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

Orthopedic
Inpatient hospital

Diagnosis: Shoulder injury
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This case describes a male patient who sustained an electrical shock while changing a ceiling fan bulb. He was evaluated in the emergency department where an evaluation and x-rays revealed a posterior fracture-dislocation of the right glenohumeral joint. An attempt was made for a closed reception in the emergency room (ER) but this was unsuccessful. The patient was then admitted for definitive care of this injury. 

The inpatient hospital admission was not medically necessary for this patient's posterior fracture dislocation of his right shoulder. An attempt was made at closed reduction of this injury in the emergency department but this was unsuccessful. The patient was then managed with surgical intervention. This management was consistent with the recommendations of the current, peer-reviewed literature as documented by Khira and colleagues in the Orthopedics journal and by Gerber and associates in the Journal of Shoulder and Elbow Surgery. The patient, however, had no significant medial history and sustained no documented complications of this surgery. The patient's lab values and vital signs were within normal limits and he was deemed stable for discharge. Thus, the medical necessity of the inpatient hospital stay is not established in this case. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Respiratory
Inpatient hospital

Diagnosis: dyspnea
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a female with atrial fibrillation (afib) (not on anti-coagulation given post-menopausal uterine bleeding and plans for biopsy), hypertension (HTN), breast cancer status/post (s/p) mastectomy, and prior COVID infection. She presented with 2 days of cough, hemoptysis, and worsening dyspnea. A chest x-ray (CXR) at urgent care suggested pneumonia, and it was recommended that she go to the emergency department (ED).

The inpatient hospital admission was medically necessary. The patient needed close monitoring given hemoptysis and pre-anticoagulation bleeding, elevated risk scores, and day 2 hemoglobin drop.
While she was hemodynamically stable, she met 2 criteria for admission (hemoptysis and bleeding before anti-coagulation). Both are historical features that are typical clinical factors that are used to judge the need for inpatient admission. Patients with bleeding issues prior to anti-coagulation need close monitoring to ensure there's no significant acute blood loss. Patients with PE and hemoptysis also need close monitoring on anti-coagulation for the same reason. Of note, the patient's hemoglobin did drop on day 2, re-enforcing the need for ongoing close monitoring. A lower level of care would not be appropriate. She was higher risk by routine scoring systems pulmonary embolism severity index (PESI) and was not a candidate for outpatient treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sarcoidosis
Treatment: Increase to Consumer Directed Personal Care Assistance Services: Total of 33 Hours per Week
The insurer denied the Increase to Consumer Directed Personal Care Assistance Services: Total of 33 Hours per Week.
The determination is upheld.

The patient has a past medical history significant for sarcoidosis, diabetes, hypertension, and atherosclerosis. An increase in personal care hours, to 33 hours a week is requested. The patient has been approved for 23 hours a week of the consumer directed personal assistant services. At issue is the medical necessity of the requested increase in the hours of consumer directed personal care assistance services to 33 hours per week.
The requested health service is not medically necessary for this patient.
Additional services were denied by the health plan based on the following: The patient reported a change in his health condition, however, the change was noted not to be major and does not impact the current personal care needs. The hours are enough to help with activities of daily living such as bathing, dressing, toileting and housekeeping related services. The Uniform Assessment System (UAS) State of New York, nursing supplemental form, Aide tasking service plan, Care plan, Letter of appeal from the patient were reviewed. The Uniform Assessment System Aide Task Service Plan (UAS-ATP) Summary of Hours recommended noted that the patient required a total of 18.96 hours a week. The patient is currently approved for 23 hours a week. In the patient's appeal, he requested additional hours for deterioration of health and also assistance and travel to doctor's appointments due to coronavirus disease (COVID).
From the UAS, there does not appear to be a significant deterioration in the patient's medical status necessitating additional services. The patient appears to have a significant concern about developing a COVID infection similar to many other adults. He notes that he requires constant assistance and vigilance to avoid infection. However, this concern along with assistance with an aide because of this does not necessitate additional medical services for activities of daily living (ADLs) or Instrumental activities of daily living (IADLs). The demonstrated need for additional services is not met. The services allotted are adequate to meet the patient's functional needs.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia.
Treatment: Ambulatory surgery [Peroral Endoscopic Myotomy].
The insurer denied Ambulatory surgery [Peroral Endoscopic Myotomy].
The determination is overturned.

