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

Diagnosis: Class II canines, maxillary and mandibular crowding, excessive overjet, and anterior crossbite.
Treatment: Braces
The insurer has denied coverage for braces. 
The denial is upheld. 

This is a patient who consulted an orthodontist for orthodontic care. Diagnostic imaging was performed that included lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images. The orthodontist recommended comprehensive orthodontics due to Class II canines, maxillary and mandibular crowding, excessive overjet, and anterior crossbite. The orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are 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 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 claimed an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. However, 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. The patient's HLD index achieved a score of 8 points for 3 points overjet, 2 point overbite, and 3 points labiolingual spread. The criteria to qualify for orthodontic care requires a total score of 26 points to be considered necessary. Thus, coverage for braces is not considered 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 braces is upheld. The medical necessity is not
substantiated.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Persistent Stridor 
Treatment: Inpatient hospital admission
The insurer is denied coverage for inpatient hospital admission.
The denial is overturned. 
This is a male patient with a history of congenital cardiomyopathy and autism spectrum disorder (ASD) and persistent stridor. He presented to the hospital for a scheduled bronchoscopy to determine the cause of his stridor. The patient underwent the bronchoscopy which revealed mid-tracheal right sided extrinsic vascular compression that was pulsatile and approximately 2 cm above the carina consistent with innominate artery compression. The patient was transferred to the Pediatric Intensive Care Unit (PICU) for continued monitoring. The patient received dexamethasone and intravenous (IV) fluids. The patient was evaluated and was noted to have done very well post-extubation tolerating feedings without difficulty. The patient was discharged the following day, with instructions to follow-up as outpatient.

The ultimate goal of any airway management strategy is to maintain adequate oxygenation and avoid any level of life-threatening hypoxemia. In this case, this is a male child patient with congenital cardiomyopathy as well as moderate autism spectrum disorder (ASD) with persistent stridor who was at risk for airway compromise, especially after manipulation of the airway during bronchoscopy. For this reason, it was medically necessary for the patient to be admitted for close observation during the immediate post -operative period. 

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

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

Diagnosis: Cellulitis right leg
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

No, the Inpatient admission was not medically necessary.

The patient is a female whose inpatient admission is under review. The patient has a history of bilateral lymphedema, asthma, HTN (hypertension), obesity, and alcohol abuse. She presented with three days of increasing RLE (right lower extremity) erythema and pain. The patient's allergies include penicillin.

In the ER, the patient's vital signs were as follow: T (temperature) - 97.7, BP (blood pressure) - 129/75, P (pulse) - 73, RR (respiration rate) - 18 (increased to 22), BMI (body mass index) - 51.55. On general examination, the patient was noted to be NAD (no acute distress). Examination of the patient's chest, CVS (cardiovascular system), and abdomen were normal. Examination of the patient's RLE revealed it to be edematous, warm, and erythematous.

According to the Infectious Diseases Society of America (IDSA), the patient has mild disease (no systemic signs of infection such as leucocytosis, fever, or tachycardia--even the respiratory rate was <24/min) (1), and there was no suspicion of deeper infection, inability to give or tolerate PO (oral) medications, and no social or compliance issues such as homelessness. Therefore, the patient could have been treated by as an outpatient. Thus, this admission was not warranted, and not supported by IDSA guidelines. The patient could have been treated as an outpatient, and other non-penicillin options were available (clindamycin, Linezolid).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Otitis Externa, Dementia.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial was upheld.

