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

Diagnosis: Worsening numbness
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This is an adult who presented to the emergency room complaining of worsening numbness in both legs and the right upper extremity.  The patient had comorbidities consisting of H. pylori (helicobacter pylori) and gastritis as well as a history of migraine headaches.  The triage notes stated the patient underwent vascular work-up at a separate facility with notation of bilateral sensory loss and demyelinating neuropathy.  On assessment, the patient was initially hypotensive with a blood pressure reading of 105/30.  The vital signs were otherwise stable.  The patient was alert and oriented x4 (person, place, time and event), ambulatory, with no other complaints other than bilateral leg pain.  Records indicated the patient was admitted to the hospital the prior month for similar symptoms and was found to have likely vasculitis versus side effects of diet and medication causing symptoms.  The patient underwent extensive vascular and rheumatology work-up but left the hospital before further imaging was completed. The patient was reportedly following up with rheumatology but had not seen a vascular specialist.  The patient was supposedly scheduled for magnetic resonance imaging (MRI) as an outpatient, but claimed the symptoms worsened over the last 1-2 days.  The patient was advised to go to the emergency department. The patient denies chest pain, shortness of breath, abdominal pain, nausea/vomiting/diarrhea, dizziness, syncope, fever, or chills.  Exam findings were relatively unremarkable with no abnormal neurological findings.  The patient was admitted for further work-up.  

According to the Milliman Care Guidelines, criteria for admission to inpatient care for those individuals presenting with a neurological problem are indicated for select conditions.  Based upon the provided information, the patient did not meet criteria for inpatient admission.  The patient could have had care rendered on an observational basis or outpatient basis with all appropriate testing/work-up and treatment rendered without the need for an inpatient stay, much less throughout the timeframe in question.  The patient did not present with an emergent condition and had reportedly undergone prior work-up for the same symptoms the month prior.  There were also reports that the symptoms were likely related to diet and medication.  Given these findings, the prior determination is upheld as the inpatient admission was not considered medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 
The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep impinging overbite

Treatment: procedure code D8080 (comprehensive orthodontic treatment of the adolescent dentition)

The insurer denied coverage for procedure code D8080 (comprehensive orthodontic treatment of the adolescent dentition)

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, 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, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, the use of an orthodontic Index, the HLD report index modeled after Handicapping Labiolingual Deviation Index. 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 plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer with a total of 16 points.

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 referenced studies. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for procedure code D8080 (comprehensive orthodontic treatment of the adolescent dentition) services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Substance Abuse

Treatment: full hospital admission

The insurer denied coverage for full hospital admission

The denial is modified

This adult male reportedly was admitted to this inpatient hospital after he had an overdose after snorting cocaine which was suspected of being laced with opiates. He reportedly had altered mental status and syncope in the setting of a drug overdose and was hypoxic with bradypnea and had hyperkalemia, lactic acidosis, and had glucose in the 700's, and had elevated liver function test (LFT's). He reportedly also had an abnormal (electrocardiogram) EKG and was given aggressive intravenous (IV) fluids, IV antibiotics, and IV heparin. He reportedly was given Narcan and responded with improved mental status. He was discharged.
     
This reviewer disagrees with the decision to deny coverage for acute inpatient hospital treatment on day 1 as the medical records provided enough specific evidence to support that he required hospital treatment then but agree with the decision to deny coverage for the remaining 2 days as the medical records did not provide enough specific evidence to support that he still required 24-hour acute hospital treatment. 

According to the Milliman Care Guidelines (MCG) Guidelines for Drug verdose/Ingestion, he met criteria for hospitalization on day 1 as he had altered mental status initially and had other medical issues including being hypoxic with bradypnea and had hyperkalemia, lactic acidosis, and had glucose in the 700's, and had elevated LFT's. He reportedly required and received aggressive IV hydration due to his lactic acidosis, in addition to the aggressive IV hydration with IV fluids. 

The medical records supported that he was considered a medical risk and at risk for withdrawal as he reportedly used cocaine which was thought to possibly being laced with opiates and he reportedly had syncope and altered mental status after that with medical consequences including being hypoxic with bradypnea and had hyperkalemia, lactic acidosis, and had glucose in the 700's, and had elevated LFT's. He required the day in the hospital for treatment and monitoring. However, notes on day 2 reported that he had improvement in mental status and was stable and asymptomatic with no signs of infection and he had stable vital signs. He reportedly was alert and oriented and after aggressive IV hydration and it was reported that that treatment improved his lactic acidosis. It also was reported that Narcan improved his mental status. He reportedly still was improved on day 3 and was discharged. As a result, the recommendation is to modify the previous decision and approve coverage for hospital treatment for 1 day but deny coverage for remaining 2 days.