The patient has achalasia, cardiomyopathy, cardiac murmur, hypertension, and arthritis. She has had dysphagia with solids, liquids, and pills, postprandial regurgitation, and retrosternal chest pain. She has had unintentional weight loss. An esophagogram showed moderate narrowing at the gastroesophageal junction, and barium tablet was unable to traverse it. An esophagogastroduodenoscopy revealed normal esophageal biopsies, and showed normal stomach and duodenum. Esophageal manometry showed an elevated basal lower esophageal sphincter pressure of 82.4 millimeters of mercury (mmHg), high integrated relaxation pressure of 30.8 mmHg, and very high amplitude of contraction, consistent with hypercontractile esophagus. At issue is whether the proposed health service or treatment ambulatory surgery [Peroral Endoscopic Myotomy] is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Peroral endoscopic myotomy (POEM) is likely to be more beneficial than any standard treatment or treatments for the patient's achalasia than any available alternatives. The American Gastroenterological Association best-practice guideline for peroral endoscopic myotomy states that "if the expertise is available, POEM should be considered as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes" (1). The American Society for Gastrointestinal Endoscopy has recently published a statement based on available evidence, stating that POEM is a "a potential attractive option for the treatment of achalasia that offers a minimally invasive endoscopic approach to myotomy with the potential for a durable response to therapy" (2) Committee, et al). Clinical studies and trials have shown comparable efficacy with surgery when expertise in POEM is available (3,4). However, despite comparable efficacy, POEM is significantly less invasive than surgical intervention, resulting in less postoperative pain and a more rapid recovery (5).
In this patient, with severe symptoms including dysphagia, regurgitation, chest pain, and unintentional weight loss, the use of POEM is supported by current medical literature and guidelines. For these reasons, POEM would be considered likely to be more beneficial than any standard treatment or treatments for the enrollee's type III achalasia.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hypertension. 

Treatment: Formulary Exception for Edarbyclor Tablet (Azilsartan-Chlorthal).

The insurer denied coverage for the Formulary Exception for Edarbyclor Tablet (Azilsartan-Chlorthal).

The denial is overturned. 

This is a female patient who has a history of hypertension that has been controlled on Azilsartan-Chlorthalidone (Edarbyclor 40/25).  The patient's physician has requested that the patient be continued on this medication and provides documentation that she failed a trial of candesartan in the past. 

Trials of antihypertensive medications that may not be effective may result in adverse reactions such as poorly controlled hypertension and even hypertensive urgency.2 This patient has failed one of the formulary drugs-candesartan. When compared to other thiazide diuretics including hydrochlorothiazide, chlorthalidone is the preferred diuretic treatment for patients with hypertension based on its long half-life and proven trial reduction of cardiovascular disease.1 Chlorthalidone is not listed as one of the formulary medications. 

In conclusion, the patient should be maintained on Azilsartan-Chlorthalidone.

The Formulary Exception for Edarbyclor Tablet (Azilsartan-Chlorthal) is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness.

