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

Diagnosis: Skeletal Class I, maxillary and mandibular crowding, Class II canines, and deep impinging overbite

Treatment: D8080 braces

The insurer denied coverage for D8080 braces. The denial is upheld. 

This patient is a male child with no significant past medical history documented. Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, maxillary and mandibular crowding, Class II canines, 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. 

It is evident that the patient exhibited a significant malocclusion. However, to assess for severity of the malocclusion and therefore determine the 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 claimed an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. However, this condition does not meet the automatically qualifying condition criteria. There was no evidence of soft tissue damage, and did not provide support for comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify for orthodontic care. The patient's HLD index is calculated to a sum of 20 points (3 points for overjet, 5 points for overbite, I0 points for anterior crowding and 2 points for labiolingual spread). This HLD score of 16 does not meet the criteria for 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.

Thus, based on the review of the medical record provided and the literature, orthodontic care is not 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 braces is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain, nausea, vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission; the denial is overturned.

The Inpatient admission was medically necessary.

The patient is a male. He was admitted through the ER with abdominal pain.   He has a history of two partial nephrectomies for the treatment of renal cell carcinoma.  

The patient's vitals were 98.8-153/82-88-18. CT imaging demonstrated a left upper quadrant fluid collection, a left ureteral stent and moderate left hydronephrosis.  The WBC (white blood cell) count was 19,700.  The urinalysis had large leukocytes.  The admitting diagnosis was "acute abdominal pain, nausea, vomiting."  IVF (intravenous fluids) and IV antibiotics were started.  Surgery consultation noted that he had chronic abdominal pain and was stable.  He had a laparoscopic splenectomy four months prior.  He had not shown for his stent removal.
 
The patient's antibiotics were changed to Aztreonam by Infectious Disease (ID).  He had continued pain but was afebrile.

The next day, the belief was that the patient's hypoperfusion of the left upper pole of the kidney was chronic, rather than an acute infarct.   A UTI (urinary tract infection) was suspected as the etiology of his symptoms.  IV antibiotics were continued.  In the evening, he was seen for a new complaint of right testicular pain.  Epididymo-orchitis was diagnosed.  The WBC count was 17,200.

The following day, the patient was transferred to the Bellevue ER for testicular torsion evaluation.

The reasons for an acute inpatient admission were as follows:
- marked leukocytosis that did not improve
- abdominal pain of unknown origin not responsive to IV antibiotics
- need for ID, general surgery and urology (phone) consultations
- need for transfer to another facility for further evaluation.

The patient was potentially unstable medically, and he was unreliable for followup. Therefore, the Inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis
Treatment: L3020 - Custom shoe inserts
The insurer denied L3020 - Custom shoe inserts.
The denial is overturned.

The L3020 - Custom shoe inserts are medically necessary.

The patient is a female who was diagnosed with arthritis of the left foot first metatarsal phalangeal joint, as well as cavovarus deformity of the foot.  An MRI was ordered, as well as custom orthotics.  The MRI showed arthritis of the first metatarsal phalangeal joint.  Based on these findings, custom orthotics were ordered.  The patient had first tried over-the-counter orthotics without any relief of pain.  This was the result of a prior incompletely healed fracture.  This led to the persistent pain.

From the clinical records provided, the patient has posttraumatic arthritis.  She has a history of fracture that healed, based on the description in the clinical records provided.  Her ongoing pain and MRI confirming arthritis indicate that she most probably developed posttraumatic arthritis. Given her age, it is unlikely she has chronic systemic arthritic condition.  

In order to prevent further worsening of her arthritis and disability, an orthotic is typically utilized, first a non-custom orthotic, followed by a custom orthotic.  She has already tried a non-custom orthotic, according to the clinical notes.  Surgery at this point is not indicated, given her age.  A custom orthotic would be medically necessary to prevent worsening of her symptoms.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High Blood Pressure, Pain and Swelling of the Right Hand and Forearm
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a past medical history significant for gout, hypertension (HTN), depression and polysubstance abuse who presented to the Emergency Department for complaints of pain and swelling of the right hand and forearm. 