This is a male patient with a medical history of COPD, severe aortic stenosis, Gastrointestinal Reflux Disease (GERD), H. pylori, BPH, and bilateral deep vein thrombosis (DVT).  He presented to the emergency department (ED) with complaints of generalized body aches. It was noted the patient was recently admitted and discharged for similar symptoms and was found to be having Respiratory Syncytial Virus (RSV).  The physical examination revealed a blood pressure of 128/73 with a pulse of 74 bpm; the patient was in no acute distress.  The physician indicated the physical exam did reveal mildly dry mucous membranes.  There were no neurological findings however there was concern for generalized weakness possibly secondary to worsening dementia.  It was recommended that the patient undergo laboratory and diagnostic studies. A magnetic resonance imaging (MRI) was performed which was unremarkable.  The patient's laboratory studies revealed an albumin of 3.4 with protein of 5.7.  A chest x-ray did not reveal any findings of infiltrate. The patient was admitted for further monitoring. Neurology was consulted and noted suspicion for worsening dementia with recommendations that the patient undergo an electroencephalogram. An electroencephalogram was done which was negative for seizures.  The patient was prescribed ofloxacin for a possible ear infection with continued physical therapy services.  Suggestions were made for admission to a rehabilitation facility.  Given the patient continued to improve the patient's family requested the patient be discharged with home therapy services.  The patient was discharged with instruction to follow-up if needed.

According to the patient's records, there is no clear evidence of acute change in the neurological examination suggestive of acute stroke. There were no acute motor, sensory or visual deficits that suggest an acute stroke. In addition, there was no instability, new focal neurological signs, acute stroke, hemodynamic or cardiovascular compromise or acute prolonged metabolic decompensation or seizure.   Therefore, the patient's condition did not fulfill criteria for acute inpatient care admission. 

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

Diagnosis: Substance Abuse
Treatment: Inpatient detoxification admission
The insurer is denied coverage for inpatient detoxification admission.
The denial is overturned.
This is a male patient who was admitted for inpatient substance detoxification due to heroin withdrawal. The patient reportedly had withdrawal symptoms that included hot and cold sweats, elevated heart rate of 105, yawning, sleeping problems, joint pain, anxiety, dilated pupils, tremors, irritable mood, and anxiety. The patient's urine toxicology was positive for opiates and methadone. The patient reportedly had a significant history that included using 5 bags of intravenous (IV) heroin per day, $10 per day of cannabis 3-6 times per week resulting in multiple, past inpatient substance detoxification treatments including a recent one. The patient continued to relapse despite multiple past substance detoxification treatments. The patient was put on a Methadone taper protocol and took Methadone. The patient left against medical advice (AMA).

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. In this case, this patient had been using heroin daily and cannabis. The patient was at risk for death from overdose of heroin.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use large amounts of heroin daily despite multiple past inpatient substance detoxification treatments, and he needed detoxification medication including Methadone to modify his withdrawal from heroin. The patient had long term multiple substances of use including heroin and cannabis. The patient needed 24-hour treatment then as he was at risk for worsened withdrawal symptoms. The patient likely would have relapsed again as evidenced by his history of relapsing after numerous past inpatient substance treatments. The patient reportedly took Methadone and then left against medical advice (AMA). The patient could not have been safely and effectively treated in a less restrictive setting other than this medical hospital detoxification treatment as he was at risk for more severe withdrawal and overdose. Thus, inpatient detoxification admission was medically necessary for this patient.

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

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

Diagnosis: Acute Kidney Injury, Colitis.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is overturned. 

This is a male patient with a medical history of hypertension, diabetes mellitus, and chronic kidney disease. The patient presented to the Emergency Department (ED) with complaints of nausea, vomiting, diarrhea, and fever for the past couple of days. The patient had returned from Jamaica prior to presentation. The patient's blood pressure was 132/76 and temperature was 98.1. The patient denied chest pain, shortness of breath, and dysuria. The patient's physical examination revealed dry mucous membranes. The patient had tenderness in the left lower quadrant of the abdomen with positive bowel sounds in all 4 quadrants of his abdomen. The patient's laboratory studies revealed CO2 17, glucose 151, BUN 64, creatinine 4.0, albumin 3.1, bilirubin less than 0.2, white blood cell (WBC) count 10.67, red blood cell (RBC) count 2.75, hemoglobin 8.0, and hematocrit of 24.9; the iron level was 22. The patient was to be treated with intravenous (IV) fluids and medications. The patient's computed tomography (CT) scan of the abdomen and pelvis revealed colitis involving the transverse, descending, and sigmoid colon; there was urinary bladder wall thickening versus under-distention. The patient was admitted for acute kidney injury, colitis, and dehydration. The patient was stabilized and discharged.

