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

Diagnosis: Chest Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient with type 2 diabetes, obesity, and obstructive sleep apnea, on continuous positive airway pressure (CPAP) who presented to the hospital with chest pain, present since the previous evening. He was given sublingual (SL) nitroglycerin (NTG) spray with a decrease in symptoms. He had recently had an abnormal stress nuclear test and had been scheduled for coronary angiography. An electrocardiogram (EKG) showed nonspecific ST and T wave changes inferiorly. He was admitted and started on intravenous (IV) heparin. He was given aspirin and NTG. He was ruled out for a myocardial infarction (MI) with negative troponins. He was seen in a cardiology consultation. He underwent coronary angiography which showed 95 percent (%) stenosis of the left anterior descending coronary artery. He underwent angioplasty and stenting. Dual antiplatelet therapy was started. He was discharged. At issue is the medical necessity of an inpatient stay.
Inpatient admission was indicated for this patient with unstable angina and moderate risk HEART [history, EKG, age, risk factors, troponin] score, indicating significant potential risk for major adverse cardiovascular events (myocardial infarction, need for revascularization, cardiovascular death). He required intravenous medication (heparin), invasive coronary angiography, and revascularization.
He had several risk factors for coronary artery disease and had a recent abnormal stress nuclear study. He presented with unstable angina. His HEART score was 6, indicating moderate risk for major cardiac events. Inpatient admission is recommended, per standard American College of Cardiology (ACC) guidelines (2).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ankle fracture
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This is an adult female who sustained a right ankle fracture. She fell from a trampoline. She was admitted to the hospital and underwent open reduction internal fixation (ORIF). Her post-surgical course was complicated by delays in physical therapy (PT). She was reported to have light-headedness. She was discharged on day # (number) 4. This was based upon her functional status. Her body mass index (BMI) was 42.79.

The requested health service was not medically necessary.

The records showed a non-complicated operation and post-surgical course. The surgery was approximately 1.5 hours with limited blood loss. The vital signs were stable. The wound was satisfactory. There was no evidence of bleeding. Pain medication could be taken orally. There was no indication for additional imaging or specialty consultation. Physical therapy was provided. It was noted with a body mass index of 42, gains would likely be minimal. There were no extenuating circumstances to substantiate the hospitalization at that level. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic sinusitis with polyposis
Treatment: Dupixent
The insurer denied Dupixent.
The determination is overturned.

This is a male patient with a history of asthma, allergic rhinitis, anosmia, nasal obstruction secondary chronic sinusitis with polyposis with exacerbation of symptoms despite undergoing maximal medical and surgical therapy including multiple courses of high dose oral corticosteroids, mometasone corticosteroid rinses and extensive bilateral endoscopic sinus surgery in the past. Endoscopic examination as reported by the treating otolaryngologist demonstrates recurrent nasal/sinus polyposis. The treating otolaryngologist requests approval for prescribing adjunctive Dupixent for patient's chronic sinusitis with polyposis. The Dupixent is under review for medical necessity.

Dupixent is considered medically necessary for this patient and has received Food and Drug Administration (FDA) approval for use in patients with medically refractory chronic sinusitis with polyposis. The patient has demonstrated medically refractory chronic sinusitis with polyposis, having tried multiple courses of antibiotics, multiple courses of oral corticosteroids, and prolonged treatment course of Mometasone rinses, in addition to prior endoscopic sinus surgery. He has already completed several years of Mometasone sinus rinses, which is an alternative intranasal corticosteroid.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic intrahepatic cholangiocarcinoma. 
Treatment: Positron Emission Tomography and Computed Tomography (PET-CT), a special picture of your body from your head to your thighs (code: 78815). 
The insurer denied: Positron Emission Tomography and Computed Tomography (PET-CT), a special picture of your body from your head to your thighs (code: 78815). 
The denial is upheld. 

The patient is an adult female with metastatic intrahepatic cholangiocarcinoma. Positron emission tomography/computed tomography (PET/CT) from last year revealed liver lesions and bony lesions. The patient was treated with palliative radiation to the bony sites of disease. She was treated with durvalumab, gemcitabine, and cisplatin. Positron emission tomography/computed tomography was done to assess response to treatment, based on the provided records. An appeal letter indicated that the patient was having pain and that a computed tomography (CT) did not demonstrate a clear reason. Those computed tomography scans revealed stable metastatic disease. Records do note that the patient was having left shoulder pain, and that magnetic resonance imaging (MRI) was done, and this study revealed active osseous metastatic disease. 

The requested health service is not medically necessary. 

This patient has metastatic cholangiocarcinoma and has been treated with palliative radiotherapy followed by durvalumab, cisplatin, and gemcitabine. Positron emission tomography/computed tomography (PET/CT) was done to assess response to treatment, based on the provided records. 
There is no evidence clearly showing that positron emission tomography/computed tomography improves health outcomes compared to conventional imaging for the assessment of treatment response in patients with metastatic cholangiocarcinoma. Records do not clearly document that this patient had inconclusive conventional imaging leading to the positron emission tomography/computed tomography done 3 months ago. The patient had stable metastatic disease on computed tomography scans and while she was having left shoulder pain, magnetic resonance image demonstrated active metastatic disease explaining that pain.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia, Lung Cancer
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is overturned. 