It appeared that the insurer acted reasonably for remaining 2 days but did not act in the best interest of the patient for 1 day.

Based on the above, the insurer's denial must be modified. The health care plan act partially reasonably with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient level of care is partially substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This patient has a history of ischemic heart disease and presented to the hospital with chest pain. Pain began while the patient was driving and was exacerbated by movement of the left arm. Past medical history was significant for heart failure with reduced left ventricular ejection fraction (LVEF 25% [percent]), atrial fibrillation, severe mitral regurgitation status post-surgical repair and implantable cardiac defibrillator.  Upon arrival to the hospital, vital signs were stable (Blood Pressure 100/67mmHg [millimeters of mercury], Pulse 97). Physical examination revealed no significant abnormalities.  A 12-lead electrocardiogram (EKG) revealed atrial fibrillation with a controlled ventricular rate and nonspecific T (interval on EKG) wave changes.  Serum blood testing revealed no elevation in troponin (<0.01) or Brain natriuretic peptide (30 pg/L [picogram per liter]). The patient was admitted to the hospital for monitoring and treatment.  

The pretest probability of coronary artery disease is intermediate (Reference 1). Utilizing the HEART (history, EKG, age, risk factors, and troponin) score, he was considered intermediate risk (Reference 2). Risk assessment of patients presenting with chest pain and no significant ST (interval on EKG) changes on electrocardiogram was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events (myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation that includes serial troponin measurement, echocardiography and ischemia work up prior to discharge. However, numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Moreover, clinical findings were consistent with musculoskeletal pain (patient's pain occurred at rest and was exacerbated with arm movement).  Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care (References 4,5).  They found no significant difference in outcome at 30 days between the two groups.  Fernando Bellolio et al. noted that patients presenting with chest pain, that were managed in an observation unit, had similar 30-day myocardial infarction rates as those admitted to the hospital (Reference 5).  

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

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

Diagnosis:  Congestive heart failure (CHF) exacerbation.
Treatment:  Inpatient hospital Admission.

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

The patient is a male with a history of congestive heart failure, ejection fraction of less than 20% (percent), atrial fibrillation, and hypertension, who presented to the hospital with worsening dyspnea for three days, with associated weight gain, due to dietary noncompliance. The patient reported medication compliance and had recently undergone a left heart catheterization at another facility that did not require significant interventions. On examination, he was noted to have one plus (1+) edema to the lower extremities. He is on chronic antiarrhythmics with amiodarone and guideline-directed medical therapy with Coreg, lisinopril, atorvastatin, and nifedipine. Temperature and heart rate were normal. His blood pressure was 153/84. Oxygen saturation was 97% on a 2 liters (L) nasal cannula. He was admitted for nonspecific troponin elevation and congestive heart failure (CHF) exacerbation.

The health plan's determination is upheld.

Based on the provided documentation, the hospital admission at the inpatient level of care was not medically necessary. The patient suffered from a mild heart failure exacerbation caused by dietary indiscretions. There is no documentation of clear acute coronary syndrome or severe pulmonary edema that would require noninvasive or invasive ventilatory support. There is no documentation of anasarca. The patient only has 1+ edema of the lower extremities. After two doses of IV diuretic therapy, the patient improved and was discharged home. There is no concurrent evidence of pneumonia, worsened renal failure, severe electrolyte derangements, or severe cardiac arrhythmias on the monitor that would require inpatient monitoring and treatment. This presentation could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative colitis
Treatment: Rinvoq
The insurer denied Rinvoq.
The health plan's determination is upheld. 

The patient is a male with severe refractory Ulcerative Colitis. Magnetic resonance enterography has shown disease in the duodenum, ileum, colon, and rectum. He has failed prednisone, methotrexate, high-dose infliximab (secondary non-response), Stelara, and Entyvio. He presented with abdominal pain, diarrhea, hematochezia, fever, and unintentional weight loss despite Entyvio and methotrexate. Under review is Rinvoq for the treatment of Ulcerative Colitis.

