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

Diagnosis: Sickle cell disease and fever
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned

The patient is a toddler aged male with sickle cell disease. He was admitted for fever. He had a one-day history of a temperature at home to 100 Fahrenheit and intermittent sneezing. He presented to his primary physician's office and had a temperature of 102.5 Fahrenheit. The patient's vital signs in the ED (emergency department) were T (temperature) 37.7 Celsius, P (pulse) 135, R (respiration) 36, and pulse oximetry 100%(percent) on room air. His exam was normal. He was given ceftriaxone and IV (intravenous) fluids. The patient was admitted due to meeting high risk criteria with a WBC (white blood count) above 30. Viral testing was negative. His electrolytes were normal. Blood cultures were obtained. During the admission, he was intermittently febrile. His blood cultures remained negative. He was discharged home on day #2.

The Inpatient admission was medically necessary.

The child was admitted for sickle cell disease and fever. Children with sickle cell disease and fever are at high risk for bacteremia, sepsis and cardiorespiratory compromise, particularly when well-established risk factors are present. This child met high risk criteria, as he had a WBC (white blood count) above 30. He therefore required acute inpatient care in order to provide close cardiorespiratory monitoring, IV (intravenous) antibiotic administration, and IV (intravenous) fluids. His care could not have been safely provided at a lower level of care. The requested acute inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prevention of Cytomegalovirus infection beyond 100 days post-transplant
Treatment: Prevymis 480MG (milligrams) TAB (tablets)
The insurer denied the Prevymis 480MG TAB.
The health plan's determination is overturned.

The patient is a female who underwent a lung transplant. The transplant was bilateral for combined pulmonary fibrosis and emphysema and was from a Cytomegalovirus (CMV) positive donor to a CMV positive recipient. For CMV, she was originally on Valganciclovir but developed breakthrough viremia and was changed to Letermovir.

The health plan in its determination of medical necessity did not act reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of Prevymis (Letermovir) is medically necessary for the patient. The patient has undergone a lung transplant and she is immunosuppressed. She received her lungs from a CMV positive donor, and she herself is CMV positive. The usual recommendation for prophylaxis in this case is for at least 6 to 12 months, potentially longer based on risk. She has already had an episode of CMV viremia despite Valganciclovir, raising the risk and concern for an active CMV infection.
There are few options for managing CMV, and Letermovir is one that has supporting data that is cited below. While it may not have Food and Drug Administration (FDA) approval beyond 100 days, the patient has few options, requires prophylaxis beyond this point, and has already failed the standard treatment. As she needs some type of treatments, options are limited, and Letermovir has literature-supported effectiveness and this treatment is medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting, inability to tolerate oral intake
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

This is a toddler aged female patient. The patient had vomiting and inability to tolerate oral intake (PO). She was hospitalized. The reason for prior denial was that the requested service was not medically necessary. On day number one, the patient was seen in the emergency department for vomiting of two days duration likely viral illness/acute gastroenteritis. The patient received intravenous (IV) fluids; she was unable to tolerate oral intake. The patient was admitted for IV fluids and hydration. On day number two, there was no more vomiting; the patient tolerated oral intake. The patient was discharged home.

The proposed treatment was not medically necessary.

As documented in the clinical notes and summarized above, this patient had vomiting for two days prior to this hospital admission. The patient was diagnosed with viral illness and acute gastroenteritis. During the hospital stay, the patient received IV fluids and oral intakes. The patient stopped vomiting after admission and tolerated oral intake. There was no documentation of any other acute events such as high fever, respiratory distress and cardiovascular instability. Acute gastroenteritis may require IV fluids for dehydration and can be managed at observational level of care (1-3). Thus, the proposed acute inpatient care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COVID 19

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is overturned

 
This patient presented to the hospital complaining of palpitations. She had tested positive for COVID 19 virus two days prior to presentation. The patient had no prior cardiac history. On arrival to the hospital the patient was tachycardic with an irregular pulse of 165 beats per minute (bpm). Blood pressure (BP) was 133/73. No abnormal findings were noted on physical examination. Subsequent vital signs demonstrated persistent tachycardia with heart rates up to 201 bpm and BP 201/103. A 12-lead electrocardiogram (ECG) demonstrated atrial fibrillation (AF) with a rapid ventricular rate of 175 bpm, a normal axis and no ST (interval on an ECG) or T wave (interval on an ECG) abnormalities. Serum blood testing revealed normal thyroid and renal function. An echocardiogram demonstrated a left ventricular ejection fraction of 66-70%. The patient was admitted to cardiac telemetry and treated with intravenous diltiazem and oral anticoagulant therapy. She spontaneously reverted to normal sinus rhythm and was discharged after two days of observation and treatment. 

