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

Diagnosis: Hyperemesis gravidarum.
Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.  The denial is upheld. 

This female patient was pregnant at 11 weeks gestation and referred to the hospital by her obstetrician because of continuous vomiting and epigastric pain. She was doing well on antiemetic medications but had to stop Zofran because her insurance did not cover it. Note that the patient was evaluated twice previously with the same complaints. She presented to the emergency department  and her vital signs were stable. The examination was unremarkable except for some epigastric tenderness. The patient was not in distress. There were no electrolyte anomalies. The provider decided to admit the patient with the diagnosis of hyperemesis gravidarum. Progress notes stated the patient was feeling fine, hungry, and tolerating fluid. The patient was tolerating regular food. She was discharged later that day.

As per American College of Obstetricians and Gynecologists (ACOG), there are no controlled trials comparing hospitalization with outpatient management of hyperemesis gravidarum. When a woman cannot tolerate liquids without vomiting and has not responded to outpatient management, hospitalization for evaluation and treatment is recommended. After the patient has been hospitalized on one occasion and a workup for other causes of severe vomiting has been undertaken, intravenous hydration, nutritional support, and modification of antiemetic therapy often can be accomplished at home. Nevertheless, the option of hospitalization for observation and further assessment should be preserved for patients who experience a change in vital signs or a change in affect or who continue to lose weight.

According to UpToDate: Women who are unable to maintain adequate hydration, normal electrolyte levels, and acid-base balance with the initial interventions described above should be admitted to the hospital for intravenous fluids and medications. Women who have severe vomiting, weight loss, ketonuria, dry mucous membranes, poor skin turgor, dehydration, hypotension, alkalosis from hydrochloric acid loss, hypokalemia, or nutritional deficiencies are admitted to the hospital. The decision to admit versus discharge to home needs to be individualized based on the patient's severity of disease, resources, ability to comply with the management plan, and ability to obtain and have access to outpatient resources.

This patient presented with nausea and vomiting. She was stable. There was no evidence of ketonuria, hypokalemia, or nutritional deficiencies. She could have been hydrated in the emergency department (ED), restarted on Zofran and sent home.
The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lumbar disc herniation with radiculopathy.
Treatment: Inpatient hospital admission.

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

This female patient with a medical history of low back pain radiating down to her right lower extremity. She was admitted to the orthopedic service at the hospital with a diagnosis of lumbar disc herniation with radiculopathy. It was noted the patient attempted and failed at conservative treatment for her lumbar spine pain. On this same date, the patient had an elective laminectomy/discectomy lumbar 5 (L5) and sacral 1 (S1). The patient tolerated the procedure but had some mild back pain that was well controlled. The treatment plan included intravenous (IV) antibiotics, analgesic pain control, prophylactic treatment for deep vein thrombosis, physical therapy, and to tolerate weight bearing activity. The patient was cleared for discharge with outpatient instructions and medication for pain management. 

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The medical record states that the patient underwent an uncomplicated, minimally invasive surgery (MIS) tubular discectomy. It was single level with no additional procedures required. There was minimal blood loss and no postoperative problems. The patient was able to tolerate oral pain medications. The patient did not require treatment for an underlying medical condition. There was no evidence of fever, bleeding, infection or excessive pain that warranted inpatient level of care and admission. There was no change in this patient's neuromuscular status. There was no positive test or other clinical finding that would require acute level of care. The patient could have been kept in observation type status.

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

Diagnosis: Tooth crowding; Impacted canines.

Treatment: Dental braces.

The insurer denied coverage for dental braces.

The denial is overturned.

This patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to severe crowding and impacted canines. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated. 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 on the HLD index attaining only 12 points on 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 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 claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated. 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.

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 dental braces (code D8080) and monthly visits X 8 (code D8670) is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right lower extremity cellulitis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned. 

This is a male patient with a benign past medical history who presented to the Emergency Department with complaints of right leg erythema and pain.  The patient had been prescribed doxycycline by urgent care.

Vitals on presentation included: temperature 101.0, blood pressure 114/74, pulse 124, respiratory rate 20, and oxygen (O2) saturation 97% on room air.  Laboratory results included the following: White blood cell (WBC) count-9.9, hemoglobin (HGB)-12.2, hematocrit (Hct)-39.5, creatinine-0.6, glucose-95, CRP-31.9, and ESR-62.

The patient was started empirically on intravenous antibiotics (vancomycin and ceftriaxone) for right lower extremity cellulitis.  Cultures remained negative.  Duplex ultrasound was negative for deep vein thrombosis (DVT).  The patient remained afebrile, clinically, and hemodynamically stable.  He was discharged to continue oral antibiotics (Zyvox and Augmentin) as an outpatient. 
   
According to documentation, this patient presented to the Emergency Department with a worsening right lower extremity pain despite treatment with doxycycline as an outpatient.  The patient had fever to 101.0 and tachycardia; laboratory results showed elevated inflammatory markers.  Based on above findings, in this patient with documented failure of outpatient management, hospital admission was medically warranted for administration of intravenous antibiotics and additional diagnostic evaluation.  

