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

Diagnosis: Congenital hypotonia, muscle weakness
Treatment: Physical Therapy
The insurer denied the Physical Therapy.
The determination is upheld.

The patient has a diagnosis of congenital hypotonia, muscle weakness (generalized), congenital deformity of sternocleidomastoid muscle.
Available records include an appeal request which documents that the patient has been receiving therapy, an office note documents the patient's musculoskeletal exam as normal and gait as normal. Physical therapy progress reports state "patient has made good progress" but does not document progress made in any of the therapy goals. There are no standardized instruments utilized in any of the documentation from Power of Movement physical therapy. At issue is the medical necessity of physical therapy.

The patient has already received appropriate medical treatment for his congenital hypotonia, muscle weakness, congenital deformity of sternocleidomastoid muscle. His return to age-appropriate activities including soccer and the ability to perform within the normal for physical activities indicates that appropriate gains have been met and he does not have current physical or functional deficits that warrant the treatment of physical therapy services.
The requested physical therapy health service are not medically necessary for this patient. The patient's therapy progress notes documentation do not support medical necessity for standards of practice for physical therapy. There are no standardized instruments utilized in any of the documentation from Power of Movement physical therapy. No specific progress towards the goals is documented in the records provided. The patient's physician documents the patient's musculoskeletal and gait as both "normal."
The decision is consistent with accepted standards for physical therapy medical necessity. Physical therapy is medically necessary when there is documentation that it is improving a patient's current condition, or preventing or slowing further deterioration of the patient's condition, or to help a person keep, learn or improve skills and functioning for daily living to maintain the patients current condition and all of the following elements of the plan are documented in the health care record: the services are considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition the level of complexity or sophistication or the condition of the patient is such that the services required can be safely and effectively performed only by a qualified health care provider; and the services including amount, frequency and duration are reasonable under accepted standards of practice.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral sensorineural hearing loss
Treatment: Durable Medical Equipment (bilateral hearing aids {both ears}), Pre-service
The insurer denied the Durable Medical Equipment (bilateral hearing aids {both ears}), Pre-service
The denial is overturned

The patient is a female with a history of bilateral sensorineural hearing loss (SNHL).  There is a history of a left facial nerve neuroma excised.  The provider is requesting coverage of bilateral hearing aids.  The request was previously denied as not medically necessary and the patient is appealing the denial.

Yes, the proposed bilateral hearing aids are medically necessary.
All records were reviewed.  The request was denied as not medically necessary.  

The patient has bilateral significant hearing loss.  The patient's ear canals were clear without obstruction.  The audiograms confirm the extent of the hearing loss. The standard of care treatment for the patient's condition would be bilateral hearing aids, consistent with scientific literature.  Therefore, based on the information provided, the medical necessity of the hearing aids requested is confirmed.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD (chronic obstructive pulmonary disease), Asthma exacerbation.
Treatment: Full hospital admission.

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

The patient is a female with a history of chronic obstructive pulmonary disease (COPD)/ asthma, hypertension (HTN), and polysubstance abuse who presented to the emergency department (ED) with complaint of wheezing, shortness of breath (SOB)/ chest tightness. She reported having these symptoms for over a month. The patient had been seen for upper respiratory infection (URI) symptoms and was prescribed azithromycin. She was given duo nebulizers and dexamethasone on route to the hospital. At presentation to the ED, her temperature was 36.9 Celsius, heart rate (HR) 80, respiratory rate (RR) 20, blood pressure (BP) 190/110, and oxygen (O2) saturations 96% (percent). The patient was noted to have bilateral wheeze and peak expiratory flow (PEF) was 150-160. Baseline not known. The patient was alert and oriented. Labs revealed white blood cell count (WBC) 4.6, hemoglobin (Hgb) 14.2, electrolytes within normal limits and venous blood gas (VBG) 7.38/46/56/27.

The patient was treated with duo nebulizers, magnesium, racemic epinephrine, azithromycin, and bilevel positive airway pressure (BiPAP) as needed. She was also given clonidine for hypertension at presentation. She was restarted on maintenance blood pressure medications. Chest x-ray revealed no acute infiltrates. Testing for Influenza and Covid was negative. The patient was admitted for COPD/Asthma exacerbation. She was continued on duo nebulizers, solumedrol 40 mg (milligrams) every 8 hours, and azithromycin. She improved with treatment and was discharged home on tapering steroid bronchodilators.

Later, she was afebrile with BP 168/82, RR18, HR 70, O2 saturations 98%, and PEF 170. The patient was able to tolerate medications by mouth. She was speaking in short sentences. WBC was 7, Hgb 14.2, and electrolytes were within normal limits. 

This patient could have been switched to oral steroids. She was stable to be discharged home on oral steroids, and bronchodilators and or antibiotics if needed. This patient was afebrile and hemodynamically stable. Lungs with no wheeze and labs were stable. The patient was not hypoxic, was speaking short sentences and tolerating by mouth.

