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

Diagnosis: Gastrointestinal/Liver
Treatment: Prescription coverage
The insurer denied the prescription drug
The health plan determination is upheld in whole. The treatment of Epclusa is not medically necessary. 

According to peer-reviewed literature, for patients with genotype 3 infection and decompensated cirrhosis, sofosbuvir-velpatasvir plus ribavirin for 12 weeks [1] or daclatasvir plus sofosbuvir plus ribavirin for 12 to 24 weeks [2] are effective options. Neither sofosbuvir nor daclatasvir require dose reduction in the setting of moderate to severe hepatic impairment (Childs class B or C). In patients with decompensated cirrhosis, anemia is common, so it is recommend that ribavirin be initiated at a dose of 600 milligrams (mg) daily (to a maximum of 1000 mg for < 75 kg or 1200 mg for >=75 kg). Based on these studies it is anticipated that 15-20% of patients will not be able to tolerate ribavirin based on side effects, particularly worsening anemia.

The patient has no contraindication to the cited recommended option, ribavirin. Specifically, the patient does not have anemia, unstable cardiac disease or renal impairment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated liver enzymes
Treatment: Hereditary Hemochromatosis genetic testing 
The insurer denied the Hereditary Hemochromatosis genetic testing. 
The denial is upheld. 

No, the hereditary hemochromatosis genetic testing was not medically necessary.

The patient is a male who had been noted to have significantly elevated liver enzymes on evaluation.  An ultrasound was noted to be normal.  As part of the patient's evaluation, the provider ordered a hereditary hemochromatosis genetic panel. The Plan denied this testing as there was no pre-authorization. The plan's determination was then appealed. 

The aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were 157 and 230, respectively. The ferritin level was normal. A progress note reports that a prior evaluation with creatine phosphokinase (CPK) and aldolase showed that the liver function tests (LFTs) were elevated from a muscle origin and no further liver evaluation was undertaken.

The patient had a prior evaluation showing the elevated liver enzymes were not from a hepatic origin. The patient also had a normal iron and ferritin level. The patient did not have a transferrin reported, which has high specificity and sensitivity for hemochromatosis. Without these indications there is no support for a genetic hemochromatosis test. This approach is noted in Bacon and Britton as well as Brittenham, as cited below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Preterm uterine contractions, history of type 1 diabetes 
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female who presented to the hospital with preterm uterine contractions at 31 weeks.  Her history was remarkable for type I diabetes on a combination of oral medications and insulin.  A random blood sugar was 131 and her exam was otherwise unremarkable with cervix long and closed and contractions were irregular. It was documented on the admission note that her cervix had not changed for two hours. She was admitted for abdominal pain of unknown etiology.  The patient was given intravenous hydration and metformin and her insulin was continued. Betamethasone was given.  The contractions stopped and she was discharged on hospital day #1.  

No evidence was presented that the patient met criteria for diabetic ketoacidosis or diabetes out of control, peritonitis, or hyperemesis gravidarum.  There was no evidence of a life threatening condition or one that could not have been resolved at a lower level of care.  The workup and treatment could therefore have been given at a lower level of care and therefore the admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anginal pain 
Treatment: Inpatient hospital stay 
The insurer denied coverage for inpatient hospital stay. 
The denial is upheld. 

The patient was then a female with a history of uncontrolled diabetes mellitus, hypertension, hyperlipidemia, and coronary artery disease.   The patient presented to the Emergency Room (ER) with reports of chest pressure for then the past several weeks, gradually increasing shortness of breath, dyspnea on exertion, fatigue, and poorly controlled diabetes with increased thirst and urination. The patient's vital signs were stable. The patient's troponin T high sensitivity was less than 6, which was normal. The patient's chest x-ray showed clear lungs.  The patient's electrocardiogram (EKG) showed normal sinus rhythm with incomplete right bundle branch block and no diagnostic ischemic changes.  The patient was treated with aspirin and intravenous (IV) fluids.  The ER provider note stated that the patient's symptoms were consistent with angina. The patient was admitted to Telemetry with a diagnosis of anginal pain.  The patient was seen by Endocrinology and Cardiology.  The patient's condition was ruled out for myocardial infarction. The patient's echocardiogram was normal. No arrhythmias were detected on telemetry during this patient's inpatient stay. The patient was discharged.

