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

Diagnosis: Class II malocclusion. 
Treatment: Orthodontic care. 

The insurer denied coverage for orthodontic care. The denial is upheld. 

According to the documentation submitted, this is a female child seen for evaluation and need of orthodontics treatment. After clinical examination and analysis by her dentist, the findings revealed that there is a class II malocclusion and increased overjet crowding and deep bite. The Handicapping Labio-Lingual Deviation (HLD) Index Report score is 21 points including a score 7 for overjet, 3 for overbite, 5 for anterior crowding and 6 for labio-lingual spread. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extra-oral and intra-oral clinical images, and narrative letters, 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 HLD index attaining 26 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 21 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 26 points 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 cited below 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 healthcare plan did act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer concurs with the index completed by the insurer attaining a total of 21 points on the HLD index (7 points ove1jet, 3 points overbite, 5 points anterior crowding and 6 points labiolingual spread) which is below the threshold of 26 points to support orthodontic care. 

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

Diagnosis: Alcohol Dependence, Rhabdomyolysis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female with a history including HIV (human immunodeficiency virus) on HAART (highly active antiretroviral therapy), heart failure, MDD (major depressive disorder), HTN (hypertension), and CAD (coronary artery disease). She presented to the ED requesting alcohol detox. She had begun drinking one year prior. She drinks 3-40 oz beers daily. Her last drink was the morning PTA (prior to admission).  

The patient's VS (vital signs) were as follows: T (temperature) 97.7, P (pulse) 94, RR (respiratory rate) 16, BP (blood pressure) 207/117. Her exam was unremarkable. Her labs were as follows: WBC (white blood count) 2.42, H/H (hemoglobin/hematocrit) 14.7/43.8, Na (sodium) 146, K (potassium) 3.8, BUN/Cr (blood urea nitrogen/creatinine) 13/.8. CXR (chest x-ray) revealed left middling nodule. EKG (electrocardiogram) revealed NSR (normal sinus rhythm), Q waves in V1-3, depression 3 F V4-6.

The patient was admitted. Plan of care included Ativan prn and CIWA (clinical institute withdrawal assessment) protocol, transfuse one-unit platelet for thrombocytopenia and start Decadron, check hepatitis B and C, monitor CBC (complete blood count) and LFTs (liver function tests).  

No, the inpatient admission was not medically necessary.

This patient was admitted after presenting for alcohol detox. The patient was hemodynamically stable and afebrile. BP was elevated. She did not have tachycardia or arrhythmia. She did not have vomiting, delirium, seizures, or gross tremor. Labs were remarkable for thrombocytopenia. The patient was admitted with plan for platelet transfusion and CIWA protocol. The patient did not have signs of alcohol withdrawal during hospital stay. Hospital stay was primarily remarkable for workup of thrombocytopenia. The patient was clinically stable and did not have findings of severe alcohol withdrawal. She did not have symptoms that required an acute inpatient level of care. She had not failed management in a lesser level of care. The requested inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Influenza; Dehydration

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This was a female child who was referred by her primary care provider to the Emergency Department (ED) for evaluation of her fever, sore throat, vomiting and poor feeding in the setting of recently diagnosed influenza. The patient was started on Tamiflu treatment as outpatient. The ED Physician history noted that the patient's last vomiting episode was the night prior to this ED presentation and that the patient hadn't eating since the day prior. It is also noted that the patient had a sore throat with 4/10 in pain intensity and odynophagia. The patient's initial temperature was 98.9F and later spiked to 102.1F, which subsided with antipyretic. Otherwise, the patient was hemodynamically stable. Physical exam was recorded as mostly normal in both the ED attending's note and the admitting attending's note with mention of mildly dry oral mucosa in the ED note, and nasal congestion and moist cough on the admitting physician and nursing notes. The patient's lab studies including urinalysis were essentially within normal limits. It is noted in the ED note that the patient received intravenous fluids (IVF) bolus of normal saline, but there is no documentation of reevaluation after that hydration attempt. The patient's chest x-ray obtained was unremarkable.  The patient's admitting diagnoses were influenza septicemia and moderate dehydration secondary to decreased appetite. As per progress notes, the patient was tolerating oral intake with no episodes of vomiting.  The patient's fever and skin showed improved turgor (even though there was no prior notation of abnormal skin turgor). The patient was discharged then home 3 days after admission.

