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

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a female patient who presented to the emergency department complaining of chest pain. Her medical history was remarkable for hypertension, diabetes and gastroesophageal reflux disease. Her blood pressure was 128/78 millimeters of mercury (mmHg) with a heart rate of 88 beats/minute. Her room air oxygen saturation was 98 percent (%). An electrocardiogram showed sinus rhythm without acute changes. Her serum troponin I level was 0.158 nanograms/milliliter (ng/ml), which was in the indeterminate range. A chest x-ray showed no acute pathology. The patient was treated with aspirin, a statin, enoxaparin, and metoprolol and admitted to the hospital to rule out acute coronary syndrome (ACS). Repeat troponin I levels were 0.083 ng/ml and 0.034 ng/ml. A cardiac catheterization was performed and showed normal coronary arteries. An echocardiogram showed a left ventricular ejection fraction of 55%. The patient was discharged. The medical necessity for an inpatient admission is at issue.

Based on the documentation provided, an inpatient level of care was not medically necessary.

This patient presented with symptoms that were thought to possibly represent ACS. Accordingly, observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with no ischemic electrocardiographic changes. While her serum troponin level was mildly elevated it was in the indeterminate range and not diagnostic of myocardial infarction. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be both safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE)/American College of Chest Physicians (CHEST)/Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned. 

This young adult was admitted to inpatient substance rehabilitation treatment as he reportedly was smoking marijuana daily with a history of use. He reportedly had a positive toxicology screen for tetrahydrocannabinol (THC). He reportedly also had comorbid depression and anxiety and had past trauma issues as well as insomnia. He was unemployed and lived with his parents and brother. He reportedly was unable to remain abstinent as his longest reported abstinence was 2 weeks. He attended group and individual therapy and was discharged with a referral to outpatient substance treatment.
  
The medical records provided enough specific evidence to support that he required this 24-hour therapeutic supervised and structured inpatient substance rehabilitation treatment. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. He was at risk for cardiac complications of cannabis use and also withdrawal. He reportedly lacked the coping skills and ability to identify relapse triggers to stop use. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he met criteria for inpatient substance rehabilitation treatment. He reportedly also had comorbid psychiatric issues including depression, anxiety, and trauma related issues. He reportedly lacked positive peer support, lacked coping skills for abstinence, and lacked the ability to identify triggers to use or insight into use and needed to learn better coping skills, improve insight into use, and better identify relapse triggers. He was unable to stop substance use without being in a sober and supervised therapeutic inpatient substance rehabilitation setting. 

Without this structured and supervised therapeutic rehabilitation treatment, he likely would have relapsed and likely would not have been able to maintain any abstinence as evidenced by the fact that his longest reported abstinence was 2 weeks.  

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

Diagnosis:  Uterine mass.
Treatment:  Full hospital admission.

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

The patient presented to the emergency room (ER) with complaints of worsening flank pain and Urinary Tract Infection (UTI) symptoms.  The patient was diagnosed two days prior with a kidney infection and was started on Ciprofloxacin.  The patient had taken two doses of Ciprofloxacin.

The evaluation was consistent with a uterine mass that was causing right hydroureteronephrosis. The patient was diagnosed with obstructive uropathy and was scheduled for bilateral ureteral stent insertion. The patient underwent ureteral stent placement, as well as an endometrial biopsy and pap smear, in the operating room.  The patient was discharged afterwards.

The patient was admitted for management of obstructive ureters.  The patient had a pelvic mass suggestive of uterine fibroids. The patient underwent ureteral stents placement as well as a Dilation and Curettage (D&C). Neither procedure requires hospital admission. Both procedures are done in offices or in ambulatory surgery centers.

Full hospital admission was not medically necessary. This is consistent with standard of care and Milliman Care Guidelines (MCG). 

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 full hospital admission before and after urinary surgery is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: Braces

The insurer denied coverage for braces

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, overbite, and anterior crowding among other findings and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) score attaining 27 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 having attained a score of 18 points on the HLD index.

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, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 27 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 18 points on the HLD index (3 overjet, 2 overbite, 10 anterior crowding, 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care. Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. 

Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

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 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, weakness, slurred speech
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female for which an inpatient hospitalization is under review. The patient had a history of hypertension. The day before presentation, the patent's physician started her on two blood pressure medications. She presented with left side face and body weakness, headache, and slurred speech. The blood pressure was 224 over 110. She was in no distress. Scans of the head and neck were unremarkable. The electrocardiograms were reported as non-acute. Troponins were negative. The blood pressure was treated in the emergency department and the patient's symptoms improved. The blood pressure in the emergency department was 177/123. The creatinine was normal. Echocardiography was normal. The patient remained stable. Her blood pressure normalized, and she was discharged.

The proposed treatment was not medically necessary.