The patient is a female with a history of small cell lung cancer and large cell neuroendocrine cancer, on chemotherapy. Her presenting complaints were dyspnea and a productive cough, in addition to diarrhea. A computed tomography (CT) scan of the chest performed as an outpatient 3 days prior to admission demonstrated findings consistent with multifocal pneumonia and a small right pleural effusion: she was started on Augmentin as an outpatient. On arrival to the emergency department, the patient's vital signs were blood pressure 101/70, heart rate 137, respiratory rate 18, with an oxygen saturation of 98 percent (%). The physical exam was notable for diminished bibasilar breath sounds, and tachypnea. Lab results were unremarkable. Radiology was notable for a chest x-ray with increased right upper lobe collapse, and the computed tomography (CT) findings discussed above.
At issue is the medical necessity of an inpatient stay.
Full hospital admission was medically necessary. The patient presented with pneumonia in the context of advanced lung cancer and immunosuppression from chemotherapy. Her pneumonia severity risk class would be IV, suggesting that inpatient management be provided. In addition, she demonstrated failure of outpatient management of the pneumonia, with symptoms progressing despite Augmentin. She needed close monitoring and treatment of her pneumonia which could only have been provided at an inpatient level of care. A lower level of care would not have been appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:
Treatment: braces/monthly visits
The insurer denied braces/monthly visits.
The health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on tooth 7. She presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for Braces and Monthly Visits to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity.

Braces and monthly visits are medically necessary for this patient.
This patient presents with an anterior crossbite on tooth 7, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dental malocclusion.

Treatment: braces and monthly visits.

The insurer denied coverage for braces and monthly visits.

The denial is overturned.


Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, anterior crowding, and ectopic eruption among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index attaining 27 total points. 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 attaining only 15 points on the Handicapping Labio-Lingual Deviations (HLD) index by internal reviewers. 

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, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD), New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist completes the second portion of the index arriving at 27 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support 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. 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.

Braces and monthly visits are considered medically necessary for this patient.

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

Diagnosis: abdominal pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


This is an adult with a history gastric bypass twenty years ago. The patient presented to the emergency department (ED) complaining of generalized abdominal pain for 4 days with nausea but no vomiting. The patient had gone first to the urgent care center for these symptoms and had blood work and was recalled because liver function tests (LFT's) were elevated. She was advised to go to the emergency department (ED). The patient denied any vomiting or fever or chills. The patient's vital signs were stable. An examination revealed scleral icterus and abdominal tenderness without guarding or rebound. The plan was sonogram and possible computed tomography (CT).  The ultrasound showed acute cholecystitis with moderate gallbladder wall thickening. There was no dilation of the hepatic ducts. The pancreas body was unremarkable. The patient was tolerating an oral intake, was started on Flagyl and Rocephin and was admitted. 

On surgical consultation, the white blood cell (WBC) count was 8.3. The impression was acute cholecystitis versus choledocholithiasis. Given the patient's history, the patient would require common bile duct (CBD) exploration versus intraoperative endoscopic retrograde cholangio-pancreatography (ERCP) through the gastric pouch. A magnetic resonance cholangio- pancreatography (MRCP) was done and demonstrated no stone in the common bile duct (CBD) and no acute cholecystitis. The liver function tests (LFT's) were down trending and the patient was feeling well without vomiting and had no pain at rest. 

Repeat labs showed a white blood cell (WBC) count of 6.0, aspartate aminotransferase (AST) level of 313, alanine aminotransferase (ALT) level of 542, total bilirubin 3.5, direct bilirubin 2.0 and alkaline phosphatase (alk phos) of 298.

Because the liver function tests (LFT's) were down trending, it was felt that the patient had passed a stone or sludge. The patient continued on nonoperative management and clinically improved. The patient's diet was advanced, and the patient was discharged home on oral antibiotics.

According to the guideline Milliman Care Guideline (MCG) Health Inpatient and Surgical Care- 27th edition Gall Bladder or Bile Duct Inflammation or Stone ORG: M-555 (ISC), the clinical indications for admission to inpatient care were not met. 

Milliman Care Guidelines (MCG) Health in General Recovery Care 27th edition General Admission Criteria GRG: CG-GAC (ISC GRG) were also not met to indicate inpatient admission necessity. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the full hospital admission is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Obesity

Treatment: Wegovy

The insurer denied coverage for Wegovy

The denial is upheld.

 
This is an adult female diagnosed with obesity. This request is for Wegovy.  Her weight was 116 kilograms (kg); Body Mass Index (BMI) was 45.14.