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

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

Diagnosis: Transitory lightheadedness.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a male patient who presented to the Emergency Department (ED) complaining of being lightheaded.  The submitted documentation indicated that the patient has a past medical history that includes diabetes as well as seizures and schizophrenia.  The patient on physical examination had a blood pressure of 128/60 with pulse of 79.  The patient's oxygen saturation was 98%.  The patient was not in any acute distress.  The remainder of the physical examination was normal.  The physician recommended that the patient undergo multiple diagnostic and laboratory studies.  The patient's computed tomography (CT) scan revealed mild cerebral atrophy and mild periventricular white matter disease.  There was no intracranial bleed identified.  There were no significant changes when compared to the prior examination.  The patient's angiogram also revealed no acute findings in the arteries of the head and neck.  The patient's laboratory studies revealed white blood cell (WBC) count of 13.7.  The patient was noted to have a partial thromboplastin time (PTT) of 40.2 with a troponin at 0.012.  The patient was given multiple medications and intravenous (IV) fluids.  The patient's blood gases revealed a venous potential of hydrogen (pH) of 7.36 with partial pressure of carbon dioxide (PCO2) of 56.3.  The recommendation was made to admit the patient for further evaluation.  The documentation indicated that the patient was admitted and continued to receive treatment which included medications.  The patient continued with the evaluation and no further significant abnormalities were noted.  The documentation indicated that the patient maintained a period of clinical stability after admission, and was then discharged the following day with instruction to follow-up in the outpatient setting.

Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient. In this case, the patient developed transitory lightheadedness with normal neurological examination and negative CT scan of the head.  According to the patient's records, there is no clear evidence of instability, hemodynamic compromise or metabolic changes or acute prolonged metabolic decompensation or cardiopulmonary instability to justify acute inpatient care.  There was no clinical evidence of acute stroke or seizure that warranted inpatient level of care.  The patient's care could have been safely provided at a lower level of care, such as observation status and outpatient setting.

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

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

Diagnosis: Chronic Rhinosinusitis with Nasal Polyps
Treatment: Dupixent 300mg/2ml Syringe
The insurer denied the Dupixent 300mg/2ml Syringe.
The denial is overturned. 

The patient is a male. The patient has a history of chronic sinusitis and nasal polyposis. He has had surgical resection and nasal steroid spray.  He has been on dupilumab.  His visit demonstrated small polyps on dupilumab.  The patient was also started on budesonide rinses at that time.

He had follow-up at which time he was noted to have an increase in symptoms with congestion and drainage after a four-day steroid taper.  He is on topical intranasal steroid in an ongoing fashion.  Nasal endoscopy showed polypoid edema and frank polyps.  He is noted to be worse since dupilumab was not renewed.

Yes, the treatment with Dupixent is medically necessary.

Medical necessity for treatment with Dupixent has been established in this case. 

There is documentation of inadequate response to nasal steroid spray.   He has also failed systemic steroid.

The patient meets the standard of care for medical necessity of Dupixent by way of documented prior nasal surgery and systemic steroid therapy.   As per Food and Drug Administration (FDA) recommendation, Dupixent requires con-commitment use of nasal steroid spray.  The patient's provider documents ongoing use of nasal steroid and that the patient will use the nasal steroid spray in conjunction with the Dupixent when renewed.

Given the additional information of systemic, topical steroid use,  and documented progression of disease, the Dupixent should be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Family history of cancer.
Breast MRI Study (CPT 77049).
The insurer denied the Breast MRI Study (CPT 77049).
The denial is overturned. 

The patient is a female with a lifetime risk of breast cancer of 19.9%.  She has a family history of breast cancer. Breast MRI (magnetic resonance image) was performed for screening purposes.

Yes, the health plan should cover the Breast MRI Study (CPT 77049).

Yes, the breast MRI is likely to be beneficial.

With a lifetime risk of breast cancer of 20% based on family history, this individual would meet accepted criteria for screening breast MRI (magnetic resonance image).  The NCCN (National Comprehensive Cancer Network) and the medical literature support screening breast MRI (magnetic resonance image) at a lifetime risk of 20% or more.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Family history of cancer.
Breast MRI Study (CPT 77049).
The insurer denied the Breast MRI Study (CPT 77049).
The denial is upheld. 

The patient in this case is a woman who has no personal history of breast cancer. Her family history is notable for father diagnosed with multiple cancers (bladder cancer, gastric cancer, esophageal cancer). Her mother had no history of cancer. Her maternal grandmother was diagnosed with ovarian cancer. Her paternal grandmother was diagnosed with gastric cancer and passed away. Her maternal aunt had three daughters. One was diagnosed with breast cancer, and that individual was found to have a CHEK2 (checkpoint kinase 2) mutation. Another was also diagnosed with breast cancer and did not have a CHEK2 (checkpoint kinase 2) mutation. Her maternal uncle has one daughter who was diagnosed with breast cancer twice. One aunt (records do not specify side of the family) was diagnosed with breast cancer and had an abnormality in ATM (Ataxia-Telangiectasia mutation), though records do not specify if this was a variant of undetermined significance (VUS) or a pathogenic mutation.

