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

Diagnosis: Obesity

Treatment: Procedure code 15830, panniculectomy

The insurer denied coverage for procedure code 15830, panniculectomy.

The denial is upheld.

This is a patient with a history of obesity. She presented to the Plastic Surgeon's office. She had abdominal laxity, an umbilical hernia, lipodystrophy, abdominal bulges, and excess skin in the lower abdomen. The patient weighs 220 pounds (lb) and is 5 feet 7 inches. The physician recommended panniculectomy. The panniculectomy is not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The medical records do not provide any documentation in the form of primary care physician (PCP) or Dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to physician directed topical therapy or 2) despite initial response, have recurred and caused significant functional impairment. 

The patient's PCP has submitted a letter indicating that the patient has failed medical management, but office notes or prescription records documenting failed treatments are not provided. In addition, the photos do not show rashes in the pannus fold. 

In a multiple regression analysis of postoperative complications after body-contouring surgery written by Parvizi, et al, the authors found that the overall rate for major complications that required operative revision and/or antibiotics was 10.2% (percent). In addition, 41% had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscences. Therefore, conservative, non-operative treatment would be recommended, such as improved hygiene, topical creams or powders, and watchful waiting. Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. Summary treatment letters and member appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care.

The insurer's denial of coverage for the procedure code 15830, panniculectomy is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Advanced arthritis, vision loss, diabetes
Treatment: Increase in Home Care/Personal Care (HHC-level II personal care services, per 15 mins) to 56 hours per week
The insurer denied the Increase in Home Care/Personal Care (HHC-level II personal care services, per 15 mins) to 56 hours per week.
The denial is overturned.

This male patient has conditions including advanced arthritis, heart disease, hypertension, diabetes, great toe and partial foot amputation, and vision loss. This is an appeal of denial for an increase in Home Care/Personal Care to 56 hours per week. The patient has been approved for home health care (HHC) 36 hours per week.  

Uniform Assessment System (UAS) evaluation completed shows the patient has modified independent cognition and functional status: total dependence with meal preparation and housework; maximal assistance with managing medication and shopping; extensive assistance with manning finances, phone use, stairs, transportation, bathing, personal hygiene, and lower body dressing; limited assistance with upper body dressing, locomotion, toileting, and bed mobility; and independent with eating. He is able to turn side to side in bed. He uses a walking stick to ambulate in the house. He has infrequent bowel incontinence. He had a recent fall in the tub. Compared to UAS evaluation completed previously, there has been a decline in functional status with shopping, transportation, lower body dressing, toileting, and bed mobility, as well as bowel continence.

A letter from the provider notes the patient has multiple medical conditions and needs constant supervision and assistance with activities of daily living (ADLs).

Yes, the proposed treatment is medically necessary.

Personal assistance services provide hands-on assistance to individuals to include: assistance with ADLs, health maintenance activities, and routine support services.  

This patient has multiple chronic conditions. This is an appeal of denial for an increase in Home Care/Personal Care from 36 hours per week to 56 hours per week. UAS evaluation completed shows the patient requires assistance with all activities of daily living ADLs and personal care needs, except eating. Compared to UAS evaluation completed previously, there has been a decline in functional status with shopping, transportation, lower body dressing, toileting, and bed mobility as well as bowel continence. The patient has also developed bowel incontinence since the previous UAS evaluation. He had a recent fall in the tub. The appeal letter notes the patient needs constant supervision and assistance with ADLs. This patient requires significant assistance with ADLs/instrumental activities of daily living (IADLs) and his physical functioning has declined between UAS evaluations. The information provided supports increasing home care/personal hours. The current home care/personal hours 36 hours per week is inadequate to meet the patient's needs for assistance. The proposed increase in home care/personal hours to a total of 56 per week is medically necessary to meet this patient's needs for assistance with ADLs and personal care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression, Suicidal Ideation
Treatment: One Additional Day Mental Health Service
The insurer denied the one additional day mental health service.
The denial is upheld.