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. The patient presented to the hospital with severe gastroenteritis and colitis with inability to keep food/fluids down and hypovolemia resulting in acute kidney injury. The patient had a positive history of recent travel, and computed tomography (CT) scan for pancolitis. The patient was also anemic. In this setting, the patient's illness is considered severe and inpatient acute care admission was appropriate to treat the complications of renal failure, evaluate the causes, and provide supportive care. Given the severity of this patient's medical condition, the observation level of care would not have been appropriate. Thus, inpatient admission was medically necessary.

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

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

Diagnosis: Skin disorders
Treatment: Prescription medications
Issue: The insurer denied the prescription medication
The health plan's determination is upheld in whole

The patient has  moderate to severe psoriasis (over 40% body surface area involvement). The patient has tried and failed topical steroids. The patient improved on Otezla samples.
Modern dermatology literature [1-4] supports use of medications such as Methotrexate, Acitretin, and/or Phototherapy as similarly efficacious to the requested Otezla, particularly for a patient with little to no history of systemic psoriasis therapy previously utilized, and recommend use of these  agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, and
consistent with modern dermatology literature [1-4], the requested Otezla is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lupus 

Treatment: Herpes zoster (shingles) vaccine

The insurer is denied coverage for herpes zoster (shingles) vaccine

The denial is overturned. 

This patient has previously been diagnosed with cryptosporidiosis. The documentation detailed she also suffers from lupus and has been utilizing methotrexate. The patient was vulnerable due to being in an immunocompromise state. The submitted documentation from the physician indicated the patient has had shingles and is now being recommended to undergo a vaccination due to the above. The documentation indicated she was seen for a consultation. The chart note indicated the patient was status post treatment for cryptosporidiosis and did have improvement of abdominal symptoms. It was recommended she begin digestive probiotics and it was also recommended she receive a shingles recumbent vaccine.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes. This patient is a good candidate for herpes zoster (shingles) vaccine.

Herpes zoster (shingles) vaccine is the best available treatment for this patient at this time.

In 2017 Shingrix was approved for immunocompetent adults > 50 years old to prevent HZ infection. So far it has not been officially approved for patients under 50 years and there are few data on efficacy of the vaccination in patients under 50 yrs. However there are studies that show that in special populations which include people who have both primary and acquired immune deficiency disorders, patients undergoing stem cell or solid organ transplants, those who have autoimmune conditions including lupus, RA, etc. both over and under the age of 50 are more prone to infection by HZV than the general population. This special population also includes patients on immunomodulator therapies like the patient. She was taking Methotrexate and had been on steroid therapy. She had also just recovered from cryptosporidium infection which is known to be more severe in immunocompromised individuals. She had also reported having H zoster before and per Advisory Committee on immunization (ACIP) HZV infection can recur again and has the potential to call widespread disease in immunocompromised individuals such as the patient.

There is also no contraindication to receiving the vaccine once the symptoms of acute herpes zoster have resolved.

Based on the above, the insurer's denial of herpes zoster (shingles) vaccine is overturned. This vaccine is likely to be more beneficial than any other standard therapy
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: SLE (systemic lupus) 

Treatment: Herpes zoster (shingles) vaccine

The insurer is denied coverage for herpes zoster (shingles) vaccine.   The denial is upheld.
 
The patient is a woman with SLE (systemic lupus) on MTX (methotrexate). She was seen by Infectious Diseases (ID) with a recent history of cryptosporidiosis. The patient was given a zoster vaccine recombinant adjuvant at that time. 

The patient is appealing the decision. She notes that she has SLE and is on immunosuppressive therapy. She contracted shingles last year and was at high risk for contracting it again. In a letter affirmed that the patient has SLE on MTX and is immunocompromised. He notes that the vaccine in this case is indicated as per literature provided by her rheumatologist.

Evaluate whether the herpes zoster (shingles) vaccine is considered more beneficial for this patient's diagnosis, addressing the following in your discussion:

The FDA-labeling is for immunocompetent adults 50 or older. Guidelines noted above include immunocompromised patients 50 or older.

The patient is as noted above; there is no safety, efficacy data for those less than 50. Therefore it cannot be stated that this is likely to be more beneficial than any standard medical service.

