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

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

This male was hospitalized for chest pain. He presented to the hospital emergency department for evaluation of chest pain since the prior day. His past medical history is pertinent for lymphoma, schizophrenia, polysubstance abuse on methadone and chronic anemia. Vital were stable with a heart rate (HR) of 56, blood pressure of 119/66, and oxygen saturation of 98% (percent) on room air. He had reproducible chest wall pain on exam. His electrocardiogram showed sinus bradycardia (SB) and no ST-Segment Elevation Myocardial Infarction (STEMI). There were no arrhythmias or elevated troponin documented. Chest x-ray was negative. The patient was clinically stabilized and he was discharged with the plan to do outpatient stress test and follow up with cardiology. 

This is an appeal of the denied claim that the requested Acute Inpatient Hospital Stay was medically necessary for this patient which was approved at the Observation level of care.

No, the proposed inpatient admission was not medically necessary.
Based on the peer reviewed medical literature and my expert medical opinion, 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. Medically necessary criteria for acute inpatient hospital stay were not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization 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 evaluation of uncomplicated, musculoskeletal chest pain like in this case, is routinely provided safely and effectively at a lower level of care, such as at the hospital's Observation level of care. Therefore, the proposed treatment is not medically necessary, based on the submitted information and the current published medical literature.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient admission. 

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

The patient is a female admitted with sharp chest pain and back pain with swallowing. Symptoms were present for several months. It was "Highly atypical for cardiac pain". Computed tomography (CT) was negative for perforation.  Electrocardiogram (EKG) showed normal sinus rhythm (NSR), non specific changes, and premature ventricular contractions (PVCs). The patient was mildly hypertensive, her troponin was 0.33.  She had no risk factors for coronary artery disease (CAD). The Cardiologist recommended discharge and outpatient work up.  The reason for appeal was the denial of the inpatient admission. 

No, the proposed inpatient admission was not medically necessary. 

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome. Exam (blood pressure normalized) and cardiac findings were normal. Biomarkers and electrocardiogram showed no evidence of acute ischemia. Chest x-ray (CXR) was normal. Echocardiogram showed no wall motion abnormality.  The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for acute coronary syndrome such as intravenous heparin, dual antiplatelet inhibitors, high dose beta blockers or intravenous nitroglycerin (NTG).  

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care.  There was no "complex" care that required inpatient level of care in this patient's care. This patient had no evidence of coronary artery disease (CAD).  All tests showed absence of ischemia.  While there is always a potential for an adverse event, one did not happen and no actual treatment was added. 

Milliman criteria requirements were not fulfilled as there was never any evidence of acute coronary syndrome present. 

All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary. 

The denial explanation was consistent with guidelines and usual community care. 

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient. 
Appropriate level of care determination based on sound medical judgement is in best of interests of patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Humira. 
The denial is overturned in whole. 

This patient is a male with a medical history of abdominal pain and bloody diarrhea. He was recently diagnosed with Crohn's disease. His disease is reported as severe and involving the upper gastrointestinal tract in addition to the terminal ileum. Humira has been recommended for this patient.
At issue is the medical necessity of Humira.

The health plan's determination of medical necessity is overturned in whole.

The requested health treatment of Humira is medically necessary for this patient.
Anti-tumor necrosis factor alpha (TNF-a) (such as Humira) are considered the standard treatment for pediatric Crohn's disease. The clinical practice guidelines recommend early biologic therapy for selected children with high risk for poor outcome such as patients with upper gastrointestinal disease or stricturing disease (Ruemmele FM et al). 
Furthermore, there is growing scientific evidence supporting the early use of biologics in the treatment of pediatric Crohn's disease. Many peer reviewed literature reports showed superior efficacy and less disease complications when biologics are used early in the disease course. Yun Seok Lee et al, showed that early anti TNF use led to decreased relapse rate compared to conventional therapies in pediatric Crohn's disease. Thomas D. Walters et al, showed improved effectiveness with early use of anti-tumor necrosis factor-a in pediatric Crohn`s and improved growth parameters. Other studies showed that early use of biologics can delay disease progression to stricturing and/or penetrating disease when compared to conventional therapy (Basavaraj Kerur et al).
Finally, Remicade is approved by the Food and Drug Administration (FDA) for pediatric Crohn's disease. However, the proposed "conventional therapies" such as azathioprine and methotrexate, are not United States Food and Drug Administration (FDA) approved for pediatric Crohn's disease and are associated with major side effects including lymphoma and skin cancer. This patient has Crohn's disease with upper gastrointestinal involvement. He is considered at high risk for complications based on the current practice guidelines. The early use of Humira in this case is appropriate and medically necessary despite not trying conventional therapy.
Therefore, the requested health treatment of Humira is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: atopic dermatitis