The patient is a female who was admitted to inpatient care due to increased depression, anxiety, nightmares, flashbacks, dissociation, and episodes of depersonalization. She was tolerating her medications and had stable mood. She was diagnosed with post-traumatic stress disorder (PTSD). The patient was on Lexapro, Wellbutrin, Trazodone, Lamictal, Periactin, and Abilify. As of the date in question, the patient denied any suicidal ideation (SI)/homicidal ideation (HI)/audio-visual hallucination (AVH). 

No, the proposed one additional day mental health service was not medically necessary.

The patient was no longer suicidal, homicidal, or gravely impaired for self-care. She had shown continued progress in treatment to a point that could have allowed her to be transitioned to a less restrictive level of care. She was not disturbed in thinking/behavior to require around the clock nursing supervision.

The patient was treated appropriately; however, the dates of service in question were not medically necessary and these services could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain

Treatment: Inpatient level of care

The insurer denied coverage for inpatient level of care.

The denial is overturned.

This case involves a male patient who presented to the emergency department complaining of right lower quadrant abdominal pain.  He did not have any associated symptoms.  The physical examination revealed tenderness to palpation to the right lower quadrant.  There was no rebound and no guarding.  The recommendation was made for laboratory diagnostic studies.  He had a lactate of 4.7.  The documentation indicated he did undergo a computed tomography (CT) scan with no abnormal findings.  The patient continued with right lower quadrant pain with an increasing lactate.  Surgery was recommended for consult.  The physician indicated the patient should be admitted for gastroenterologic (GI) evaluation.  The submitted documentation indicated he was treated with morphine for pain and fluid bolus.  He was recommended to undergo a colonoscopy per gastroenterology.  Given a lack of adverse events he was discharged with instruction to follow-up regarding the recommended procedures.

The patient presented to the emergency room with severe abdominal pain and significant abnormal lab values including acidosis and elevated venous lactate.  Moreover, this lactate continued to rise, requiring aggressive fluid resuscitation.  But the CT scan did not show any obvious acute finding, this is a potentially dangerous clinical situation which needs to the monitored and managed aggressively.  It is appropriate for the patient to be admitted to the inpatient service and surgical gastroenterology consults are also appropriate.  While the patient outcome was good with conservative measures, this could not have been predicted in the emergency room with the laboratory parameters described above. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient level of care is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperhidrosis.
Treatment: Botox SOLR 200 Unit, Pre-service.
The insurer denied the Botox SOLR 200 Unit, Pre-service.
The denial is overturned. 

The patient is a female with hyperhidrosis, treated with prescription and over-the-counter anti-perspirants.  Her provider performed Botox injections to the axillae.

Yes, the requested Botox is medically necessary.
It is generally accepted as national standard-of-care that Botox treatment for hyperhidrosis is medically necessary, and is far superior in efficacy to other treatment modalities.  Hyperhidrosis can have a devastating effect on a patient's quality of life, causing physical discomfort, social embarrassment, and disruption of occupational and daily activities.

Hyperhidrosis treatments have undergone major improvements in the 21st century. The FDA (United States Food and Drug Administration) approval of Botox injections for the treatment of axillary hyperhidrosis has helped to transform the lives of many thousands of sufferers. By "turning off" the process that leads to sweating excessively, Botox treatments allow sufferers to lead more normal lives, free, at least temporarily, from the overwhelming symptoms of hyperhidrosis. Results of Botox injections last on average six to nine months, and maintenance injections are necessary for continuous control.

It is the position of the International Hyperhidrosis Society that treatment of this condition with Botox injections is the gold standard and considered medically necessary. Patients should not be required to suffer until they experience a secondary skin complication or functional impairment. Functional impairment requires further classification within the criteria, as this patient has experienced impairment in her personal and professional life.

A recent review discovered that there is evidenced to be an increase in the duration of efficacy of botulinum toxin A injections with the repetition of injections in patients with primary axillary hyperhidrosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8080 braces

The insurer is denied coverage for D8080 braces.

The denial is overturned. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, and insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to severe crowding and impacted permanent anterior teeth. The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anterior where extraction is not indicated. 