Based on the review of the medical record, the patient presented with chest pain.  The patient's initial evaluation in the Emergency Room (ER) was unremarkable, including non-diagnostic electrocardiogram (EKG) and cardiac biomarkers. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted, however inpatient admission criteria was not met.  There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. Thus, inpatient admission was not medically necessary to treat this patient's medical condition.

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

Diagnosis: Multiple falls with confusion, UTI
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a female. The patient has a history of alcohol (ETOH) abuse, cirrhosis, hypertension (HTN), and diabetes mellitus (DM), who presented to the hospital after a fall and subsequent confusion. The patient had three falls within the few days (with rib and vertebral fracture) before coming to hospital. Urine analysis (UA) showed 686 WBC (high), three epithelial, two-plus nitrites, and positive for bacteria. The patient was evaluated in the by ER and trauma physicians for fall and possible trauma. She was not thought safe to discharge and was admitted with urosepsis and toxic metabolic encephalopathy. She was started on intravenous (IV) ceftriaxone, improved after a few days and was discharged on oral (PO) antibiotics.

Outpatient treatment for pyelonephritis in women is given for uncomplicated cases (1). In this patient, the pyelonephritis was complicated for the following reasons:
1) Multiple falls occurring in the week prior to admission leading to rib and vertebral fractures.
2) Confusion. The patient had toxic encephalopathy from a urinary tract infection (UTI).
Thus, this admission was warranted, supported by standard of care and the Infectious Diseases Society of America (IDSA) guidelines. Discharging a patient with confusion (or treating them as an outpatient), after having several falls that result in broken bones would go against the most basic standard of care. Setting this aside, new onset confusion in and of itself should lead to inpatient hospitalization. UTI with confusion in the elderly also signals bacteremia, yet another reason for close inpatient observation and treatment. Failure to admit such as a patient could have led to loss of function, permanent neurologic damage, septic shock, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Systemic lupus erythematous and fibromyalgia
Treatment: Acthar 80 Unit/ML Vial 
The insurer denied the Acthar 80 Unit/ML Vial.  The denial is upheld.

The proposed treatment with Acthar 80 Unit/ML Vial is not medically necessary.

The patient is a female with systemic lupus erythematous (SLE) and fibromyalgia.  She has failed treatment with prednisone (gastrointestinal [GI] upset) and methylprednisolone (lack of efficacy).  Her active symptoms include muscle pains, joint pains, rashes, itching and dryness.  She has also failed treatment with the muscle relaxant tizanidine and topical lidocaine.  Per attached documentation, the patient additionally takes Plaquenil 200 milligrams (mg) daily.  

Methotrexate was prescribed, but there is no documentation of methotrexate dosing or clinical response to methotrexate.  Per attached progress note, treatment with Benlysta was started, and an appeal request indicates that this patient failed treatment with Benlysta.  

Per documentation, this patient has been treated with Acthar 80 Unit/ML and her pain decreased from ten out of ten (10/10) to four to five out of ten (4-5/10) with improvement in energy.  Appeal is for Acthar 80 Unit/ML Vial for the treatment of SLE.

This patient with SLE has failed treatment with steroids and Plaquenil.  Methotrexate was prescribed, but there is no documentation of methotrexate dosing or clinical response to methotrexate.  Per attached progress note, treatment with Benlysta was started, and an appeal request indicates that this patient failed treatment with Benlysta.  It is indicated that this patient responded to Acthar.  