Admission for monitoring and treatment was medically necessary. Patients presenting with atrial arrhythmia with rapid ventricular rates require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days. This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation. This patient presented to the hospital with chest pain, new onset atrial fibrillation, and acute renal failure.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiectasis

Treatment: E0483, high frequency chest wall oscillation system

The insurer denied coverage for E0483, high frequency chest wall oscillation system

The denial is overturned

 
This is an adult patient with a history of asthma, Tracheomalacia, and obstructive sleep apnea. The patient has significant mucus production (chronic cough with thick creamy phlegm). The patient had a Computed Tomography of the chest which revealed Bronchiectasis. The patient had a Fiberoptic Bronchoscopy (FOB) done which revealed airway inflammation and tracheobronchomalacia. The patient has been using Vest therapy for airway clearance which has been helping.

Vest therapy is approved as an airway clearance technique in patients with Bronchiectasis and is highly effective in reducing hospitalizations, antibiotic use and improves subjective experience of airway clearance. This patient should be approved for use of a High Frequency Chest Wall Oscillation device.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for E0483, high frequency chest wall oscillation system is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ischemic Heart Disease.
Treatment: Inpatient Admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

This is an adult female with a history of ischemic heart disease, hypertension and diabetes mellitus that presented to the hospital for elective cardiac catheterization after reporting symptoms of worsening chest pain on exertion. Cardiac catheterization revealed a 95% (percent) in stent restenosis of the right coronary artery. Left Ventricular (LV) ejection fraction was 70%. A drug eluting stent was successfully placed. No perioperative complications were noted, and the patient was discharged the following day.

This patient presented for elective percutaneous revascularization. She underwent an uncomplicated procedure and stents were placed in the right coronary artery. She was discharged the following day. Several investigators have studied same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (Reference 1-3). Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care. In conclusion, inpatient admission was not medically necessary. The patient could have been managed at a lower level of care.

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

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

Diagnosis: Recurrent pregnancy loss

Treatment: Embryo transfer with Lovenox

The insurer denied coverage for an embryo transfer with Lovenox.
 
The denial is upheld.

The patient is a female with a history of recurrent pregnancy loss (RPL). She underwent an embryo transfer. The transfer was unsuccessful. The patient requested coverage for a second transfer with Lovenox.  

Low-molecular weight heparin (LMWH) is frequently offered to women with unexplained recurrent miscarriage. However, trials show no benefit to LMWH treatment in women without an inherited thrombophilia. One double-blind trial randomly assigned 258 pregnant women who had a history of unexplained RPL (two or more consecutive miscarriages before 15 weeks gestation) and a negative thrombophilia work-up to either subcutaneous daily LMWH (enoxaparin 40 mg [milligrams]) or placebo. Enoxaparin treatment did not improve the chance of a live birth. In another trial of 449 women with RPL and no thrombophilia, there were no differences in live birth rates between women randomly assigned to dalteparin 5000 international units daily versus placebo (86 and 87 percent).

Based on the above, the requested embryo transfer with Lovenox is not medically necessary.

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

The insurer's denial of coverage for an embryo transfer with Lovenox is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Advanced dementia and hip fracture
Treatment: Increase Home/Personal Care to 24 Hours per Day (Live-in)
The insurer denied: Increase Home/Personal Care to 24 Hours per Day (Live-in)
The denial is overturned

The proposed treatment is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living, including toileting, walking, transfers, turning/positioning, or feeding. This patient has multiple chronic conditions, including advanced dementia. She was hospitalized last year with a hip fracture. She is appealing denial of increase home/personal care from 48 hours per week to 24 hours per day (live-in). Uniform Assessment System (UAS) evaluation completed five months ago shows the patient requires assistance with all activities of daily living, except eating. She has bladder incontinence. Compared to Uniform Assessment System (UAS) evaluation completed one and a half years ago, there has been a decline with bathing, personal hygiene, dressing, walking, locomotion, toileting, and bed mobility. Appeal statements support that the patient's cognitive and physical functioning have declined and that the patient needs assistance with all activities of daily living. The patient is noted to have frequent needs for nighttime assistance with toileting due to urinary incontinence. This patient's physical functioning is significantly impaired. The need for extensive assistance to total dependence with all activities of daily living, except eating, cannot be met with the approved personal care services at 48 hours per week. The proposed increase to 24 hours per day, live-in, is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting and Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This is an adult female with a history of substance abuse disorder (heroin, alcohol [EtOH]) who presented to the emergency department for nausea, vomiting, and right upper quadrant (RUQ) pain. The patient had tenderness in the right upper quadrant and epigastric areas. Abdominal ultrasound showed a positive Murphy's sign with equivocal gallbladder thickening. The patient's computed tomography (CT) of the abdomen / pelvis showed soft tissue prominence in the ampulla, dilated common bile duct. The patient was treated with intravenous fluids, intravenous Zofran, and intravenous morphine. The patient was treated with nothing by mouth (NPO) and cardiac monitoring. The patient declined further management with esophagogastroduodenoscopy (EGD) and magnetic resonance image (MRI) / magnetic resonance cholangiopancreatography (MRCP). The patient eloped (left against medical advice) on the third day. The primary diagnosis was abdominal pain with nausea/vomiting and dilated common bile duct (CBD) likely secondary to choledocholithiasis secondary to gallstones secondary to alcohol abuse versus gastroesophageal reflux disease (GERD). 
Per the documentation:
"Patient was admitted to medicine service and then was transferred to surgical service. Studies were concerning for ampullary mass on the CT imaging. Plan for the patient included obtaining DI EGD with biopsy of the ampullary mass, obtain MRI MRSP with liver protocol. Patient refused EGD due to wanting to eat and wanting her home dose of methadone. Continued to refuse despite counseling on the rationale, risks, and benefits from multiple services. Her home dose of methadone was confirmed and started on day #3. On day #3 patient still refused any test/procedures and all risks/benefits were discussed. Patient eloped on day #3 and did not want to wait for surgery team to have further conversation."