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

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Growth Hormone Deficiency (GHD)

Treatment proposed medication (J2941 - injection, somatropin, 1 mg [milligrams]), Norditropin FlexPro 15 mg /1.5 ml (milliliter) subcutaneous injection 7 days a week

The insurer denied coverage for proposed medication (J2941 - injection, somatropin, 1 mg), Norditropin FlexPro 15 mg (milligram)/1.5 ml (milliliter) subcutaneous injection 7 days a week

The denial is overturned

This is a male diagnosed with growth hormone deficiency (GHD). This request is for Norditropin 1.1 mg 7 days a week. As reported; he started on growth hormone (GH) therapy; his current does is 1.1 mg 7 days a weekly; manufactures samples and since starting his height jumped from the 1st percentile to the 2nd percentile in less than 3 months. His GH stimulation test with arginine and clonidine peaked at 9.9. His pretreatment insulin-like growth factor 1 (IGF1) was 81; Z-score was -2.1 standard deviations (SD). 

Classic GH deficiency

Classic GH (Growth Hormone) deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society [1], the Lawson Wilkins Pediatric Endocrinology Society [2, [3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists [4]. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 SD (standard deviation) below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 year more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 year in children over 2 year of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 year or more than 1.5 SD sustained over 2 yr. The biochemical criteria include low IGF1 or IGFBP3 (insulin-like growth factor binding protein) or GH stimulation testing with a peak GH less than 10ng/ml (nanogram per milliliter).
		
This patient met biochemical criteria. GH stimulation testing peaked at less than 10ng/ml and IGF1 was low. The patient met height criterion 2 as his height is more than 1.5 SD below target height SD. The patient met both height and height velocity and biochemical criteria for the diagnosis of GH deficiency. GH in the treatment of GH deficiency is medically necessary. 

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

The insurer's denial of coverage for proposed medication (J2941 - injection, somatropin, 1 mg), Norditropin FlexPro 15 mg (milligram)/1.5 ml (milliliter) subcutaneous injection 7 days a week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Inpatient admission. 

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

This patient is a previously healthy woman. She presented to the ED (emergency department) with the complaint of abdominal pain. 

The patient's examination revealed a right lower abdominal tenderness. Vital signs were normal at the time of presentation. The WBC (white blood cell) count was normal at 7.9 K (thousand). Surgical consultation was obtained. CT (computed tomography) scan was completed showing findings of appendicoliths. The initial treatment plan was for non-operative monitoring. 

The patient had persistent lower abdominal pain. The patient underwent laparoscopy with appendectomy for the condition of appendicitis. Following surgery, the patient was treated with IV (intravenous) fluid and analgesia. Vital signs were consistently normal in the perioperative period. She was transitioned to oral medications and diet. She was discharged from the hospital following a period of recovery. 

The health plan rationale for denial is that the patient underwent uncomplicated appendectomy. The denial letter states that there was no documentation of need for an inpatient level of care. This letter references MCG (Milliman Care Guidelines)-Surgery. 

No, the Inpatient admission was not medically necessary for this patient. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

Acute inpatient hospitalization was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely monitored with a lower level of care. 

This patient presented to the ED (emergency department) with abdominal pain of several days duration. Her evaluation with examination, lab data, and CT (computed tomography) scan was completed. She was monitored overnight. She underwent uncomplicated appendectomy. She was monitored in the early post-surgical period and was discharged from the hospital. 

There is no clinical documentation to support need for inpatient admission on these dates. The patient remained hemodynamically stable throughout the perioperative period, there was no fever, or documented complication of surgery. This patient's clinical needs could have been satisfied at a lower level of care. This level of care would have provided for pre-surgical assessment, clinical follow up, surgical treatment and post-surgical recovery including overnight observation. The records support that the care provided was clinically appropriate. It is the level of care that is at issue in this case. 

A lower level of care would have provided for pre-surgical assessment, surgical follow up, surgical treatment and post-surgical recovery including overnight observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nephrotic Syndrome

Treatment inpatient stay

The insurer denied coverage for inpatient stay

The denial is upheld

The patient was admitted for elevated blood pressure and volume overload. Nephrology consult was requested for nephrotic syndrome work up and underwent kidney biopsy which was done without complications. He did not require renal replacement therapy during this admission, had stable creatinine and his condition responded to diuresis and anti-hypertensive within 48 hours.

Based on the patient's presenting signs/symptoms and the predictability of something adverse that will occur to the patient based on these presenting signs/symptoms, his level of acuity did not meet any guideline requirement for inpatient hospitalization.  When taking into account the patient's exam, imaging, and lab findings as well as his lack of need for diagnostic testing beyond what was done in the emergency room (ER) and the availability of any additional diagnostic testing as an outpatient, there were no clinical criteria for inpatient level of care.  Overall, the patient's condition could have been managed safely on an observation basis. Nothing was done for the patient during his inpatient level of care that could not have been or had not already been managed on an observation level of care. Based on all these reasons, he had no requirements for inpatient level of care.

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

The inpatient stay is not considered medically necessary for this patient.

The insurer's denial of coverage for an inpatient stay is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins
Treatment: Endovenous ablation therapy
The insurer denied Endovenous ablation therapy.
The determination is overturned.