The patient is at risk for shingles and a vaccination would be desirable. And this recombinant form of the vaccine would presumably be safer than the attenuated live-virus vaccine. But the current literature does not provide support for its use in a person less than 50 year old.

Based on the above, the denial of herpes zoster (shingles) vaccine performed is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep Vein Thrombosis 
Treatment: Acute inpatient stay 

The insurer is denied coverage for acute inpatient stay. The denial is upheld. 

This is a male patient who was recommended to be seen in the Emergency Department (ED) for a new left femoral deep vein thrombosis (DVT). The patient had complaints of a painful lower leg. The patient indicated that his physician sent him for his pain to his legs as well as swelling. The patient's past medical history was significant for chronic obstructive pulmonary disease (COPD), deep venous thrombosis (DVT), gout, and gastroesophageal reflux disease. The patient had Eliquis prescribed for his DVT. The patient reported stopping taking Eliquis due to finding blood in his sputum. Upon physical examination, there was redness to the bilateral feet with pain to the lower leg.  It was recommended that the patient undergo laboratory and diagnostic studies. In the ED, the patient's initial vital signs were Temperature 97.4, Pulse 83, Respiration 20, Blood Pressure 135/82 and Oxygen Saturation of 94% on Room Air. The patient's laboratory studies did not reveal any significant abnormalities. The patient's lab showed that his PT was 13.9 and BNP was 9. The patient's chest x-ray revealed shallow inspiration with vascular crowding. There was no focal consolidation, no pneumothorax and no pleural effusion. The patient's computed tomography (CT) scan of the chest revealed a limited study due to respiratory motion. The patient was recommended to continue with a heparin drip while hospitalized. The patient was discharged with follow-up instructions. 

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient presented with left leg pain and edema for which his workup was consistent for a new left femoral deep venous thrombosis (DVT). The patient reported that he had been off his anticoagulation medication, which was likely the cause of his DVT. Otherwise, the patient was clinically stable. The patient had normal bloodwork, and was hemodynamically stable. The patient's computed tomography angiography (CTA) of the chest ruled out pulmonary embolism (PE), and the patient did not have congestive heart failure or chest pain. Given that this was an uncomplicated DVT without evidence of abnormal vital signs, abnormal chest x-ray, abnormal CT chest with PE protocol, active malignancy, hypoxia, chest pain, myocardial infarction (MI), heart failure, etc., this was a case that could have been safely treated with re-starting his anticoagulation in the Emergency Department (ED) or Observational level of care, refilling prescription for his anticoagulation, and discharge home with close
follow-up with his Primary Care Physician (PCP). 

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

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

Cardiac/Circulatory Problems - Chest Pain
Inpatient Hospital

The patient is a male who presented with near syncope on the day of presentation. He was bowing at the time and developed substernal chest pressure, profuse diaphoresis and dyspnea that lasted for 20 minutes despite sitting and resting. The patient felt lightheaded and was close to passing out. The patient also felt back pain. The patient had history of hypertension (HTN), hyperlipidemia (HLD), post loop recorder implantation, gastroesophageal reflux disease (GERD), depression/anxiety, kidney tumor post resection and eye melanoma.

The patient was admitted to telemetry with diagnosis of chest pain for ischemia work up. His orthostatics were checked and were negative. His chest x-ray (CXR) revealed cardiomegaly. His carotid duplex was abnormal. It revealed heterogenous atherosclerotic plaque in the bilateral carotid arteries. There was no stenosis of the internal carotid arteries, right and left. There was mild stenosis of the right external carotid artery.

A Cardiology consultation was obtained and an echocardiogram was recommended. The Cardiology impression was that the patient most likely suffered from vaso-vagal syncope.

The health plan's determination is upheld. The patient was admitted with near syncope. This was not his first episode. The work-up previously done was unremarkable. His loop recorder did not reveal any significant arrhythmia. The patient underwent extensive work up and it was all negative. His condition remained stable.
This patient's condition and the level of care did not meet inpatient admission criteria. The patient was stable. He underwent multiple tests, but the results were negative. The care for this patient could have been provided at a lower level of care.