The proposed inpatient hospital admission was not medically necessary.

An inpatient level of stay was not medically necessary since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, and did not have any complications such as intra-abdominal abscess or a surgical abdomen. The patient required an esophagogastroduodenoscopy and further imaging which were not completed as the patient left against medical advice. However, these could have been performed at a lower level of care (i.e., outpatient level of care).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: for D8080 braces

The insurer denied coverage for D8080 braces

The denial is overturned

 
Upon review of the submitted documentation including lateral cephalometric radio graph, panoramic radio graph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified deep impinging overbite. The orthodontist has completed the Handicapping Labia-Lingual Deviation (HLD) index choosing the automatically qualifying condition of deep impinging overbite with severe soft tissue damage on the HLD index. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index by internal reviewers attaining a score of 12 points. 

Upon review of the submitted documentation 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, New York State requires, as of September I, 2012, the use of an orthodontic Index, the Handicapping Labia-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. 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 completes the HLD index, choosing the deep impinging criterion and impacted permanent anteriors criterion to justify orthodontic care. The clinical circumstance meets this criterion for approval of 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. 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. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for D8080 braces services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crowding; crossbite
Treatment: Full Braces and Monthly Adjustment Visit
The insurer denied the Full Braces and Monthly Adjustment Visit
The denial is overturned.

The patient is a female. The request is for dental benefits for orthodontic treatment (braces) and monthly visits. Per the provider's dental clinical summary, the patient presents with moderate maxillary and mandibular crowding, complete buccal crossbite-maxillary left first premolar, anterior crossbite with gingival attachment loss (mandibular right canine).

The health plan denied coverage for the claim because, "it was not medically necessary," and that the info submitted did not support a crossbite with gingival attachment loss.

The provider appealed the claim based on his diagnosis of the crossbite.

Yes, the requested braces and monthly visits are medically necessary.
This patient presents with two crossbites. The complete buccal crossbite (maxillary first premolar) is so severe that this tooth does not occlude (touch) the opposing tooth that it is meant to engage during the process of chewing.

The overall malalignment and crowding will have a very detrimental effect on the patient's dentition. This will affect the level of oral hygiene that the patient will be able to achieve, and lead to decrease function. More specifically, proper speech, the ability to chew and digest food effectively are all compromised as a result of the malalignment.

Therefore, given the above, the braces and visits are medically necessary.

No, the health plan did not act reasonably with sound medical judgement and in the best interest of the patient.
Considering the severity of the malalignment as supported by the photos and the x-rays, the ramifications of the patient's overall dental health will be compromised and diminished if treatment is not received.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine fibroid
Treatment: procedure to shrink fibroids
The insurer denied procedure to shrink
The determination is upheld.

The patient has a history of uterine fibroids for three years. She complains of heavy and painful menses. She had a pelvic ultrasound which showed uterine fibroids and a previous magnetic resonance imaging (MRI) scan which showed a 7-centimeter (cm) fibroid. She has opted for radiofrequency ablation of uterine fibroids and this is under review for medical necessity.

The requested health service/treatment of procedure to shrink fibroids is not medically necessary for this patient.
Currently, radiofrequency ablation is a treatment for uterine fibroids when a person has persistent symptoms such as abnormal uterine bleeding or bulk symptoms. Bradley and co-workers (2019) carried out a systematic review of prospective studies for treatment of uterine fibroids with radiofrequency ablation (RFA). At 12 months follow-up, fibroid volume decreased by 66 % (percent), health related quality of life (HR-QOL) increased by 39 points, and symptom severity score (SSS) decreased by 42 points. The authors concluded that RFA of uterine fibroids significantly reduced fibroid volume, provided significant durable improvements in fibroid-related QOL, and was associated with favorable re-intervention rates. However there are no studies to show its superiority when compared to traditional treatments and future fertility is still unclear with this uterine sparing treatment. In addition, the quality of the studies may influence conclusions. Therefore, the radiofrequency ablation in comparison to traditional therapy is not medically necessary.