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 of hypertension, diabetes mellitus, and chronic kidney disease.  The patient presented to the Emergency Department (ED) with subjective complaints of dizziness for 2 days.  The patient stated he felt unsteady on his feet and lightheaded.  The patient had been admitted to the hospital the week prior for the same complaints.  The patient had changed blood pressure medications.  The dizziness persisted since then.  The patient also stated he felt anxious and afraid after an incidental kidney mass was found on the prior admission.  The patient now believed that the dizziness could be caused by cancer with metastases to the brain.  The patient's blood pressure was 155/84.  The patient was not in acute distress.  The patient had a slightly unsteady gait.  The patient's finger-to-nose showed mild deviation from target.  The patient's heel-to-shin was normal. The patient's dizziness could occur on rest and exertion.  The symptoms were not new or different.  There were multiple bowel episodes in the past with no relief or diagnosis given.  The patient denied headaches, blurry vision, chest pain, shortness of breath, and abdominal pain.  The patient's vital signs were stable.  The patient was to be assessed for cerebellar disease or intracranial pathology and acute coronary syndrome or metabolic changes as the cause of the symptoms.  The patient's computed tomography angiography (CTA) of the neck with contrast revealed mild anterior circulation stenosis.  The patient's computed tomography (CT) of the head without contrast revealed diffuse cerebral atrophy, chronic periventricular white matter changes; no acute intracranial pathology, intracranial hemorrhage, or intracranial mass.  The patient was assessed by neurology who recommended a magnetic resonance imaging (MRI) of the brain and magnetic resonance angiography (MRA) of the head and neck as well as a transthoracic echocardiogram.  The patient was admitted for a further evaluation. 

Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient.  The patient presented with abrupt onset of dizziness with mild ataxia with finger to nose and ataxia of gait.  There was no evidence of stroke on CT imaging study.  The patient was treated with medical management.  The patient could not complete MRI secondary to his claustrophobia.  Care provided could have been performed in the ED setting and at an observation level of care.  Care provided did not require inpatient admission. Therefore, the inpatient hospital admission is not considered medically necessary for this patient.

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

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

Diagnosis: Dental Problems (skeletal Class I, maxillary spacing, Class II canines, maxillary and mandibular crowding and deep impinging overbite).
Treatment: Braces (code D8080) and monthly visits x 12 (code D8670).
The insurer denied coverage for braces (code D8080) and monthly visits x 12 (code D8670).
The denial is overturned. 

This patient is a male child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, maxillary spacing, Class II canines, maxillary and mandibular crowding and deep impinging overbite.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage. 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 significant 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 6 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 deep impinging overbite with severe soft tissue damage.  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 the insurer and the plan criteria to justify orthodontic care.
 
Braces (code D8080) and monthly visits x 12 (Code D8670) are considered medically necessary for this patient.

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

The medical necessity for braces (code D8080) and monthly visits x 12 (code D8670) is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class II with retruded mandible, maxillary spacing, mandibular spacing, and excessive overjet and deep impinging overbite). 
Treatment: D8080 Comprehensive Orthodontic Treatment of the Adolescent Dentition and D8670 Periodic Orthodontic Visit.
The insurer denied coverage for D8080 Comprehensive Orthodontic Treatment of the Adolescent Dentition and D8670 Periodic Orthodontic Visit.
The denial is upheld. 

This patient is a male child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class II with retruded mandible, maxillary spacing, mandibular spacing, and excessive overjet and deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 12 points on review by their internal reviewers.

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides 6 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 deep impinging overbite with severe soft tissue damage.  This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage, and does not support comprehensive orthodontic care.  In this case, the clinical circumstance does not meet the insurer and the plan criteria to justify orthodontic care.  This reviewer concurs with the HLD index of the insurer attaining 12 points (i.e., 4 points overjet, 5 points overbite, and 3 points labiolingual spread).

The coverage for D8080 comprehensive orthodontic treatment of the adolescent dentition and D8670 periodic orthodontic visits is not considered medically necessary for this patient.

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

The carrier's denial of coverage for D8080 Comprehensive Orthodontic Treatment of the Adolescent Dentition and D8670 Periodic Orthodontic Visit should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, low back, knee and foot osteoarthritis.
Treatment: Increase Personal Care Aide (PCA) Level 2: 12 Hours per Day- 7 Days per Week; 12 Hours per Day 7 Days per Week (split-shift); a Total of 168 Hours per Week.
The insurer denied the Increase Personal Care Aide (PCA) Level 2: 12 Hours per Day- 7 Days per Week; 12 Hours per Day 7 Days per Week (split-shift); a Total of 168 Hours per Week.
The denial is overturned. 