Semaglutide (Wegovy) is a glucagon-like peptide-1 receptor (GLP1R) agonist that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity. Recent studies published in major peer-reviewed medical journals have shown the safety and efficacy of Semaglutide for the treatment of obesity. This medication is now available for the treatment of obesity in the form of Wegovy.

The standard of care based on multiple societal guidelines[8-13] requires that the patient participate in lifestyle modification. It also requires that the patient has a BMI of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension, and hyperlipidemia. 

The patient has a BMI of 45.15, however, there is no documentation of participation in lifestyle modification. 

The request does not meet the standard of care.

The need for a formulary exception is not substantiated. 

No formulary alternatives were provided by the insurer.

The carrier's denial of a request for a Formulary Exception for Wegovy (semaglutide) to treat obesity is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes

Treatment: Freestyle Libre Kit 3 sensors

The insurer denied coverage for Freestyle Libre Kit 3 sensors

The denial is upheld 

The patient states they have diabetes and gastroparesis. The patient has terrible neuropathy in both legs.  As reported, the patient is regularly monitoring their blood glucose (BG) 4 or more times per day. The patient has recurring episodes of hypoglycemia. The patient's hemoglobin A1C was 6.6 %.

The requested device is a flash glucose monitoring system (1-4) that is Food and Drug Administration (FDA) approved for persons age 18 and older with diabetes. It has been shown to be effective in patients with type II diabetes who are on an intensive insulin regimen. It was associated with sustained reduction in hypoglycemia and safely and effectively replaced blood glucose monitoring (5,6).  The patient's current medications include Trulicity, metformin and Jardiance. The patient is not on an intensive insulin regimen.  

The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Freestyle Libre Kit 3 sensors is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Evaluation and comprehensive dental treatment
Treatment: Root canal, post and core and crown for tooth #26, root canal and crown for tooth #12, post and core for tooth #11
The insurer denied coverage for: Root canal, post and core and crown for tooth #26, root canal and crown for tooth #12, post and core for tooth #11
The denial is: Upheld
Upon review of the submitted documentation which includes copies of undated periapical radiographs and insurer correspondence, it appears that this patient presented to the dentist for evaluation and comprehensive dental treatment. Based on the documentation, multiple endodontic procedures and posts and crowns were recommended in addition to a maxillary removable partial denture. The insurer has denied the services stating that these services are not medically necessary treatment as the clinical documentation does not support it insofar as the patient does not meet the criteria for approval of the requested services. The insurer has since approved the upper partial denture. The patient is appealing.

Based on the submitted objective Information for review, which consists solely of the radiographic examinations, the radiographic documentation does not support the extensive dental treatment recommended by the dentist. There are no dental treatment notes, no dental charting, nor periodontal charting provided for review. There does not appear to be any gross odontogenic pathology that would necessitate root canals on teeth numbers 12 or 26 nor does the documentation support post and core for #11. Further, as per Emblem Health insurance letter, the maxillary removable partial denture was approved. As the provided documentation is inadequate to support the other treatment, these services are considered not medically necessary.

Uphold denial for coverage for root canal, post and core and crown for tooth #26, root canal and crown for tooth #12, post and core for tooth #11 as the provided documentation for review is inadequate and did not support the extensive treatment recommended. As per the letter from the insurer the maxillary removable partial denture is approved.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for root canal, post & core, and crown for tooth #26, root canal and crown for tooth #12, post & core for tooth # 11, and with exception of previously approved upper partial denture, is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male with a history of pancreatitis, and alcohol use disorder, who was admitted with mid-epigastric abdominal pain. The pain was sharp and associated with nausea but no vomiting. Due to the duration, he came to the emergency room (ER). There was no associated nausea or vomiting. On exam, he appeared in no distress. Abdomen was tender with no guarding or rebound. He received morphine for pain. Lipase was markedly elevated. A right upper quadrant (RUQ) ultrasound (US) showed no gallstones and no biliary dilation. LFT's (liver function tests) were otherwise normal. 

The inpatient hospital services were not medically necessary. The patient had uncomplicated pancreatitis. There was no evidence of pancreatic necrosis, and the patient was hemodynamically stable and non-toxic appearing throughout. The patient's electrolytes were normal and there were no major systemic complications such as systemic inflammatory response syndrome (SIRS) picture or adult respiratory distress syndrome (ARDS). He had nausea but was able to tolerate nutrition by mouth (PO) and therefore did not need bowel rest or parenteral nutrition. The main avenue of treatment is supportive care with as needed (PRN) pain medication. This does not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: braces and monthly visits
The insurer denied braces and monthly visits.
The determination is overturned.

The patient has an anterior crossbite on tooth 10. She presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for 24-30 months of orthodontics to address the crowding and crossbite, but the treatment was denied due to a lack of medical necessity. At issue is the medical necessity of braces and monthly visits.

This patient presented with an anterior crossbite on tooth 10, as well as moderate crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3)
If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For this reason, treatment is medically necessary.