This patient presented with hypertension that normalized and remained stable. There were no mental status changes, acute neurologic or coronary syndrome, seizure, congestive heart failure, aortic dissection, renal failure, need for prolonged intravenous medications, administration of high-risk medications requiring ongoing in-hospital monitoring, or recurrent severe hypertension. In this setting, an inpatient level hospitalization, compared to for example observation, has not been established as standard of care towards improved hypertension related outcomes. As such, it is considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overactive bladder
Treatment: Percutaneous Tibial Nerve Stimulation (CPT 64590)
The insurer denied percutaneous tibial nerve stimulation (CPT 64590).
The denial is overturned.

The patient is an adult female with overactive bladder, nocturia, bladder pain, and mixed urinary incontinence with more bothersome urge incontinence that started 4 years ago. The patient has been treated with conservative therapy, medical therapy including Vesicare 5 mg (milligrams) and increased to 10 mg, but with lack of significant improvement in symptoms. The patient was changed to mirabegron 25 mg, which improved symptoms, but she had headaches and dry mouth. The patient has trialed medical therapy for 3 years. Due to the patient's lack of efficacy and intolerance to medical therapy, third-line options were reviewed, including intradetrusor injection of botulinum toxin, sacral nerve stimulation, percutaneous tibial nerve stimulation and Ecoin system, an implantable tibial nerve stimulation therapy. The patient wished to proceed with Ecoin. Preauthorization was denied coverage by the health plan, as medical policy on sacral nerve stimulation and percutaneous tibial nerve stimulation for urinary and fecal incontinence and urinary retention considers percutaneous tibial nerve stimulation not medically necessary for all indications. The requested service does not meet the standard of care for the patient's problems. This denial is being appealed.

The requested percutaneous tibial nerve stimulation is medically necessary.

The patient has documented overactive bladder refractory to behavioral therapy, mirabegron, and Vesicare. The request is for an FDA (United States Food and Drug Administration) approved implantable subcutaneous tibial nerve stimulator therapy. The patient is documented to have failed first- and second-line therapies. The AUA (American Urological Association) guidelines recognize peripheral tibial nerve stimulation as a third line of therapy option for overactive bladder in addition to intradetrusor injection of botulinum toxin and sacral nerve stimulation. The service was denied as not being considered a standard of care, however, that is not consistent with the AUA guidelines. The requested service is a form of peripheral tibial nerve stimulation, is FDA approved and has efficacy and safety data available for one year's time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Syncope, chest pain.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

This is a male patient with a past medical history (PMH) of diabetes mellitus type 2 (DM2) who was admitted with complaints of (c/o) syncope and chest pain. The vital signs were unremarkable. The physical exam was unremarkable. Lab work was unremarkable, with negative troponins. Imaging studies included a computed tomography (CT) scan of the head which showed no acute intracranial or cervical spine injury, transthoracic echocardiogram (TTE) which showed no significant abnormality with normal ejection fraction (EF). An electrocardiogram (EKG) showed sinus bradycardia. The patient was diagnosed with syncope and was treated with telemetry, clinical monitoring, cardiac work-up, and expert consultations. An electroencephalogram (EEG) did not show any seizure activity. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o syncope. He did not have structural heart disease, hematocrit (HCT) less than (<) 30, shortness of breath (SOB), hypotension, or a family history of sudden cardiac death. Additionally, the patient did not have any history of dilated cardiomyopathy, aortic stenosis, hypertrophic cardiomyopathy (HCM), left ventricular outflow disease, pre-excitation syndrome, Brugada syndrome, QT interval abnormalities or conduction blocks. The patient did not have a subarachnoid hemorrhage, pulmonary embolism, acute gastrointestinal (GI) bleed, malignant arrhythmia, supraventricular tachycardia (SVT) or ventricular tachycardia (VT), confirmed acute coronary syndrome (ACS), evidence of heart failure, cerebrovascular accident (CVA), shock, coma major trauma, or cardiac arrest. In addition, the patient had negative troponins and cardiology recommended an outpatient cardiology work-up after a normal transthoracic echocardiogram (TTE). The patient was diagnosed with syncope and was treated with telemetry, clinical monitoring, cardiac work-up, and expert consultations. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Eczematous dermatitis and prurigo nodularis
Treatment: Dupixent 300mg (milligrams) /2ml (milliliter) injector
The insurer denied coverage for Dupixent 300mg/2ml injector
The denial is overturned
 
This patient is an adult with a diagnosis of atopic dermatitis and prurigo nodularis. The patient has moderate disease with severe prurigo nodularis. The patient has failed therapy with topical steroids, tacrolimus, and phototherapy.  

The patient has moderate atopic dermatitis and prurigo nodularis which requires systemic therapy. The use of Dupixent is reasonable given that it is Food and Drug Administration (FDA) approved for the treatment of atopic dermatitis. The request for Dupixent is supported by the medical literature. Dupixent is the first systemic therapy approved by the FDA for the management of atopic dermatitis (AD). In early 2017, the FDA approved Dupixent for adults with moderate-to-severe AD who are inadequately controlled with topical treatments.  According to consensus guidelines "Dupilumab (Dupixent) has shown strong efficacy and safety for treatment of moderate-to-severe AD .... Considering the safety profiles of conventional systemic therapies, which are not FDA-approved for AD treatment, it is recommended that dupilumab be used as a first-line systemic treatment ... with moderate-to-severe AD who are uncontrolled with topical therapies". 