The patient is a female with a history of dementia, low back, knee and foot osteoarthritis, dizziness and associated gait ataxia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 168 hours per week Personal Assistance Services to offer increased activities of daily living support.

Yes, the proposed treatment of 168 hours per week Personal Assistance Services is deemed medically necessary.

Recent correspondence from the patient's medical provider indicates that due to worsening functionality and progressively worsening cognitive impairment, the currently approved plan of 84 hours per week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 168 hours per week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Kidney Failure

Treatment: Hospital Admission

The insurer denied coverage for hospital admission

The denial is upheld.

The patient is a female with progressing kidney failure who was scheduled to have access placed as an outpatient for dialysis initiation but was found to have elevated potassium of 6.2 and was given Veltassa prior to the Emergency Department (ED) evaluation. The patient's repeat potassium level was 5.5 and did not have severe electrocardiogram (EKG) changes. The patient was evaluated by vascular surgery and underwent tunneled dialysis catheter placement, and the patient was started on dialysis which was tolerated well and then discharged.

Based on the review of the medical record and literature, hospital admission was not medically necessary for this patient. This patient presented with hyperkalemia due to the progression of her chronic kidney disease (CKD). However, the patient did not have persistent, severe hyperkalemia with severe EKG changes. There were no signs of severe volume overload or hypoxia, no documentation of severe uremia such as encephalopathy or uremic bleeding. The patient had routine dialysis catheter placement while inpatient which was tolerated well without immediate complication. The patient's condition could have been treated safely under lower level of care.

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 hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Symptomatic Bilateral Lower Extremity Varicose Veins, Left Leg Phlebitis

Treatment: Left Great Saphenous Vein (GSV) Radiofrequency Ablation (RFA) and Ambulatory Phlebectomy

The insurer denied coverage for Left Great Saphenous Vein (GSV) Radiofrequency Ablation (RFA) and Ambulatory Phlebectomy

The denial is upheld 

This case involves a male patient with a medical history of varicose veins of both lower extremities, phlebitis, biceps tendon tear, gastroesophageal reflux, phlebitis, sleep apnea, varicose veins, seizures, and venous insufficiency who has been recommended to undergo a left great saphenous vein (GSV) radiofrequency ablation (RFA), and ambulatory phlebectomy.  The submitted documentation indicated that the patient underwent a duplex scan revealing left great saphenous vein reflux at the saphenofemoral joint of the mid-calf with evidence of deep vein reflux.  There was no evidence of deep vein thrombosis (DVT) diagnosis.  The patient was seen with complaints of symptomatic bilateral lower extremity varicose veins and left leg bypass.  The patient reported that he has been having worsening symptoms.  The patient has been utilizing compression hose with minimal relief.  The patient is noted to have a history of phlebitis.  It was recommended that the patient continue to follow-up.  The patient underwent the diagnostic study revealing the right femoral vein was compressible with no evidence of thrombus. The patient returned from the follow-up regarding his right leg varicose veins.  The patient did continue to have discomfort despite compression.  The patient underwent diagnostics revealing no significant peripheral arterial disease.  The patient also underwent a right leg reflux study demonstrating refluxing symptoms with no significant greater saphenous vein reflux, small saphenous vein reflux, or deep venous thrombosis (DVT).  The physical examination revealed moderate to large viscosities on the right.  The physician indicated that the patient had symptomatic varicose veins in the setting of previous history of right leg DVT; also has resolving left leg phlebitis.  It was recommended that the patient wear thigh-high compression and utilize aspirin.  It was recommended that the patient follow-up in 1 month to undergo additional reflux studies.

According to the provided documentation, the patient's right leg is more symptomatic. However, the request has been made for treatment to the left leg. The submitted documentation does not indicate the official pulse volume recording (PVR) examination detailing no arterial disease is not present for review and the requested codes are also not appropriate.  Additional information clarifying the above would be needed prior to certification of the requested procedure. Thus, based on the information provided at this time, the ambulatory surgery requested is not considered medically necessary for this patient.

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

The insurer's denial of coverage for Ambulatory Surgery is not substantiated.  The insurer's denial should be upheld.