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, a Handicapping Labiolingual Deviation 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 anterior where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

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

D8080 braces is considered medically necessary for this patient.

The insurer's denial of coverage for D8080 braces is reversed. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperlipidemia

Treatment: Vascepa

The insurer is denied coverage for Vascepa.

The denial is overturned. 

This male patient has a history of essential hypertension, hyperlipidemia, Gilbert's syndrome, gastroesophageal reflux disease (GERD), and asthma.

Regardless, it appears that good efforts were made to use a statin with the patient, although he appears to be intolerant of statins, having tried and failed challenges with both lipophilic (atorvastatin, simvastatin) and hydrophilic (rosuvastatin) preparations, due to myalgia. The use of ezetimibe as monotherapy was also attempted and was not tolerated. In real terms, he appears to be taking the strongest statin he can take, which is, unfortunately, none. Despite his statin intolerance, it appears clear that high triglycerides do increase cardiovascular risk in patients not taking statins and should be treated even without statin use. (8)

There is insufficient data submitted to precisely calculate the patient's 10-year cardiovascular risk. However, using conservative placeholders, the American College of Cardiology/ American Heart Association (ACC/AHA) calculator (9) assessed the patient at relatively high risk of >18%. (This reviewer used total cholesterol of 175, high-density lipoprotein (HDL) of 40, blood pressure of 120/80, non-diabetic, and non-smoker for the unknown variables to obtain a conservative estimate; the patient's risk may be higher). Given his elevated risk, medical therapy is indicated. 

In a population with risk of >10%, UpToDate recommends highest tolerated dose of statins in patients with moderate hypertriglyceridemia (150-885 mg/dL), and the addition of ezetimibe if needed to obtain target LDL levels. This approach was tried with the patient. As the next step, "...or patients with a triglyceride (TG) level 150 mg/dL who have been managed with the above approach and who are at high risk of cardiovascular disease [such as the patient], we consider adding a drug that lowers non-HDL-C through effects of very-low-density lipoprotein (VLDL) ...to further lower TG...For these high-risk patients, we usually start with icosapent ethyl [Vascepa]." (10)

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

The carrier's denial of coverage for the Vascepa is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right upper quadrant pain

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admission.

The denial is upheld. 

This female patient has no significant medical history.

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Stone (M-555) include having upper abdominal pain and systemic signs of inflammation such as fever and leukocytosis. The patient did not have systemic signs of inflammation. She also did not have a calculus or obstruction of the gallbladder causing hemodynamic instability, severe vomiting, severe dehydration, or severe pain.

This patient had abdominal pain with evidence of gallbladder disease. However, she did not have systemic signs of inflammation. She also did not have peritoneal signs or require any surgical interventions at this time. She was stable to have had the gallbladder workup as an outpatient. She did not meet Milliman Care Guideline (MCG) criteria for admission for Gallbladder or Bile Duct Inflammation or Stone.

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

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

Diagnosis: Psoriasis.
Treatment: Otezla 30 milligram tablet.
The insurer denied the Otezla 30 milligram tablet.
The denial is overturned. 

The patient is a male with psoriasis for whom Otezla is requested. The patient has already started therapy with Otezla samples. He has tried and failed topical steroids and Eucrisa.

Yes, the proposed Otezla is medically necessary.
The patient is not a candidate for phototherapy due to the location of affected areas on the face and groin/buttocks which is not amenable to treatment with ultraviolet (UV) light. In the era of biologic and small molecule therapies for psoriasis, use of methotrexate, cyclosporine or acitretin is not the most appropriate first line treatment because their long term safety and efficacy are inferior to newer therapies.

Otezla, an inhibitor of phosphodiesterase IV (PDE4), is indicated for the treatment of adult patients with active psoriatic arthritis and patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy.  (Celgene)  Otezla is an oral small molecule inhibitor of phosphodiesterase IV (PDE4) specific for cyclic adenosine monophosphate (cAMP) and is indicated for the treatment of adult patients with active psoriatic arthritis (PsA) as well as the treatment of patients with moderate to severe plaque psoriasis. (Celgene)  The patient has moderate to severe psoriasis (based on location in sensitive areas) for which therapy with Otezla is appropriate and medically necessary.