The patient was hemodynamically stable. Electrocardiogram (ECG) was unremarkable. The patient had no symptoms of chest pain. His troponin level was found to be 0.04. A repeat level was undetectable. He was admitted to rule out acute coronary syndrome (ACS). X-ray of the hand did not show any acute changes. No stress test or cardiac catheterization was planned. His outpatient oral medications for blood pressure (BP) control were continued.  The patient was discharged home with a plan for outpatient follow-up.

No, the proposed inpatient admission was not medically necessary.

This patient presented for evaluation of right hand swelling and pain and was diagnosed with acute arthritis. His initial troponin was minimally elevated, and the repeat testing was normal, consistent with a lab error.  There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. No ischemic work-up was planned. The clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: ARC1 syndrome. 
Treatment: Continued Rehabilitation Stay. 
The insurer denied the Continued Rehabilitation Stay. 
The denial is overturned. 

The patient is a male child with extremely complex medical history significant for the following: arthrogryposis secondary to ARC1 syndrome (arthrogryposis-renal dysfunction-cholestasis syndrome caused by VPS33B mutation) with proximal renal tubular dysfunction and cholestasis, variable electrolyte abnormalities (e.g., hypernatremia), severe failure to thrive with feeding intolerance requiring a combination of enteral nasogastric tube feedings and total parenteral nutrition via central line, severe pruritus secondary to bile acid salt dysfunction treated with multiple medications, macrocytic anemia due to B12 deficiency, and global developmental delay. He and his family emigrated for medical care. He has been hospitalized numerous times since arriving in the US, most recently admitted for skilled nursing care and rehabilitation. 

The patient continued to receive care while parents were undergoing appropriate training. He was discharged home with private duty nursing. 

Yes, the continued rehabilitation stay was medically necessary. 

Per Milliman Care Guidelines for Extended Stay, all of the following must exist: continued absence of acute hospital care needs, intense and complex care needs making inpatient care a more efficient option, and skilled services needed at least daily (for fall management, fever management, gastrointestinal complications management, infusion therapy, malnutrition/dehydration or electrolyte management, respiratory management, significant comorbid disease exacerbation with need for skilled clinical intervention and monitoring, tracheostomy evaluation and equipment management, urinary management, ventilator evaluation and equipment management, wound management, PT/OT/SLP (physical therapy/occupational therapy/speech language pathology) services). 

In the case of this young child with very complex autosomal recessive disorder involving multiple body systems, during the days in question he met all criteria with the following necessary skilled services: he had electrolyte abnormalities that needed to be addressed (hypokalemia), he was advancing on his enteral feedings with some vomiting noted and he remained on TPN, and his pruritus was not adequately controlled. Further, transition of care must be complete including caregiver education in order to provide safe discharge. In this case family teaching was ongoing through the last date in question. The mother was successfully learning all aspects of his care, including central line management, nasogastric tube management, enteral pump function, TPN administration, and enteral medication administration, but had not completed education prior to the last day in question. Based on the current standard of care and appropriate clinical guidelines, the hospital days in question were medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Dupixent 300mg/2mL 
The health plan denied Dupixent 300mg/2mL 
The determination is upheld.

The patient has poorly controlled asthma (persistent wheeze, airway obstruction requiring frequent prolonged courses of prednisone with incomplete response) despite being treated with montelukast, budesonide/formoterol and Spiriva with reportedly good adherence. He has a history of environmental and food allergies (laboratory-confirmed), high immunoglobulin (Ig) E, and high peripheral blood eosinophil counts.
Dupixent 300 milligrams (mg)/2 milliliters (ml) was requested for this patient. This request was previously denied citing failure to meet medical necessity criteria. Nucala and Fasenra have been suggested as alternatives to Dupixent for this patient. This decision is being appealed and the medical necessity of the Dupixent is the subject of this review.