Although Acthar is FDA approved for the treatment of various rheumatologic conditions, it not considered standard of care in the rheumatology community for the treatment of SLE. Therefore, the proposed Acthar 80 Unit/ML Vial for the treatment of SLE is not medically necessary for this specific patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, upper respiratory infection
Issue under review: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male child with medical history significant for autism and high lead levels from pica (no treatment given) that presented to the ED with three-day history of cough, fever to 102.7, and runny nose, and same-day history of rapid breathing. Vital signs included heart rate 148, respiratory rate 24, temperature 39.3, and oxygen saturation 97% in room air. Physical examination revealed no distress, nasal discharge, moist mucous membranes, clear oropharynx, tachypnea, rhonchi left base, no retractions, and non-focal neurologic exam. Chest x-ray revealed mild infiltrate left lung base region medially. Laboratory studies were obtained revealing normal white blood cell (WBC) count 5.2K, positive influenza B, mildly elevated sodium 146, and elevated aspartate aminotransferase (AST) 80. The patient was treated with one DuoNeb, ibuprofen, and ceftriaxone, and admitted for ongoing management of influenza complicated by left lower lobe pneumonia. Admission orders included regular diet, continuation of ceftriaxone, albuterol every four hours, Tamiflu, and anti-pyretics. The following day the patient was eating and drinking adequately, with no respiratory distress and no oxygen requirement. He had low-grade fever to 100.4 but was otherwise afebrile. He was deemed stable for discharge to complete his course of Tamiflu and amoxicillin, to follow-up in two to three days.

No, the proposed inpatient admission was not medically necessary.

This young child presented with history of fever with upper respiratory infection (URI) symptoms and acute-onset respiratory distress. He was febrile and tachypneic in the ED, with left-sided crackles on exam, left lower lobe infiltrate on x-ray, and testing positive for influenza B. He was hospitalized for management of influenza complicated by pneumonia. While it was not unreasonable to monitor him in the hospital for a period of time for evidence of deterioration, he was overall hemodynamically stable, with no oxygen requirement no significant dehydration, and no evidence of impending respiratory failure or sepsis. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems.
Treatment: Crowns for Tooth Number(s): 3, 5 and 18. 

The insurer denied the Crowns for Tooth Number(s): 3, 5 and 18.  The health plan's determination is upheld. 

The patient is a female who presents for evaluation and treatment of teeth # (number) 3, 5, and 18 with porcelain fused to base metal crown.  Provided for review are previous letters of appeal and denial, full mouth radiographic images, one page of claim forms, health plan language, lab values from medical examinations, and clinical notes from visits to medical doctors.

The crowns for teeth #3, 5, 18 are not medically necessary for the patient.  There is no clinical documentation stating that there is any decay present in the mouth, nor any other clinical rationale offered regarding the teeth in question.  Radiographic images do not show the presence of decay nor any infection associated with the teeth.  There is not any further clinical findings nor diagnosis to support the need for the treatment in question; hence, the treatment is not supported by any of the documentation and is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, hyperlipidemia
Treatment: Personal Care Aide-Level 2
The insurer is denied coverage for Personal Care Aide-Level 2, 49 hours/week, 7 hours x 7 days. 
The denial is upheld. 

The patient is a female with diagnoses that included hypertension and hyperlipidemia. The insurer approved PCA-level 2, 35 hours per week (5 hours x 7 days). The patient requested increase of PCA services to 49 hours per week, which was denied. The final decision upheld the denial for increase of PCA - level 2, 49 hours per week because it is not medically necessary. Approval stays at PCA - level 2, 35 hours per week. The reason was noted as follows: The patient said she needed additional hours for ADLs due to chronic illnesses. She stated she is disabled and the aide lessens her depression. She stated she needs more help because of concerns about COVID-19 virus. There were no updated medical records showing the need for additional care. Personal care needs does not cover adult supervision. Increase in aide hours does not replace medical treatment for depression. Medical necessity for increased personal care hours has not been established. The patient requested an external appeal.

She lives alone and receives assistance with ADLs and IADLs from personal care aide (PCA) 35 hours per week, and daily calls/visits from daughter who helps with IADLs. The patient requested increase of PCA services to 49 hours per week. The patient's PCA services were 21 hours per week at the time of the UAS. The insurer's final denial letter indicates that the plan approved PCA 35 hours per week. Following denial of appeal for 49 hours per week, plan approval stayed at 35 hours per week, extending approval. The patient requested an external appeal for PCA services 49 hours per week.

