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated (maxillary canine). 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 on the HLD index attaining only 17 points on review by their internal reviewers. 

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, an HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used, utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary. 

In this case, the treating Orthodontist claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care. This reviewer concurs with the findings of the insurer of attaining 17 points on the HLD index (6 points overjet, 3 points overbite, 5 anterior crowding, 3 points labiolingual spread).

Regarding the validity of the HLD 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.  

D8080 braces and D8670 monthly visit are not considered medically necessary for this patient. The clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visit is upheld. Medical necessity is not substantiated.
Appeal type: Step Therapy
Decision: Overturned

Diagnosis: Cancer/Thyroid Cancer
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested prescription drug as not medically necessary. 
The health plan's determination is overturned.

This is a female diagnosed with thyroid cancer. This request is for Levothyroxine Cap 75 mcg (Tirosint). As reported; she tried Levothyroxine products and has had significant worsening of her irritable bowel syndrome that may be related to the fillers used in the powder formulations of the brand name and generic products. She has a long history of gastrointestinal issues that are very sensitive to gluten, garlic, onions, and raw vegetables. Her symptoms got significantly worse when she started Levothyroxine products after her thyroid surgery. She had a repeat ultrasound that shows no evidence of recurrence of thyroid cancer.
At issue is the medical necessity of the requested prescription medication.

The health plan's determination of medical necessity is overturned, in whole, as the request is medically necessary.

Yes. Tirosint is a brand name of Levothyroxine. The patient is reported to have hypothyroidism. Tirosint is Food and Drug Administration (FDA) approved for the treatment of hypothyroidism [1]. As with other forms of Levothyroxine it is effective in the treatment of hypothyroidism [2, 3]. The patient has documented failure of tablets that contain fillers due to gastrointestinal side effects. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer
Treatment: PET/CT scan
The insurer denied the PET/CT. The health plan's determination is overturned.

This is a female with a history of syncrhonous edometrioid uterine cancer and mixed clear cell endometroid carcinoma of the left Fallopian tube. The patient has previously been treated with surgery and adjuvant chemotherapy (carboplatin/paclitaxel). The patient had a recurrence and subsequently underwent debunking and cisplatin + radiotherapy. A positron emission tomography (PET) / computed tomography (CT) was obtained to further evaluate findings on a computed tomography (CT) which showed a right pelvic nodule increasing in size and an increase in sclerosis of the right pubic bone.

The Positron Emission Tomography and Computed Tomography (PET CT) is medically necessary for this patient.
In the case of this patient for whom there are concerning CT findings which may be indicate progression, the National Comprehensive Cancer Network (NCCN) recommends a PET/CT. The NCCN Guidelines state "...Whole-body PET/CT may be used to clarify ambiguous findings...". This is, similarly, supported by a 2013 meta-analysis of 11 studies (10 of which were retrospective) supports the use of positron emission tomography (PET) as another modality for the evaluation of a suspected recurrence, particularly when performed with a CT scan. In this analysis, PET had a sensitivity and specificity of 95 and 93 percent, respectively. This is echoed by the authors of UpToDate. For these reasons, the PET/CT is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell anemia.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.

This is a male patient with known sickle cell anemia who presented to the hospital with 10/10 pain. He had a hemoglobin (Hgb) level of 10.5. He was afebrile, with negative chest x-ray (CXR) and non-hypoxic. He was admitted for management of uncomplicated sickle cell pain crisis. He was given intravenous (IV) fluids and pain medications. 

The patient has known sickle cell anemia. His Hgb was 10.5. He was afebrile, with negative CXR and non-hypoxic. As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate. This patient could have been managed at an alternative level of care for the treatment of an uncomplicated sickle cell pain crisis.

"Generally a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary" (American Health Information Management Association, 2018).

"Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care, or could be discharged. Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours" (Society of Hospital Medicine, 2021).

"Sickle Cell Disease (SCD) patients experience significant morbidity and mortality secondary to cerebrovascular accident, acute chest syndrome, acute vaso-occlusive pain crises, SCD-related multi-organ failure, cholecystitis, acute intrahepatic cholestasis, acute sickle hepatic crisis, acute hepatic sequestration, priapism, and renal disease. Emergency physicians must recognize acute manifestations of SCD in order to deliver timely management and determine patient disposition" (Simon E. et al., 2016).       

