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

Diagnosis: Dental Problems (overjet and overbite). 
Treatment: Braces and monthly office visits. 

The insurer denied coverage for braces and monthly office visits. 

The denial is upheld. 

This is a female child who presented for evaluation for orthodontic care. The Orthodontist identified several clinical findings including overjet and overbite and has recommended orthodontics. The Orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 6 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 6 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 10 points on the HLD index (3 points overjet, 4 points overbite, 3 points labiolingual spread) which is below the threshold of 26 points to support orthodontic care. Of note, in this case, the patient's own Orthodontist does not attain 26 points on the HLD index as required for orthodontic approval. 

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. This is confirmed by several studies. 
 
Each of the 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. 

Uphold denial as the clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval. 

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

The coverage for braces and monthly office visits is not considered medically necessary for this patient. 

The insurer's denial of coverage for braces and monthly office visits is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.

The denial is upheld.

The patient is a female with no past medical history. She presented to emergency room with shortness of breath and was found to have pulmonary embolism.

The patient was admitted to acute in-hospital level of care for the management of PE (pulmonary embolism). The patient was started on heparin drip. Echocardiogram was also ordered. The patient was also found to have DVT (deep venous thrombosis) of lower extremity, and vascular surgery was consulted.

No, the Inpatient admission was not medically necessary.

The patient had DVT/PE (deep venous thrombosis/pulmonary embolism) and was started on IV (intravenous) heparin drip. The patient had saddle pulmonary embolism, but was hemodynamically stable. The patient did not have contraindication to blood thinner. The patient was tolerating oral diet. The patient did not have any evidence of right heart strain. The requested inpatient admission was not medically necessary, since there is lack of trial and failure of lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 diabetes mellitus.

Treatment: Full hospital admission.

The insurer denied coverage for the full hospital admission.

The denial is overturned. 

This is a male patient with a history of hypertension (HTN), hyperlipidemia, and type 2 diabetes mellitus. He was seen in the Emergency Room (ER) for fatigue and hyperglycemia. His blood sugar was documented to be 1181 milligrams per deciliter (mg/dL). The patient's hemoglobin A1c (HbA1c) test result was 18%. Ketones were noted in his urine. In the ER, he was started on fluids and an insulin drip. He was noted to have an elevated anion gap and acute renal insufficiency (Creatinine- 4.0). He was counseled on diabetes management and discharged after inpatient care and management. 

Per Kodner, C. et al. (2017), "Uncontrolled blood glucose levels in hospitalized patients with diabetes are associated with potential harms such as deleterious effects on wound healing, increased risk of infection, and delays in surgical procedures or discharge from the hospital."

Per Corsino, L. (2017), patients who are "hospitalized with a diagnosis of diabetes stay in the hospital for longer than those without a diagnosis of diabetes admitted for the same condition."

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The patient had renal insufficiency and ketones in his urine.  Admission was warranted.      

The full hospital admission is considered medically necessary for this patient. The admission was necessary.  He was found to be in renal failure and had ketones in his urine. He also had a blood glucose level of 1181 mg/dL. He needed fluids and counseling.

The insurer's denial of coverage for the full hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraines.
Treatment: Formulary exception for Ubrelvy, Pre-service.

The insurer denied the Formulary exception for Ubrelvy, Pre-service.  The denial is overturned. 

The patient is a female with migraine headache disorder. She has tried and failed rizatriptan, sumatriptan and naratriptan for abortive therapy. Nurtec was not tolerated. The provider is requesting Ubrelvy.

Yes, the health plan should cover the Formulary exception for Ubrelvy.

Ubrelvy is FDA (United States Food and Drug Administration)-approved for her condition, based on data derived from high-quality clinical trials published in the peer-reviewed medical literature (Dodick et al.). She has tried and failed three first-line migraine abortive agents as well as another oral CGRP (calcitonin gene-related peptide) inhibitor abortive agent. Therefore, Ubrelvy would be considered appropriate here.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart failure.
Treatment: CardioMEMS.
The insurer denied the CardioMEMS.
The denial is overturned. 