Rinvoq is not medically necessary. The plan preferred Xeljanz has proven effective in a double-blind, placebo-controlled trial of patients with moderate-severe Ulcerative Colitis. The American Gastroenterological Association guidelines for the treatment of Ulcerative Colitis recommend Xeljanz to attain remission after failure of anti-tumor necrosis factor agents. Rinvoq is approved by the U.S. Food and Drug Administration (FDA) for the treatment of Ulcerative Colitis. However, Rinvoq has not demonstrated superior safety or efficacy to Xeljanz in the treatment of Ulcerative Colitis in a randomized clinical trial. Guidelines for the treatment of Ulcerative Colitis were written before the FDA approval of Rinvoq for the treatment of Ulcerative Colitis, and do not recommend Rinvoq over Xeljanz. There is no documented contraindication to Xeljanz which would not apply in this case. For these reasons, Rinvoq is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma

Treatment: Tezspire

The insurer denied coverage for Tezspire

The denial is overturned

The patient is an adult female who was seen by physician's assistant for follow up and to receive Fasenra when she reported cough, fever, dyspnea, frequent short-acting beta-agonist (SABA) use and chest tightness as well as a recent course of prednisone and antibiotics. No wheezing was heard. No pulmonary function tests were reported.  

She was seen by an Allergy & Immunology specialist. Two courses of prednisone had been taken. Her medications listed included Symbicort, Fasenra and Spiriva. Frequent albuterol use was reported. No wheezing was heard, and no pulmonary function tests were performed. The plan noted that there was an intention to change her biologic to Tezspire. 

She was seen by physician's assistant when she reported dyspnea and chest tightness while on Symbicort 160 and Spiriva. No wheezing was heard. No pulmonary function tests were reported.

There are no head-to-head studies comparing biologics in asthma. However, it is common clinical practice to change biologics if patients are not doing well. In this patient her asthma control seems to be poor given the history of frequent SABA use and 2 courses of steroids. It would be reasonable to consider Tezspire since it is like Fasenra, approved for severe asthma. Since Fasenra was administered, it can be assumed that criteria for severe asthma was supported in the past.

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

The insurer's denial of coverage for Tezspire services is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion  
Treatment: Braces and monthly visits
The insurer denied coverage for braces and monthly visits.
The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, and open bite and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index attaining 16 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 21 points by internal reviewers.

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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 16 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining at total of 16 points on the HLD index (6 overjet, 8 open bite, 2 labiolingual spread) which is below the threshold of 26 points to support orthodontic care. Of note in this case, the patient's own orthodontist does not attain 26 points on the HLD index as required/or orthodontic approval.

In this case the patient's own orthodontists complete HLD index total score of 16 points remains below the threshold of 26 points to justify orthodontic care.

Braces and monthly visits are not considered medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for braces and monthly visits services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This patient is a young adult female, previously healthy, who presented to the emergency department with the complaint of abdominal pain. Examination revealed right lower abdominal tenderness. The patient's vital signs identified an elevated temperature of 101.5 Fahrenheit at the time of presentation. The white blood cell (WBC) count was 10.85 thousand (K). Surgical consultation was obtained. Computed tomography (CT) scan was completed showing findings of acute appendicitis. The patient was started on intravenous antibiotics. The patient underwent laparoscopy with appendectomy for the condition of appendicitis. The operative note is not included with the review material, but operative findings are referenced in the hospital appeal letter. Following surgery, the patient was treated with intravenous fluid and analgesia. Her vital signs were consistently normal in the perioperative period. The patient was transitioned to oral medications and diet. She was discharged from the hospital following a period of recovery on the next day. 
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 and the care rendered could have been provided without admission to the hospital.

The proposed inpatient hospital admission was not medically necessary.

The 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 during this period of time.
This patient presented with abdominal pain. The evaluation with examination, lab data, and computed tomography scan supported the diagnosis of acute appendicitis. The 
patient underwent uncomplicated appendectomy. She was admitted to an inpatient level of care and was discharged from the hospital on the first post-surgical day. 
There is no clinical documentation to support the need for inpatient admission. The patient remained hemodynamically stable throughout the perioperative period, there was no documented complication of surgery. This patient's clinical needs could have been satisfied without need for an inpatient designation and could have been satisfied with a lower level of care. This lower level of care would have provided for pre-surgical assessment, surgical treatment and post-surgical recovery including observation (if required). The records support that the care provided was clinically appropriate. It is the level of care (inpatient versus outpatient / observational) that is at issue in this case.