The patient has the benefit of the aide's assistance and encouragement with daily activities 5 hours per day. The patient's daughter calls and/or visits the patient daily as another source of support. However, there does not appear to be a need for additional assistance with ADLs or IADLs; and therefore, there is no indication to provide the patient with additional PCA hours. Medical follow-up is needed to address the patient's symptoms of depression and anxiety, and address the issue of medication compliance.

Personal Care Aide - level 2, 49 hours per week, 7 hours x 7 days is not medically necessary; the patient's needs can be met with Personal Care Aide - level 2 services at 35 hours per week, 5 hours x 7 days as approved by the insurer. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Personal Care Aide-Level 2, 49 hours/week, 7 hours x 7 days is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crossbite

Treatment: D8080 braces

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

The patient was a male child. 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 Class II canines, maxillary and mandibular crowding, and excessive overjet, retained primary canine and anterior crossbite. The orthodontist completed the HLD index as required and had chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin were present to support orthodontic necessity.
Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibited a significant 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. 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.

In this case, the treating orthodontist claimed an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin were present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. 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 21 points (3 points overjet, 7 point overbite, 3 points ectopic eruption, 5 anterior crowding and 3 points labiolingual spread).

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

D8080 (braces) and periodic treatment visits are not considered medically necessary for this patient.

The carrier's denial of coverage for D8080 braces should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), prior transient ischemic attack (TIA), hypertension, osteoarthritis, dizziness and gait ataxia

Issue under review: Increase Consumer Directed Personal Assistance Program (CDPAP) -12 Hours Per Day, 7 Days Per Week - A Total Of 84 Hours Per Week

Insurer denied the Increase Consumer Directed Personal Assistance Program (CDPAP) -12 Hours Per Day, 7 Days Per Week - A Total Of 84 Hours Per Week

The denial is upheld. 

The patient is a male with a history of chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), prior transient ischemic attack (TIA), hypertension, osteoarthritis, dizziness and gait ataxia. Due to impairments related to these conditions, he requires assistance for completion of many of his activities of daily living (ADLs). 

However, an in home assessment of the patient's overall functionality was completed and revealed that the currently approved plan of 35 hours/week personal assistance services is sufficient to meet the patient's current needs. There is no additional documentation which indicates that the patient has sustained additional functional decline since the date of this last assessment. For these reasons,  the proposed treatment of an increase in Consumer Directed Personal Assistance Program (CDPAP) to 12 hours/day - seven days per week - total of 84 hours per week is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Systemic autoimmune inflammation disorder
Issue under review: Panzyga (IVIG - intravenous immunoglobulin)
The insurer denied the Panzyga (IVIG - intravenous immunoglobulin).
The denial is upheld. 

No, the requested Panzyga IVIG is not medically necessary.

The patient is a female with neuropathic pain and muscle fatigue and a diagnosis of systemic autoimmune inflammation disorder. 

The patient does not have a condition that is amenable to treatment with IVIG. There are no high-quality clinical trials or standard of care guidelines to support the safety or efficacy of IVIG for this patient's condition. Therefore, medical necessity for Panzyga cannot be established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental.
Treatment: orthodontic procedure.
The insurer denied removal of braces. 
The denial is overturned.

Dental records were not included in this review. The issue in question is the medical necessity for removal of braces/make retainers (D8680). The patient has been approved for monthly braces adjustments (D8670).

The health plan's denial of medical necessity is overturned in whole.

By approving monthly visits but not the eventual removal of braces the health plan has not acted reasonably, with sound medical judgment or in the best interest of the patient.
This is a very unusual situation. I cannot comment as to the disposition of the patient's mouth since there are no dental records included for review, but there is a clear approval of the monthly braces' visits provided in the documentation submitted for review. Since monthly visits were approved, it would lead to the assumption that orthodontic braces would need to be both placed and eventually removed. It is not clear why monthly visits would be approved but not removal of the braces. Braces are not designed to be permanent; their eventual removal is implied. The patient has documentation that the monthly braces adjustments are approved. Since braces are supposed to be removed, braces removal and a plan for retention is implied by the approval of monthly adjustments. Braces can increase periodontal inflammation ,[1] which is one reason for their eventual removal, and retainers are a necessary conclusion of orthodontic treatment.[2]