The patient is a male with history of congestive heart failure, NYHA (New York Heart Association) Class III CHF (congestive heart failure) with reduced EF (ejection fraction) of 20-25, ischemic cardiomyopathy, CAD (coronary artery disease) status post CABG (coronary artery bypass graft), PVD (peripheral vascular disease), status post AICD (automatic implantable cardioverter defibrillator), with multiple admissions for CHF (congestive heart failure) exacerbation, and chronic renal disease. The implantation of a CardioMEMS HF (heart failure) System to better monitor and manage patient heart failure and reduce hospitalizations is being requested.

Yes, the CardioMEMS is medically necessary.
Provision of the treatment can reasonably be expected to be health beneficial for the patient, and withholding the treatment can reasonably be expected to affect the patient's health adversely.

According to the FDA (United State Food and Drug Administration) labeling (9), the CardioMEMS HF (heart failure) System is indicated for wirelessly measuring and monitoring pulmonary artery (PA) pressure and heart rate in New York Heart Association (NYHA) Class III heart failure patients, who have been hospitalized for heart failure in the previous year. The hemodynamic data are used by physicians for heart failure management and with the goal of reducing heart failure hospitalizations. The reduction in CHF (congestive heart failure) hospitalization rate has been shown in clinical trials of this device.

This patient with known systolic CHF (congestive heart failure), with reduced LV (left ventricle) function, New York Heart Association (NYHA) Class III heart failure symptoms, difficult to control volume levels, especially in the setting of chronic renal insufficiency, and recurrent hospitalizations, meets above criteria. He is likely to benefit from the use of this device with reduction in recurrent hospitalizations for CHF (congestive heart failure) exacerbation, a known morbidity of systolic CHF (congestive heart failure).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease and dementia. 
Treatment: Personal Care Assistant (PCA) services of 7 days times 24 hours (continuous services) per week.
The insurer denied coverage for PCA services of 7 days times 24 hours (continuous services) per week.

The denial is overturned. 

This is a female patient with a past medical history of congestive heart failure, atrial fibrillation, hypertension, gastroesophageal reflux disease, hypercholesterolemia, osteoporosis, shortness of breath, chronic obstructive pulmonary disease (COPD) with continuous oxygen (O2) support via nasal cannula, and dementia. She is in Hospice care due to COPD. Per the New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and a registered nurse were present during the assessment. The patient lives alone in a private home. The patient's needs include: total dependence or maximal assistance for all functions except extensive assistance for bed mobility. The patient was unable to state personal goals of care due to her cognitive impairment. The patient uses a wheelchair and scooter for locomotion indoors. The patient also had a wound that has since healed. There were no recent falls, new wounds or hospitalizations reported. An increase to personal care assistant (PCA) services of 7 days x 24 hours (continuous services) per week is being requested.

The patient's daughter notes that the need to monitor the patient's O2 and respiratory status requires that the aide not be asleep. The patient has pressure changes in the ankle and needs turning and positioning (T&P) every 2 hours. She has had frequent urinary tract infections (UTIs) from soiled diapers. Night Time Needs Log notes multiple episodes of diaper changes and some clothing changes per night, sometime 3 hours apart. Repositioning is noted. At issue is the need for a night-time aide who is awake all the time versus one who can get 5 hours of uninterrupted sleep. 

The provision of diapers and alternate pressure beds is not adequate for prevention of pressure sores. As noted in Preventing Pressure Ulcers (2018), changing diapers regularly and positioning are also necessary. Cuing to keep on nasal cannula would appear to be in the scope of these services. If providing nebulizer therapy is beyond the scope of the services under consideration then this has to be taken into account.

The need for multiple unscheduled diaper changes with associated cleaning and positioning is documented. So is current skin breakdown, and there is a history of such. A history of UTIs is noted, and this is a risk for this patient. The available documentation supports the need for toileting and pressure-sore prevention at night on an unscheduled basis. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer disagrees with the plan's interpretation of the patient's needs. 

The insurer's denial of coverage for the requested Personal Care Assistant (PCA) services of 7 days times 24 hours (continuous services) per week is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara (ustekinumab) 90mg Every 4 Weeks
The insurer denied the Stelara (ustekinumab) 90mg Every 4 Weeks
The denial is overturned. 