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

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

Diagnosis: Migraines.

Treatment: Nurtec orally disintegrating tablet (rimegepant) to treat migraines.

The insurer denied coverage for Nurtec orally disintegrating tablet (rimegepant) to treat migraines.

The denial is overturned. 

This is a female patient with a past medical history of migraines and allergic rhinitis.  The patient was taking Fioricet as needed.  In the past she did not want to take a preventative medication.  The Fioricet was not helping anymore.  The patient had 8-10 days of headaches a month.  She previously used triptans, which caused hypertension.  The headaches lasted for 14 hours and caused a moderate decrease in her function.  The headaches were associated with photophobia, phonophobia, and irritability.  Lights with activities made the headache worse.  The relieving factors included lying down in a quiet room.  The provider requested Nurtec disintegrating tablets for the treatment of intractable chronic migraine without aura and without status migrainosus.

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

Nurtec orally disintegrating tablet (rimegepant) to treat migraines is considered medically necessary.  The patient has failed first line treatments including Fioricet and triptans.  The triptans caused hypertension.  The use of CGRP (Calcitonin gene-related peptide) receptor agonists has become part of the standard of care.  The medication is a CGRP. 

Up to Date notes that "Small-molecule calcitonin gene-related peptide (CGRP) antagonists ("gepants") are orally-administered medications that have been used for the acute treatment of migraine. In a preventive treatment trial of 1591 patients with migraine, those assigned to rimegepant had a higher response rate and greater reduction of migraine days per month over baseline compared with placebo [1]. These data support the use of oral rimegepant for the prevention as well as the acute treatment of episodic migraine."

The insurer's denial of coverage for Nurtec orally disintegrating tablet (rimegepant) to treat migraines is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder (ADHD). 
Treatment: Psychological testing. 

The insurer denied psychological testing. The health plan's determination is overturned. 

The patient is a female who reported having problems with attention, concentration, and short-term memory. Her primary care physician referred her for evaluation. She was sent for psychological testing. The evaluation resulted in a diagnosis of attention deficit hyperactivity disorder (ADHD), Combined Presentation and mild anxiety. 
Under review is the medical necessity of the psychological testing. 

Psychological Testing is medically necessary for this patient. There are complexities to the case that warranted a more thorough assessment. 
ADHD diagnostic criteria require a detailed interview and history gathering to determine the developmental nature of symptoms (i.e., onset in early childhood and before adolescence). In this patient, such a process is necessarily more time intensive and requires carefully ruling out other related causes of symptoms that may mimic ADHD. 
Most physicians are hesitant to prescribe stimulant medication (which is usually the front line treatment for ADHD) because it is a controlled substance and has abuse potential. As such, this fact makes it more necessary to screen for other problems (such as a substance abuse history) and to increase one's confidence that it is, in fact, ADHD that is driving the patient's symptoms (versus (vs). numerous other related conditions). 
ADHD is becoming increasingly malingered, or its symptoms exaggerated, in routine clinical care for the purpose of obtaining medication that is known to improve the performance of otherwise normal, healthy people and/or to obtain accommodations in one's educational or employment setting. A simple clinical interview and brief rating scales are not sufficient to rule out these other considerations. 

Psychological testing is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Home Health Care. 

The insurer denied an increase in consumer directed personal assistance services to 35 hours a week. 

The denial is upheld. 

The patient is a male with the past medical history significant for coronary artery disease, cerebral vascular disease with infarction, chronic fatigue, hypertension, history of falling, insomnia, edema, obesity, osteoarthritis, hyperlipidemia, sciatica, sleep apnea, diabetes mellitus, glaucoma and urinary incontinence. The patient is currently receiving 23 hours per week Consumer Directed Personal Assistance Services (CDPAS). The patient is requesting an increase to 35 hours per week. This was denied by the health plan based on lack of medical necessity. 

The health plan's determination is upheld. 