Furthermore, regarding need for systemic therapy for prurigo nodularis (PN) Up to Date notes that "We suggest dupilumab as first-line systemic treatment for recalcitrant PN in adults, especially in patients with underlying atopic dermatitis... Dupilumab was approved by the US (United States) Food and Drug Administration for the treatment of PN in adults in September 2022."

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Dupixent 300mg/2ml injector is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder/Other/facial numbness, left arm weakness.
Treatment: Inpatient Admission.
The health plan denied the requested inpatient admission as not medically necessary. The health plan's determination is upheld.

The patient is a man with a history of hyperlipidemia. He presented to the emergency room with a few-hour history of numbness of his entire face, scalp, and head. One week ago, he reported an episode of syncope and hit his head with a fall. The vital signs were normal. The neurologic exam revealed decreased grip strength of the left hand, mild weakness of the left leg, and decreased light touch of the face and scalp. Labs were unremarkable, and there was no acute intracranial hemorrhage or mass effect on head computed tomography (CT) scan. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The patient was admitted for further treatment and evaluation.
Upon admission to a monitored bed, the patient was treated with oral medications and Lovenox prophylaxis. The neurologist evaluated the patient and noted on exam mild weakness all over and a normal sensory exam. It was also noted that the CT angiogram of the head and neck was unremarkable. A magnetic resonance imaging (MRI) was recommended and performed. It was also unremarkable, and the patient was discharged later in the day.
At issue is the medical necessity for the inpatient stay.

The health plan's determination of medically necessity is upheld, in whole.

No, the requested health service/treatment of inpatient admission was not medically necessary for this patient.
Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no progressive neurologic symptoms or signs. There was no hemodynamic instability, mental status changes, or severe metabolic disarray. The services provided, imaging, oral medications, consultation were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary and the patient could have been managed at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overweight
Treatment: Phentermine
The insurer denied: Phentermine
The denial is upheld

This adult female is appealing denial of phentermine for overweight. Clinical note shows a body mass index of 28.7. The clinical records support the patient taking phentermine for 5 months. History includes Vitamin D deficiency, migraine, and hypothyroidism. The request for phentermine was denied due to receipt of the three months of the requested drug within the past year.

The proposed phentermine is not medically necessary.

Phentermine is Food and Drug Administration (FDA) approved for a short-term treatment as an adjunct to exercise, behavioral modification, and caloric restriction for patients with body mass index (BMI) of 30 or greater, or 27 or greater in the presence of weight related comorbid conditions. It is approved for short-term use (three months) only. This patient has had three months of phentermine in the last 365 days. The health plan denied the request due to receipt of the three months of the requested drug within the past year. The patient's body mass index is less than 30 and greater than 27, but she does not have weight related comorbid conditions. The requested phentermine is not medically necessary because it is not consistent with generally accepted standards of medical practice.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: depression
Treatment: Transcranial Magnetic Stimulation (TMS) and Cranial Electrical Stimulation (CES)
The insurer denied Transcranial Magnetic Stimulation (TMS) and Cranial Electrical Stimulation (CES).

 The health plan's determination is upheld. 

The patient is an adult female with a diagnosis of severe major depressive disorder. The patient has a history of treatment refractory depression. Progress notes indicate a PHQ-9 (Patient Health Questionnaire) scale score of 23 in the severe range for depression. The history includes failed treatment with Prozac 60 milligrams (mg) daily, Luvox 300 mg daily, and Lexapro 20 mg together with Concerta 36 mg. The patient has received psychotherapy with cognitive behavioral therapy (CBT). There are no comorbid psychiatric disorders in this case or co-occurring substance use disorders, and the patient does not have an acute or chronic general medical condition that is a focus of treatment. 

Transcranial Magnetic Stimulation (TMS) and Cranial Electrical Stimulation (CES) is not medically necessary for this patient.
In this case, the patient is diagnosed with major depressive disorder with severe symptoms as indicated with the scoring on the PHQ-9. However, the patient has only received treatment with selective serotonin reuptake inhibitor (SSRI) class antidepressants and has not received augmentation with an FDA (Food and Drug Administration) approved augmentation agent. 
Per the prevailing standards of care, clinically appropriate approaches are available for treatment of depressive disorder in this case, including other antidepressants with a disparate mechanism of action or combination therapy, or an alternative established augmentation therapy, as well as specific forms of psychotherapy that would establish that the patient is treatment refractory. Thus, standard therapeutic treatments that are known to be effective in the treatment of Major Depressive Disorder should be used first prior to treatment with Transcranial Magnetic Stimulation (TMS) and Cranial Electrical Stimulation (CES).