The patient is a female. She has had Crohn's disease for several years. She failed Remicade and has been on Stelara 90 mg (milligrams) every 8 weeks for the last several months. She started to have increased symptoms and active inflammation. Her doctor requested to increase the dose to 90 mg (milligrams) every 4 weeks.

Yes, the Stelara 90mg (milligrams) every 4 weeks is medically necessary.
A multi-center cohort study evaluate the response to Ustekinumab in children with moderate to severe Crohn's disease (Chavannes et al). At 12 months, 38.6% of the 44 patients achieved clinical remission and 47.8% achieved clinical response. They concluded that "Subcutaneous Ustekinumab should be considered a viable therapeutic option for paediatric patients who are refractory to other biologic agents."

Dayan et al published their real-world experience with ustekinumab at a tertiary care pediatric inflammatory bowel disease (IBD) center. Fifty-two children and young adults initiating ustekinumab were analyzed. Most patients (81%) failed >1 anti-TNF (tumor necrosis factor), and 37% failed anti-TNF (tumor necrosis factor) and vedolizumab; 10 patients were biologic-naive. At week 52, 75% were still on ustekinumab, and 50% (bio-exposed) and 90% (bio-naive) were in steroid-free remission. Their results suggested that ustekinumab is efficacious and safe in pediatric patients with IBD (inflammatory bowel disease).

In summary, current medical evidence shows that ustekinumab is reasonably safe and effective in children with severe Crohn's disease. The standard maintenance dose for Crohn's disease 90 mg (milligrams) every 8 weeks. For patients who respond to Stelara initially and then lost response due to low drug concentration and/or antibody formation, shortening the interval up to every 4 weeks is recommended (Battat et al; Dayan et al.).

This patient has been on Stelara 90 mg (milligrams) every 8 weeks and started to have symptoms and active inflammation. She recently received Stelara 90 mg (milligrams) every 4 weeks. Thus, continuation of Stelara every 4 weeks would be medically necessary as supported by current literature and treatment guidelines.

Current medical evidence shows that ustekinumab is reasonably safe and effective in children with severe Crohn's disease. The standard maintenance dose for Crohn's disease 90 mg (milligrams) every 8 weeks. For patients who respond to Stelara initially and then lost response due to low drug concentration and/or antibody formation, shortening the interval up to every 4 weeks is recommended (Battat et al; Dayan et al.).

This patient has been on Stelara 90 mg (milligrams) every 8 weeks and started to have symptoms and active inflammation. She recently received Stelara 90 mg (milligrams) every 4 weeks. Thus, continuation of Stelara every 4 weeks would be medically necessary as supported by current literature and treatment guidelines.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hemiplegic migraine. 
Treatment: Formulary Exception for Ubrelvy (ubrogepant). 

The insurer denied coverage for Formulary Exception for Ubrelvy (ubrogepant). 

The denial is overturned. 

This is a female patient with a history of headaches with complicated migraine.	 
The patient has hemiplegic migraine. Her Neurologist prescribed Ubrelvy.  

The insurer denied Ubrelvy and instead recommended formulary alternatives including almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan injection, sumatriptan nasal spray, sumatriptan tablet, zolmitriptan, Nurtec oral disintegrating tablet (ODT), Zembrace SymTouch, Zomig nasal spray (trial and failure of no more than three). These are all triptans and are contraindicated. 

As noted above the patient has hemiplegic migraines. This puts her at increased risk of stroke, especially if she takes a triptan. 

The requested medication is likely to produce a more clinically beneficial outcome to the patient. 

The insurer's denial of coverage for Formulary Exception for Ubrelvy (ubrogepant) is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, Vomiting and Abdominal Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.

The denial is upheld.

The patient is a male. He was admitted for abdominal pain with nausea and vomiting.

The patient was noted to have elevated creatinine and creatine kinase. He was diagnosed with acute kidney injury and rhabdomyolysis. He was started on intravenous fluid. His condition responded appropriately, and he was discharged in stable condition.

No, the Inpatient admission was not medically necessary.