There is no evidence to suggest that Dupixent is medically necessary for this patient in contrast to one of the suggested alternatives (Nucala and Fasenra). Dupixent (dupilumab) is a monoclonal antibody that blocks the interleukin (IL)-4 receptor signaling pathways and down-regulates the type-2 inflammatory processes. It may be indicated in cases of uncontrolled severe eosinophilic asthma in adults and adolescents older than 12 years.
Fasenra (benralizumab) and Nucala (mepolizumab) are similar biologics, also indicated in cases of uncontrolled severe eosinophilic asthma -- 
There are no head-to-head comparisons between these agents, and indirect comparisons fall short of providing robust clinical guidance. There is no published evidence to support the preference for Dupixent over the suggested alternatives (Nucala and Fasenra), and the submitted medical records do not explain the reason for this preference on clinical grounds.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

An adult patient with no significant past medical history presented to the Emergency Department (ED) with complaints of fevers, chills, and right lower leg erythema and swelling. The patient's vital signs on ED presentation included: Temperature max 103.1 F, Blood Pressure 158/89, Pulse 115, Respiratory Rate 18, Oxygen Saturation 97% on Room Air. The patient's laboratory results included the following: white blood cell (WBC) 11.5, hemoglobin 14.5, hematocrit 43.1, creatinine 0.7, and glucose 119. The patient was started empirically on intravenous (IV) fluids and IV antibiotics (i.e., vancomycin, ceftriaxone, Flagyl) for lower extremity infection. The patient's computed tomography (CT) scan of the lower extremity showed changes suggestive of cellulitis, but no evidence for osteomyelitis. All cultures remained negative. The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue outpatient management on oral antibiotics (i.e., doxycycline).

According to documentation, the patient presented with worsening right lower leg cellulitis. The patient had a fever of 103.1 F, tachycardia (heart rate of 115), hypertension (blood pressure of 158/89), and laboratory results showed leukocytosis (white blood cell count of 11.5) and elevated glucose. Based on these abnormal findings, inpatient admission was medically necessary for the administration of intravenous antibiotics and further monitoring.     

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 inpatient admission is substantiated. The insurer's denial should be overturned.
Appeal type: Formulary Exception
Decision: Upheld

Infectious Disease. 
Pharmacy/Prescription Drugs. 

Diagnosis: HIV. 
Treatment: Juluca. 
The insurer denied Juluca. The health plan's determination is upheld. 

The patient is a male with human immunodeficiency virus. Juluca 50-25mg was prescribed. The patient used Atripla and has been on Descovy, with a decline in renal function. The use of Juluca has been denied by the health plan. This decision is under review. 

A formulary exception is not indicated in this case. The patient has not failed or been intolerant to and has no contraindication to the individual ingredients in the combination medication taken separately, dolutegravir and rilpivirine. There are no published data demonstrating that these agents taken separately are less efficacious or less safe than the accommodation medication Juluca. In summary, the formulary drug has not been ineffective, has not had adverse effects, and would be as effective as the nonformulary drug.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: History of stage III pancreatic cancer,
congestive heart failure (CHF), osteoarthritis,
hypertension and depression
Treatment: Personal Care Services ten hours per day, seven days per week, for a total of 70 hours
The insurer denied the Personal Care Services ten hours per day, seven days per week, for a total of 70 hours
The denial is overturned. 

The patient is a female with a history of stage III pancreatic cancer, congestive heart failure (CHF), osteoarthritis, hypertension and depression. 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 ten hours per day, seven days per week, for a total of 70 hours per week Personal Assistance Services to offer increased ADL support.

Yes, the proposed treatment of 70 hours per week Personal Assistance Services is deemed medically necessary. 