The patient has symptomatic lower extremity varicose veins. She has a history of venous ablation procedures in the past and presented with a recurrence of varicose veins. She complained of severe pain and swelling of the right leg. She has used compression stockings and has failed conservative management.

A venous duplex exam of the bilateral lower extremities demonstrated reflux of the bilateral great saphenous veins, reflux of the left anterior accessory saphenous vein, and reflux of the bilateral small saphenous veins.

The patient was diagnosed with symptomatic varicose veins and venous insufficiency and was offered right leg great saphenous vein closure with VNUS radioablation and foam sclerotherapy. The patient underwent the treatment. She was seen in follow up, where she complained of severe left leg pain and swelling.

The patient was offered venous closure with radiofrequency ablation (RFA) procedure of the left greater saphenous vein (GSV) and anterior accessory saphenous vein (AASV) with sclerotherapy.

Endovenous ablation therapy was denied by the health plan an is under review.

The requested procedure is medically necessary.

The patient has symptomatic left lower extremity varicose veins and venous insufficiency. She has used compression stockings and has failed conservative management. A venous duplex exam of the bilateral lower extremities demonstrated reflux of the bilateral great saphenous veins, reflux of the left anterior accessory saphenous vein, and reflux of the bilateral small saphenous veins. Radiofrequency ablation is medically necessary and is the standard of care for the treatment of symptomatic varicose veins and venous insufficiency. The patient will benefit from the treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma/injuries/rib fracture. 
Treatment: Inpatient Stay. 

The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a male who was admitted to the hospital for broken ribs. He has a past history of atrial fibrillation and obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP). On presentation, it was noted that he fell down 8 steps the evening prior. His oxygen saturation was normal as well as other vital signs. He had rib tenderness on exam. His labs were grossly unremarkable. An X-ray noted rib fractures over ribs 7-12 on the left, and the transverse processes of L (lumbar)1 and L2. He was given Toradol and Dilaudid for pain. He was admitted for continued pain control. He was encouraged to do incentive spirometry. 

The requested inpatient stay is medically necessary for this patient. 

The patient had a fall down the stairs and sustained multiple rib fractures as well as a fracture of the transverse processes of L1 and L2. According to Sirmali et al, Liman et al, and Ullman et al, the patient was at high risk of complication as he had more than three consecutive rib fractures as well as a fracture to the spine. This required intensive pain control with multiple medications where the patient was at high risk of developing pneumonia or other severe complications. A lower level of care would not have been appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Durable Medical Equipment (DME).
The insurer denied TENS device. 
The denial is overturned.

The patient is a male with a past medical history of temporomandibular joint (TMJ) pain with associated myofascial pain, obstructive sleep apnea (OSA), and tension headaches, multiple prior sinus surgeries and lingual frenuloplasty and gingival labial frenuloplasty. He had a magnetic resonance imaging (MRI) performed of his TMJ which demonstrated mild osteoarthritis, left (L)greater than (>) right (R) changes, and meniscal intrasubstance degenerative changes. His treatment included transcutaneous electrical nerve stimulation (TENS), medications (Toradol, Zofran, methocarbamol, carbamazepine and cyclobenzaprine) and transcranial magnetic stimulation (TMS). He did not have benefit with numerous medication trials. He did report benefit with TENS including that he experienced muscle relaxation, improved jaw range of motion and decreased headaches.
At issue is whether the proposed health service or treatment TENS device is likely to be more beneficial than any standard treatment or treatments for the patient's condition.

The health plan's determination regarding the proposed health service or treatment, in regard to chronic musculoskeletal pain, is overturned in whole.

The proposed health service or treatment TENS device is likely to be more beneficial than any standard treatment or treatments for the patient's condition.
The patient had extensive therapy to attempt to treat his TMJ and myofascial pain without durable benefit. According to the medical documentation of his provider, this patient did derive benefit from TENS treatment. Given that he did not respond to most other treatments, it is reasonable to consider TENS treatment. It is within the medical standard of care to provide a TENS unit for the treatment of chronic musculoskeletal pain when used as an adjunct or alternative to pharmacotherapy or when not adequately responsive to other methods of treatment. According to the Plan's Policy 0011, the Plan considers TENS medically necessary durable medical equipment (DME) when used as an adjunct or alternative "for certain types of chronic, intractable pain not adequately responsive to other methods of treatment..."
Therefore, the proposed health service or treatment TENS device is likely to be more beneficial than any standard treatment or treatments for the patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion. 
Treatment: D8080 braces and D8670 monthly visit. 

The insurer denied coverage for D8080 braces and D8670 monthly visit. 

The denial is upheld. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. 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. 

Upon review of the submitted documentation, 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, an HLD 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 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 severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and HLD criteria to justify orthodontic care. This reviewer concurs with the HLD index with a total of 20 points (6 points overjet, 6 points overbite, 5 points anterior crowding 3 points labiolingual spread). 
 
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. 

The health care plan acted reasonably with sound medical judgement and in the best interest of the patient. 
 
The clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care. 

The insurer's denial of coverage for the D8080 braces and D8670 monthly visit is upheld. Medical Necessity is not substantiated.