Treatment: Dupixant

The insurer is denied coverage for Dupixant

The denial is upheld. 

This female patient has a history of atopic dermatitis

The requested medication, Dupixent,  is not medically necessary for this claimant's condition.  There is no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Dupixent for this patient's condition as an accepted standard of practice in the U.S. compared to alternative therapies.  

The requested medication Dupixent is not medically necessary based on the standard of care, and there are no unique clinical circumstances to this particular individual in the documentation provided that would make it medically necessary.  The patient has no true contraindications to the conventional medications commonly used for atopic dermatitis.  According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the conventional medications such as  UV light therapy and methotrexate are effective treatments for the management of atopic dermatitis.

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 Dupixant is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems-aortic stenosis
Treatment: Surgical Services (All) 
The insurer denied a cardiology procedure. 
The denial is overturned in whole. 

The patient is a male with symptomatic, moderately severe to severe aortic stenosis (aortic valve area less than 1 square centimeter [cm2]). A transthoracic echocardiogram showed maximum velocity (Vmax) at 2.8, mean aortic valve gradient, aortic valve area of 1.08 cm2 by continuity equation, 0.98 cm2 by planimetry, and ejection fraction 60 percent (%). The patient complained of dyspnea on exertion, considered to be related to heart failure. The patient had a history of coronary artery disease (CAD) with previous bypass surgery, hyperlipidemia, bladder cancer, and a previous stroke. Because of severe symptoms due to aortic stenosis, he was referred for an aortic valve replacement. His case was discussed with the Heart Team, and it was decided that transcatheter aortic valve replacement (TAVR) was preferable over a surgical aortic valve replacement (SAVR).

At issue is the medical necessity of the cardiology procedure.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of cardiology procedure is medically necessary for this patient.

The aortic valve replacement is considered medically necessary, and TAVR was preferred to SAVR in this case by the Heart Team. The patient had symptomatic severe aortic stenosis that required valve replacement. In its absence, the patient has limited life expectancy with progressive symptoms prior to death. In view of the patient's co-morbidities, previous bypass surgery, and frailty, TAVR was favored by the Heart Team over SAVR. TAVR is approved by the United States Food and Drug Administration (FDA) for this type of patient. Guidelines recommend TAVR as an acceptable treatment for severe symptomatic aortic stenosis.

As such, a TAVR is considered medically necessary and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myoepitheloid carcinoma of the left parotid gland.
Treatment: Proton Beam Radiation Therapy For Head/Neck Cancer, Pre-service.
The insurer denied the Proton Beam Radiation Therapy For Head/Neck Cancer, Pre-service.
The denial is upheld.

This patient is a male with a T2N0M0 (category 2, node negative, non-metatatic) myoepitheloid carcinoma of the left parotid gland post resection.  He is at high risk of recurrence where radiation therapy is recommended to this area and proton beam approach is requested.

No, the proposed treatment is not medically necessary. The enclosed denial letter is correct in reasoning.

Yes, the health plan did act reasonably, with sound medical judgment and the in the best interest of the patient.
The recommended proton beam radiation therapy is not considered a standard of care treatment option for this diagnosis and clinical scenario and should be denied. There are lack of any significant randomized trials published in peer reviewed journals supporting the benefit and safety of proton beam radiation therapy as compared to standard of care photon beam radiation therapy.  Until the ongoing clinical trials are complete and published in peer reviewed journals, this recommended treatment should be denied.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal (Epigastric) Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

This patient is a female on aspirin and Plavix who presented to the emergency room for coffee ground emesis and black stool.  The patient has epigastric pain.  The patient had an esophagogastroduodenoscopy (EGD) 12 hours prior to presentation which showed gastritis.  