This is a female with a history of stage III pancreatic cancer, CHF, osteoarthritis, hypertension and depression. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation was received from the patient's physician indicates that due to progressive functional decline including worsening weakness, fatigue, pain, decreased mobility, increased gait ataxia and more frequent falls, mostly due to side effects of aggressive chemotherapy schedule, the current approved plan of four hours per day, six days per week and ten hours per day, one day per week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 70 hours per week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Costochondritis, Chest Pain 
Treatment: Inpatient admission 
 
The insurer denied the inpatient admission. The denial was upheld. 

This is a male patient presented to the hospital by Emergency Medical Service after having an episode of chest pain with associated vomiting after running "very fast" at school. It was noted that the patient had recently been working out with weights. The patient was evaluated and received intravenous (IV) fluids, antiemetic, and pain medication. The patient's symptoms improved and he was discharged with outpatient follow-up instructions. 

Based on evaluation of the medical record, the admission to the hospital was not medically necessary. The following is the rationale for that decision. 

There is really no indication that the patient was significantly dehydrated to require admission. The ED documentation stated "hydration good" and the lab data showed blood urea nitrogen (BUN) of only 17 with a completely normal creatinine and normal electrolytes. 

In terms of the chest pain, the patient described an intensity in the ED and the pain was reproducible and described as "tenderness on pressing the mid sternal area of the chest." In addition, the ED physician stated that the patient was "feeling better after the Toradol." 

None of the MCG criteria presented in the appeal are met in this case. More specifically, the Vomiting Guidelines which include complete or partial gastrointestinal obstruction, metabolic derangement, hemodynamic instability, severe vomiting over a 24 hour period and persistent dehydration were not present in this case. In addition, the inpatient criteria for admission due to chest pain (MCG Chest Pain) which include hemodynamic instability, respiratory distress (none on ED exam), pulmonary edema and acute coronary syndrome were absent here. 

The diagnosis of costochondritis made in this patient does not require admission. 

Finally, the patient was admitted approximately an hour and 20 minutes after triage. Clearly, a further observation period could have been employed before the decision was made to admit this patient. 

Therefore, the insurer acted reasonably, with sound medical judgment, and in the patient's best interest. 

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

Diagnosis: Alzheimer's disease 
Treatment: Home Care/Personal care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 hour(s) per Day (Split Shift) 

The insurer is denied coverage for Home care/Personal care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 hour(s) per Day (Split Shift). The denial is overturned. 

This is a female who has Alzheimer's disease. She is married but has been living with her daughter, as her husband has health problems and he is unable to take care of her. The daughter is the patient's primary caregiver. The patient receives consumer directed personal assistance services (CDPAS) and daughter is the personal assistant. The patient had been approved for 68 hours per week personal care services and was attending day care 4 days per week. When the day care center closed due to COVID-19, personal care services were increased to 84 hours per week. The daughter reported patient's condition had declined in recent months and requested increase of services to 24 hours, split shift, which was denied by the insurer. The daughter requested an external appeal as designee for the patient. 

The patient has substantial functional impairment due to cognitive decline from dementia, and physical symptoms associated with arthritis and advanced lung cancer. The patient needs assistance with all daily activities and tasks. She needs a caregiver to provide assistance with ADLs throughout the day and night (i.e. toileting, walking). Due to the patient's sleep problems, her need to get up from bed is present throughout the night. It is not realistic or in the best interest of the patient or her daughter for the daughter to be providing care 24 hours per day. The patient needs a caregiver who is well rested and able to attend to the ADL needs of the patient at all times of the day and night. 

Therefore, it is medically necessary for the patient to have 24 hour personal care services, split shift. The insurer's denial letter did not specifically refer to CDPAS in the plan approval. The services approved were noted as "Home Care/Personal Care HHC-Level 2 Personal Care Services". The UAS and the Appeal Nurse Summary indicates the patient's services are provided as consumer directed personal assistance services (CDPAS). 

Home Care/Personal Care HHC - Level 2 Personal Care Services per 15 minutes 24 hours per day (split shift) are medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for Home care/Personal care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 hour(s) per Day (Split Shift) is substantiated. The insurer's denial is overturned.