Based on the documentation in the records, the Inpatient admission is not considered medically necessary based on the MCG 24th Edition guidelines for General Pediatric Admission and Dehydration in a Pediatric patient. The patient did not have a serious cause for dehydration noted by her stable vital signs, and did not have severe/persistent vomiting. The patient was able to tolerate oral intake. Though the patient spiked a fever in the Emergency Department, it was responsive to anti-pyretic medication. The patient did not require services warranted at an inpatient level of care. If there was concern for dehydration, the patient could have been observed in the observational level of care. Thus, inpatient admission was not medically necessary for this patient.

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

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis/substance abuse
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

This patient is a male. He presented to the ED in an intoxicated state.  The initial comments of the ED physician were that the patient came requesting detox from heroin, and that subsequently he was found to have an infected gunshot wound to the thigh.  The patient did report worsening right thigh pain, swelling and redness after sustaining a gunshot wound to the right thigh.  

The patient had normal vital signs at the time of presentation.  He was without fever.  Physical examination revealed a 2 x 2-cm red and tender area of the anterior right thigh in an area of a through and through gunshot wound.  Pulses in the distal right leg were normal.  The WBC (white blood cell) count was 7.8 K.  CT scan showed edema within the superficial subcutaneous tissues of the right thigh.  The CT report does not mention a fluid collection or abscess.  

The patient was admitted to the hospital medical service with the diagnosis of cellulitis and polysubstance use disorder.  Surgical consultation was requested.  The patient was given a regular diet.  He was receiving IV antibiotics for the right thigh cellulitis and Ativan for withdrawal symptoms.  The following day the patient remained afebrile with normal vital signs. The WBC count was 5.4 K.  The patient underwent incision and drainage (I&D) of a right thigh abscess.  He was treated with a methadone taper, starting antibiotics, and IV fluid. The progress note indicates that the patient refused to be interviewed by psychiatry.  Pain control was adequate and vital signs were normal.  He was discharged from the hospital and transferred to an inpatient rehabilitation unit for detoxification from polysubstance use.

The patient presented to the ED requesting detox from heroin, and he was subsequently found to have an infected gunshot wound to the right thigh.  He was clinically and hemodynamically stable without evidence for neurovascular compromise at the time of presentation.  The treatment provided included a medical evaluation, IV fluid, IV antibiotics, and pain medications and a detoxification plan with a Methadone taper.  Although there was concern for an abscess of the right thigh complicating the gunshot wound, the incision and drainage procedure was not performed immediately.  The clinical presentation supported that he would require less than 48 hours of care and intensity of service could have been appropriately met with an observational status.  

An inpatient level of care was not medically necessary for this patient's condition.  He was clinically and hemodynamically stable at the time of presentation.  The I&D procedure could have been performed with subsequent transfer to inpatient rehabilitation unit for detoxification from polysubstance use.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive system /Gastrointestinal /Abdominal pain.
Treatment: Inpatient hospital stay.
The insurer denied the inpatient hospital stay.
The denial is upheld in whole.

The patient with a hysterectomy completed; presented to the emergency room of the hospital with nausea and vomiting the following day.
The requested health service/treatment of Inpatient stay is not medically necessary for this patient.
The patient had a hysterectomy without any complication. She presented after discharged with nausea and vomiting. Vital signs were stable, and the physical examination was normal. The patient's CT of the abdomen was normal. The patient  was treated for her symptoms and discharged after inpatient admission. The patient could have been treated under a lower level of care. There were no complications from surgery, no infection, no hemodynamic instability nor any diagnosis that would support the need for acute, inpatient monitoring.
Therefore, the inpatient stay was not medically necessary in this particular case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Torticollis and Muscle Weakness.
Treatment:  Physical Therapy.

The insurer is denied coverage for physical therapy.  The denial is overturned.

This is a male patient child with a history of delayed milestones and childhood torticollis and muscle weakness.  The most recent re-evaluation noted that the patient had developmental delay and torticollis.  The patient was steadily improving in all aspects and had reached some goals.  The remaining goals were to be worked on in physical therapy and was mostly 50% achieved.  The patient was to continue therapy for several more weeks and then would be reassessed.  Upon his reassessment, it was reported that the patient had achieved mostly 75% of his goals.