No, the requested health service is not medically necessary for this patient. 
The patient is currently receiving 23 hours of care. Additional increase is service hours to 35 per week is not medically necessary for this patient. 
Patient is an elderly male with significant past medical history. He currently lives in an apartment with his wife. He does have multiple problems and had a recent stroke. His functional status was noted to be decreased since the previous evaluation. Between evaluations there has been a decrease in his functional ability. He was hospitalized two times for stroke like symptoms. 

The patient had previously been receiving 21 hours a week and services were increased to 23 hours a week. He is requesting increase of service is a 35 hours a week. His spouse is also a patient receiving 21 hours a week. Their grandson is a personal care assistant. 

Both Uniform Assessment System (UAS) State of New York were was reviewed. Tasking tool dated noted 18.20 hours a week of services were medically necessary, 14 of those hours were shared hours with cooking and cleaning shopping and errands.
It was noted that he can safely manage his weekly tasks with the current hours a week. His spouse is also receiving 21 hours a week with many services duplicated such as cooking and cleaning and grocery shopping. 
The patient does require help with many activities of daily living (ADLs). However, the number of hours listed are adequate to meet the patient's functional needs. He also requires help with several Instrumental activities of daily living (IADLs). The duplicate services such as shopping and cleaning and generalized housework are shared since the patient's wife also receives 21 hours. Even though the patient's health did decline, there is no information provided noting that these services cannot be provided in the time allotted. Additional hours for safety monitoring and/or supervision are not considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraines. 
Treatment: Botox (onabotulinumtoxinA) injections. 

The insurer denied coverage for Botox (onabotulinumtoxinA) injections. 

The denial is upheld. 

The patient is a female diagnosed with a past medical history of chronic migraines, asthma, hypertension, and post-concussion syndrome.  The telemedicine visit noted the patient was being treated for chronic migraine.  The patient had more than 15 headaches per month.  She had trialed Excedrin Migraine as needed and Imitrex.  The patient endorsed migraine with symptoms of photosensitivity, nausea, and vomiting.  The onset was 10 years prior to the office visit.  The patient was utilizing gabapentin and duloxetine.  The provider indicated the patient had persistent migraine symptoms over the course of the past 6 months in the setting of a flare of the syndrome which began approximately 10 years prior to the office visit.  Her pain was in the occiput and radiated anteriorly.  The spells were associated with an aura of lateralized paresthesias in the face.  The patient did not have any relief in the past with abortive therapy such as triptans.  The request was made for a trial of botulinum toxin. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Botox (onabotulinumtoxinA) injections to prevent migraines is not considered medically necessary for this patient. The documentation does not show whether this patient has been given a trial of other conventional migraine preventive meds such as - Topamax, Depakote, Beta Blockers, Elavil, etc. A reasonable trial of the noted medications has not occurred. 

The insurer's denial of coverage for Botox (onabotulinumtoxinA) injections to prevent migraines is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems (failing crown restoration, and possible recurrent caries). 

Treatment: D2740: crown on tooth #3.

The insurer denied coverage for D2740: crown on tooth #3.

The denial is overturned. 

This is a female patient who presented for comprehensive dental treatment and failing crown restoration on tooth #3 was noted with recurrent decay on this endodontically treated tooth. Based on these clinical findings, the treating dentist recommended replacement of the full coverage crown on this tooth. The insurer has denied this service stating that there are insufficient clinical findings present to justify the need for this replacement crown service and therefore it is not dentally necessary. The patient is appealing.

Upon review of the documentation, particularly the radiographs, the preexisting restoration placed on this tooth #3 appears to be failing. Radiographically there appears to be possible recurrent caries under the restoration. Given this clinical circumstance, replacement of this restoration with another full coverage crown is indicated. There is adequate bone support of this tooth and adequate coronal structure to successfully support a fixed crown restoration. In this patient, crowns are a conservative restorative option which would represent a standard of care for this clinical circumstance in general dental practice especially in endodontically treated teeth. As such these services, which are also a covered service for this individual, would be deemed medically necessary. The request meets the insurer's criteria for approval and is a standard of care in general practice.

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

The insurer's denial of coverage for D2740: crown on tooth #3 is overturned. Medical necessity is substantiated.