In the era of biologic therapies for psoriasis, use of methotrexate, cyclosporine or acitretin is not the most appropriate first line treatment because their long term safety and efficacy are inferior to biologic and small molecule therapies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crowding; Crossbite
Treatment: D8080 Braces and D8670 Monthly visit (x12)
The insurer denied the D8080 Braces and D8670 Monthly visit (x12)
The denial is upheld.

The patient is a female. The request is for dental benefits for orthodontic treatment (braces) and monthly visits. Orthodontic records have been created, and include clinical consultation, x-rays, and photos.  Per the provider's clinical report, the patient presents with class I skeletal relationship, moderate maxillary and mandibular crowding, left posterior crossbite, anterior crossbite with gingival recession loss (mandibular left central incisor).

The health plan denied the claim because the patient did not score a 26 on the HLD (Handicapping Labio-Lingual Deviation) index report, the score necessary to be approved for orthodontic treatment.

The appeal was made based on the clinical findings that the provider's consultation revealed.

No, the proposed treatment of orthodontic therapy (braces) and monthly visits are not medically necessary.
One of the automatic qualifiers for orthodontic treatment per the HLD (Handicapping Labio-Lingual Deviation) index Report is that the patient must exhibit a crossbite with gingival attachment loss. Unfortunately, the documentation submitted does not show any evidence of attachment loss for the mandibular left lateral incisor.

Therefore, given the above, the Braces and Monthly visits are not medically necessary.

Per the HLD (Handicapping Labio-Lingual Deviation) Index report, the criterion for orthodontic treatment is "attachment loss associated with a crossbite." This is not supported in the material submitted. As such, the orthodontic treatment is not warranted.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea on exertion. 
Treatment: Inpatient admission. 

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

The patient is a male with a history of asthma/COPD (chronic obstructive pulmonary disease). He presented to the ED (emergency department) complaining of progressive dyspnea on exertion x 2 days. He was admitted with COPD (chronic obstructive pulmonary disease) exacerbation.  He had no associated symptoms.  He admitted to alcohol and heroin use.  He drinks 6 beers daily.  His last heroin use was 2 days prior. 

Day two, the patient's VS (vital signs were as follows):  Temperature 98.4, pulse 80, respiration rate 18, blood pressure 134/80, pulse oximetry 100%.  His CIWA (clinical institute withdrawal assessment) was 2.  His exam was remarkable for bilateral wheezing and rhonchi.  His labs were as follows:  VBG (venous blood gas) 7.43/48/52/31, Na (sodium) 139, K (potassium) 3.5, WBC (white blood count) 10.4, H/H (hemoglobin/hematocrit) 12.8/39.1, Plt (platelets) 291.  His Chest x-ray revealed NAD (no active disease). 

The patient's plan of care included duonebs 1 hours, Advair, Solumedrol bid (twice daily), antibiotics, and lorazepam prn (as needed). 

No, the Inpatient admission was not medically necessary. 

Criteria for hospitalization of patient's with exacerbations of COPD (chronic obstructive pulmonary disease) include high risk comorbidities, such as pneumonia, arrhythmia and congestive heart failure; inadequate response of symptoms to outpatient management; marked increase in dyspnea; inability to eat or sleep due to symptoms; worsening hypoxemia or hypercapnia; and altered mental status.  This patient presented to the ER (emergency room) complaining of dyspnea.  However, his clinical presentation does not meet criteria for inpatient admission. He was hemodynamically stable and afebrile.  He did not have tachypnea or tachycardia.  His oxygen status was normal.  The patient did not have tachypnea, hypoxia or AMS (altered mental status).  Diagnostic did not show pneumonia or evidence of CHF (congestive heart failure).  He had no high-risk comorbidities that required treatment at an inpatient level of care.  The Inpatient Hospital Admission was not medically necessary.