The patient was noted to have abnormal creatinine. Given his presentation and findings, it would have been reasonable and within the standard-of-care to expect that his abnormal creatinine would be treatable and immediately reversible within a 48 hours at an observation level of care. His presentation was consistent with simple prerenal azotemia, and he had no evidence of more complex condition, such as acute tubular necrosis of glomerulonephritis. His condition did not require renal replacement therapy. In regards to rhabdomyolysis, he did not have significantly metabolic complications, such as severe hyperkalemia, hyperphosphatemia or hypocalcemia, and his condition responded adequately to intravenous fluid.

The patient was hemodynamically stable, with normal oxygenation and negative cultures. He did not have significant electrolytes disturbance. He did not have cardiac arrhythmias. He had no altered mental status or persistent nausea and vomiting with dehydration. He had no documentation of refractory pain. He was able to tolerate oral diet, and he did not require total parenteral nutrition. It would have been reasonable to expect that his condition would have responded to intravenous fluids within 48 hours at an observation level of care.

There is no evidence-based literature inpatient level of care was medical necessary, and the patient's condition could have been treated safely under a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vaginal bleeding during pregnancy. 

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned. 

This is a female patient with a history of morbid obesity and asthma.  She presented to the hospital with complaints of vaginal bleeding at 34 weeks of gestation.  The patient reported using the restroom after eating dinner and noted bright red bleeding with small clots while wiping.  The patient had Placenta Previa earlier in this pregnancy, which resolved.
  
Bedside abdominal sonogram noted no evidence of placenta previa.  Obstetrics examination revealed minimal blood on speculum.  The patient's cervix was long and closed with no evidence of active bleeding.  Fetal heart rate was reassuring.

The patient started having contractions every 2-6 minutes.  More bleeding was reported. There was a concern for placental abruption as the patient reported being kicked in the abdomen.  She was admitted for prolonged monitoring and possible delivery if active hemorrhage.

The inpatient admission is considered medically necessary for this patient. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Pregnant people with bleeding, abdominal pain, or other symptoms suggestive of abruption should be evaluated promptly on a labor and delivery unit to establish the diagnosis, assess maternal and fetal status, and initiate appropriate management.  A patient who is initially stable may deteriorate rapidly if placental separation progresses. 

The initial approach includes continuous fetal heart rate monitoring, placement of large bore intravenous lines, assessment of blood loss and maternal hemodynamic status, and evaluation for coagulopathy.

This patient had vaginal bleeding with concern about placental abruption.  The admission to the hospital was medically necessary for close monitoring and emergency management as needed.  This is in accordance with standard of care and Milliman Guidelines.

The insurer's denial of coverage for the inpatient hospital admission is overturned.  Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Finger infection.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a male patient with a past medical history significant for seizure disorder, anxiety, and polysubstance abuse who presented to the Emergency Department (ED) with complaints of right ring finger pain and swelling, as well as a right thigh abscess. The patient underwent incision and drainage (I&D) with wound packing in the ED. Vitals on presentation included: Temperature-99 Fahrenheit (F), Blood Pressure-114/64, Pulse-68, Respiratory Rate-18, Oxygen (O2) saturations-100% on Room Air. Laboratory results included the following: White blood cell (WBC) count-7.7, hemoglobin (HGB)-10.3, hematocrit (HCT)-33.8, creatinine-1.2, glucose-74. Urine toxicology was positive for opiates, Methadone, Amphetamines, benzodiazepines, and cocaine. 

The patient was started empirically on intravenous (IV) antibiotics (clindamycin and doxycycline) for a right ring finger cellulitis. X-ray of the hand showed no signs of fracture or subluxation, no foreign body, no lytic or blastic changes. The patient was also started on methadone detoxification protocol, as well as Librium. The patient remained afebrile, hemodynamically stable, and clinically improved. He signed out against medical advice (AMA). 

According to documentation, the patient was admitted with a finger infection. Otherwise, he was afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC count. There was no evidence of a disseminated infection. He tolerated I&D procedure while still in the ED. Based on these findings, the patient met criteria for observation level of care. He did not fulfill criteria for acute care hospitalization.

The healthcare plan acted reasonably and with sound medical judgment 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.