Based on the review of the medical record, the patient was making improvement but continued to have developmental delays and asymmetry.  Literatures supports that ongoing therapy was medically necessary for this patient.  Thus, the continued physical therapy services are considered medically necessary for this patient.

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

The carrier's denial of coverage for continued physical therapy services should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute on chronic kidney disease.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission. The denial is overturned.

This patient is a with a past medical history of chronic kidney disease (CKD), hypertension, diabetes mellitus, anxiety, and depression. The patient presented to the Emergency Room. The patient had subjective complaints of edema and shortness of breath. The patient denied orthopnea, paroxysmal nocturnal dyspnea, or chest pain. The patient had voiding frequency, but this was at her baseline. The patient had a dialysis AV fistula in the left arm. The physical examination revealed that the patient had (2+) pretibial edema up to her bilateral knees, and there was diffuse edema in her bilateral hands. There was no effusion on chest x-ray. The patient's electrocardiogram (EKG) was unremarkable. The patient was treated with Lasix, and magnesium.  The patient's blood pressure was 152/75. The patient's white blood cell (WBC) count was 14.6, absolute neutrophil was 11.7, RDW was 16.9, INR was 1.02, PTT was 43.1, sodium was 134, carbon dioxide was 15, BUN was 86.6, creatinine was 6.4, glucose was 131, magnesium was 1.5, AST was 10, and albumin was 2.8. The patient was admitted to Medical Surgical service for the treatment of edema and chronic kidney disease. The patient underwent hemodialysis. The patient was stabilized and discharged.

Based on the review of the medical record, the patient presented with acute on chronic kidney disease in the setting of volume overload and initially required intravenous (IV) diuretics (with subsequent oral diuretic dose titration) and electrolyte replacement (i.e., magnesium).Thereafter, the patient required the initiation of hemodialysis and a vascular surgery consultation to evaluate her AV fistula to ensure patency prior to use. Due to these issues in addition to the complexity of her multiple other medication conditions (i.e. diabetes which also required an endocrinology consultation), inpatient admission was appropriate and medically necessary for this patient.

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

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Elevated blood pressure, chest pain, cough, body aches.
Treatment:  Inpatient admission.

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

The patient is a female with hypertension and chronic kidney disease (previous creatinines 1.4-1.5), who presented to the hospital with chest pain, cough, congestion, body aches, fatigue, and sore throat after being noted to have a blood pressure of 220/110 at an outpatient clinic.  On presentation the patient complained of left-sided chest pain.  Labetalol was administered in the emergency department.  Labs were notable for a creatinine of 1.6.   The patient was alert and oriented.  A renal ultrasound demonstrated no hydronephrosis.  The electrocardiogram showed sinus rhythm without acute ischemic changes, and cardiac enzymes were negative.  Computed tomography of the brain demonstrated no acute process.  The blood pressure was 199/116 on admission.  The patient was monitored on telemetry, cardiology consulted, and oral antihypertensive agents were provided.  The blood pressure improved with adjustment of oral antihypertensive agents.  The urine culture grew coagulase-negative staphylococcus, which was felt to represent a contaminant.

No, the inpatient admission was not medically necessary.

The patient's chest pain was not accompanied by evidence of acute coronary syndrome.  Cardiac enzymes were negative, and the electrocardiogram showed no acute ischemic changes.  Although the blood pressure was significantly elevated on presentation, there was no evidence of hypertensive emergency, as there were no end-organ manifestations of the elevated blood pressures, such as acute cerebrovascular accident, hypertensive encephalopathy, microangiopathic hemolytic anemia, acute heart failure, or syncope.  The creatinine of 1.6 on presentation was only minimally greater than baseline creatinine of 1.4-1.5.  The member did not have hyperkalemia, uremia, acidosis, or volume overload.  In summary, acute inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the member in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Post Partum Pre-Eclampsia.
Treatment: Inpatient admission.
The insurer is denied coverage for inpatient admission.
The denial is upheld.

This is a female patient is a female who presented to the Emergency Department (ED)  several days after a vaginal delivery with complaints of elevated blood pressure. Blood pressure on admission and during hospitalization was 155/89. She was admitted with a plan to obtain preeclampsia labs, administer Magnesium Sulfate, and control blood pressure. She was discharged in stable condition.