In the emergency department (ED) the white blood cell (WBC) count was 10.52 and the international normalized ratio (INR) was 1.18.  The patient was treated with intravenous (IV) fluids and Pepcid.  The patient was admitted to inpatient and was made nothing by mouth (NPO).  The patient's complete blood count (CBC) was monitored.  Esophagogastroduodenoscopy (EGD) showed gastritis.  Proton pump inhibitor (PPI) twice daily and Carafate were advised.  The patient was discharged.

No, the proposed inpatient admission was not medically necessary.
An observational level of stay would have been more appropriate for this patient. An observational level of stay would have been a more efficient setting, since the patient did not require any 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 require blood transfusions, did not have active and ongoing rectal bleeding, did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, did not have fevers, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overjet, Overbite and Anterior Crowding

Treatment: D8080 braces

The insurer denied coverage for D8080 braces.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph and tracings, panoramic radiograph, montage of extraoral and intraoral clinical images, 3D (three dimensional) representations of study models and insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index, attaining 21 total points to support orthodontic care. 

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 Labio-Lingual 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 does not claim an automatic qualifying condition and completes the second portion of the index, arriving at 21 points to justify orthodontic care.  

This reviewer concurs with the index completed by the orthodontist, attaining a total of 21 points on the HLD index (8 points overjet, 4 points overbite, 5 points anterior crowding, 4 points posterior unilateral crossbite), which is below the threshold of 26 points to support orthodontic care. Of note in this case, is that 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 cited below. 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.

In this case, the patient's own orthodontist-completed HLD index total score of 21 points remains below the threshold of 26 points to justify orthodontic care. The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for D8080 braces is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class II malocclusion, posterior crossbite, overjet, overbite, anterior crowding

Treatment: D8080 braces

The insurer denied coverage for D8080 braces.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph and tracings, 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 identified several clinical findings including Class II malocclusion, posterior crossbite, overjet, overbite, anterior crowding, and has recommended orthodontics. The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index, attaining 20 total points to support orthodontic care. 

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, having attained a score of 10 points on the HLD index. 

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 does not claim an automatic qualifying condition
and completes the second portion of the index, arriving at 20 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining a total of 20 points on the HLD index (7 points overjet, 3 points overbite, 10 points anterior crowding), which is below the threshold of 26 points to support orthodontic care. Of note in this case, is that the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.
 
The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the D8080 braces is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion, overbite, overjet and anterior crossbite with gingival attachment loss

Treatment;  orthodontic treatment services codes D8080 braces and code D8670 monthly visits x (times)12

The insurer denied coverage for orthodontic treatment services codes D8080 braces and code D8670 monthly visits x12

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to Class I malocclusion, overbite, overjet and anterior crossbite with gingival attachment loss, in addition to other clinical findings. The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when gingival attachment loss and recession of the gingival margin are present. 

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, 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
crossbite of individual anterior teeth when gingival attachment loss and recession of the gingival margin are present. 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.

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.

The clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care.

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

The insurer's denial of coverage for the orthodontic treatment service codes D8080 braces and code D8670 monthly visits x12 is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Stelara 45MG/0.5ML SC SOSY
The insurer denied the Stelara 45MG/0.5ML SC SOSY
The denial is overturned.

The patient is a female with psoriasis, treated with topicals (clobetasol and calcipotriene) and methotrexate. Her provider is requesting Stelara.

Yes, the treatment with Stelara is medically necessary.
Stelara is FDA (United States Food and Drug Administration)-approved for psoriasis in children.  The phase 3, open-label, single-arm, multicenter study (Philipp et al), evaluated ustekinumab in pediatric patients with moderate-to-severe plaque psoriasis and concluded that Ustekinumab effectively treated moderate-to-severe psoriasis in pediatric patients, and no new safety concerns were identified.  Phototherapy is not always available and can be very difficult to manage with school and work schedules, and the provider noted that phototherapy is not available in their area.  Therefore, Stelara is an appropriate and effective choice. Therefore, the Stelara is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.