Of note, this patient underwent genetic testing and no pathogenic mutations were identified. The known family mutation in CHEK2 (checkpoint kinase 2) was not identified. She did have a VUS (variant of undetermined significance) in ATM (Ataxia-Telangiectasia mutation).

Tyrer-Cuzick risk assessment found that the patient had a 19.8% lifetime risk of breast cancer.

The patient underwent MRI (magnetic resonance image) of both breasts for high risk screening.

No, the health plan should not cover the Breast MRI (magnetic resonance image) Study.

No, Breast MRI Study is not likely to be more beneficial.

This patient is noted to have a 19.8% lifetime risk of breast cancer.  Breast MRI (magnetic resonance image) screening is considered standard for patients with a 20% or greater lifetime risk of breast cancer.  Records document that this patient's lifetime risk is less than 20%.  Therefore, she does not meet standard criteria for breast MRI (magnetic resonance image) screening, and this test is not medically appropriate.  There is no evidence that breast MRI (magnetic resonance image) screening can improve health outcomes in patients with less than a 20% lifetime risk of developing breast cancer.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental Health-High risk Suicide.
Treatment: Mental health inpatient.
The health plan denied the acute inpatient psychiatric stay as not medically necessary. 
The reviewer has upheld in whole the health plan determination. 

The case involves a patient admitted to acute inpatient psychiatric services for treatment of a psychiatric disorder associated with acute suicidal behavior that included suicidal ideation and threats to commit suicide. The patient was evaluated at the time of her presentation and was subsequently involuntary admitted under the State of Florida statute (Baker Act). According to submitted documentation, the patient was treated with inpatient mental health/psychiatric services with referral for rehabilitation services.

The requested health service/treatment of Inpatient Mental Health Admission is not medically necessary for this patient.
Based upon the submitted information including the clinical features in this case, there is no evidence that the patient could not have been safely and effectively managed with lower level care in a less restrictive treatment setting. Thus, medical necessity for the admission to inpatient level of care is not met with regard to prevailing standards of medical practice. This answer is consistent with the guidelines and scientific literature, referenced below.
The cited literature requires that a thorough evaluation be provided in the emergency department setting with an appropriate determination of the safety risk or suicidal risk and medical screening. The standard of care would require the evaluation and observation of the patient for an appropriate length of time before determining the clinically appropriate disposition and referral for further treatment. The submitted information failed to provide documents that would support the requested benefit of inpatient psychiatric level care in this case scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class II with retruded mandible, maxillary spacing, mandibular crowding, and excessive overjet and deep impinging overbite). 

Treatment: D8080 Braces and D8670 Monthly Visits.

The insurer denied coverage for D8080 Braces and D8670 Monthly Visits.

The denial is upheld. 

This patient is a female child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class II with retruded mandible, maxillary spacing, mandibular crowding, and excessive overjet and deep impinging overbite. The Orthodontist has completed the Handicapping Labio-lingual (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 11 points on review by their internal reviewers. 

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 the 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 insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 11 points (4 points overjet, 5 points overbite, and 2 points labiolingual spread).
 
Regarding the validity of the HLD 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.

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

Based on the above, the medical necessity for D8080 Braces and D8670 Monthly Visits is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Exposure keratopathy.
Treatment:  Contact lenses.

The insurer denied coverage for the contact lenses.  The denial is overturned. 

This is a female patient with a diagnosis of exposure keratopathy in the right eye (OD). At an office visit, the patient's visual acuities were 20/50 OD and 20/20 in the left eye (OS).  Exam showed coalesced superficial punctate keratitis OD.  Lubrication and scleral contact lens fitting was recommended. At a more recent visit, her visual acuities were 20/100 OD and 20/20 OS.  Exam showed lagophthalmos, punctual plug, and central and inferior punctate epithelial erosions OD.  There are mucus and ointment clumps OD.  Diagnosis of exposure keratoconjunctivitis secondary to right facial nerve palsy was noted.  A good fit with scleral contact lens was noted. At the most recent visit, her visual acuities were 20/80 (pinhole to 20/40) OD and 20/20 OS.  Exam showed lagophthalmos, diminished blink, punctal plug and mucus and ointment clumps on scleral surface OD.  

The patient's Optometrist noted that scleral contact lenses were medically necessary because the patient suffers from dry eye disease due to permanent paralysis of the facial nerve, and that the scleral contact lens is medically necessary to protect her cornea.

The patient suffers from exposure keratopathy due to cranial nerve 7 (facial nerve) paralysis.  As a result, she cannot close her right eye and this causes dryness on the surface.  Extreme dryness and an unprotected corneal surface can lead to visual threatening complications, such as corneal ulcers, infections and perforation.  Thus, the scleral contact lens is medically necessary to protect the patient's corneal surface to prevent any vision threatening complications.

The request for the scleral contact lens is medically necessary of this patient.  The scleral lens helps protect the cornea and prevent vision loss.  The health care plan did not act reasonably, with sound medical judgement or in the best interest of the patient.  

Based on the above, the medical necessity for contact lenses is substantiated.  The insurer's denial is overturned.