Delayed postpartum preeclampsia can be defined as signs and symptoms of the disease
leading to re-admission more than two days but less than six weeks after delivery.
The diagnosis of pre-eclampsia is based on the new onset of hypertension and either
proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman:

-Systolic blood pressure >=140 mmHg or diastolic blood pressure >=90 mmHg, and Proteinuria >=0.3 grams in a 24-hour urine specimen or protein: creatinine ratio >=0.3, or Signs of end-organ dysfunction (platelet count <100,000/microliter, serum creatinine >1/1 mg/dL or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration).

This patient had elevated blood pressure, no protein in the urine and no elevated LFTs and no end organ dysfunction. This patient did not have a diagnosis of preeclampsia. She had significant elevation in her blood pressure.

Ideally this patient would have been observed in the emergency department. Once her blood pressure was controlled, the patient could have been discharged home on home blood pressure monitoring and to return if any worsening of her blood pressure. Admission to the hospital was not medically necessary. The health plan acted reasonably with sound medical judgement in the best interest of the patient.

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

Diagnosis: Fractured tooth with decay
Treatment: Crown on tooth #5 

The Crown on tooth #5 was medically necessary.

Tooth #5 is clinically failing. The photos show many fracture lines and recurrent decay under and around the old amalgam restoration. Tooth #5 is an upper premolar, which is not a very large tooth. It is very evident from the photos that upon removal of all the old amalgam, decay and fractured areas of the tooth, there will be very little tooth left to hold a "filling." Therefore, as happens many time with premolars, this tooth will need a crown to prevent its total failure and probable splitting in half and extraction. The fractures described were not due to "attrition and abrasion," as stated in prior insurance reviews. The requested crown is medically necessary to help the patient retain this tooth for long-term use.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Edentulous in the Maxilla, Oligodontia in the Mandible 
 
Treatment:  D6010 surgical placement of implant body: endosteal implant; D6063 Abutment supported cast metal crown, tooth 18, tooth 19, tooth 25, tooth 30, tooth 31; and D6065 Implant supported porcelain/ceramic crown on teeth numbers 1,2,3,4,5,6,7,8,9,11,12,13,14,15,18,19,25,30,31. 

The insurer denied the D6010 surgical placement of implant body: endosteal implant; D6063 Abutment supported cast metal crown, tooth 18, tooth 19, tooth 25, tooth 30, tooth 31; and D6065 Implant supported porcelain/ceramic crown, tooth 1,2,3,4,5,6,7,8,9,11,12,13,14,15,18,19,25,30,31.  The denial was upheld.  This is a male patient who presented for a dental evaluation for prosthetic rehabilitation treatment for his maxilla and mandible.  It was recommended that he had endosteal implants. 

Upon review of the objective documentation which primarily consists of the panoramic radiograph the patient is edentulous in the maxilla and exhibits oligodontia in the mandible.  Regarding endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, as in this patient, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include conventional removable dentures.  Further the documentation provided is inadequate and does not support, justify, or substantiate the requested treatment, nor are there objective findings of a medical condition to support implant necessity. Therefore, as removable dentures remain a standard of care in general dental practice, the endosteal implants are considered elective and not medically necessary. 

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

Based on the above, the medical necessity for D6010 surgical placement of implant body: endosteal implant; D 6063 Abutment supported cast metal crown, tooth 18, tooth 19, tooth 25, tooth 30, tooth 31; and D6065 Implant supported porcelain/ceramic crown, teeth numbers 1,2,3,4,5,6,7,8,9,11,12,13,14,15,18,19,25,30,31 is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Plaque Psoriasis
Treatment:  Cosentyx Pen (two pens)
The treatment with Cosentyx is not medically necessary.

The patient is a male with severe psoriasis for whom Cosentyx is requested.  He cannot use methotrexate due to alcohol use, and he cannot use Humira due to kidney stones.  He has failed topical steroids in the past.

The health plan offers multiple alternatives to Cosentyx that are medically appropriate, such as Otezla, Stelara, Skyrizi, Tremfya. 

The patient is not a good candidate for conventional systemic medications, due to alcohol use (methotrexate), kidney stones and in view of the poor efficacy of acitretin and potential of serious side effects with long term use of cyclosporine.  Therefore, a biologic medication or small molecule, such as Otezla, is medically appropriate.  There is no medically justifiable reason to approve Cosentyx over the formulary alternatives.