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

Diagnosis: Acne.
Treatment: Tretinoin 0.1% cream.
The insurer denied coverage for tretinoin 0.1% cream.
The denial is overturned.

The patient is a female with a long history of acne who has tried and failed multiple topical and oral medications, including doxycycline, minocycline, spironolactone, OCP (oral contraceptive pills), benzoyl peroxide with clindamycin, aczone, and finacea. The requested medication is tretinoin 0.1% (percent) cream. The insurer denied tretinoin with a request to first try and fail OTC (over the counter) retinols.  

Based on the submitted documentation, the use of tretinoin is medically necessary. The patient has failed numerous prescription strength systemic therapies as well as prescription topicals for her acne. The use of prescription strength retinoids is a mainstay in the treatment of acne vulgaris. Although benefit can be obtained from OTC retinoids, including adapalene, the medical documentation indicates that the patient requires prescription strength medications for control of her acne. The patient has responded well to topical tretinoin without any significant documented adverse reactions and with good efficacy.  

Based on the submitted documentation, the use of tretinoin cream is medically necessary. The decision is overturned in whole.

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 Tretinoin 0.1% is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion. 
Treatment: D8080 Braces. 

The insurer denied coverage for D8080 braces. 

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. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet this specified handicapping malocclusion medical necessity requirement 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 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 plan criteria to justify 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. 

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

The insurer's denial of coverage for D8080 braces is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is overturned.

This is the case of a female with a history of arthritis, asthma, morbid obesity, hyperlipidemia, hypertension, and obstructive sleep apnea. The patient presented to the Hospital for a left knee replacement. 

The medical record demonstrates the patient had several active comorbidities. Her morbid obesity is associated with higher complication rates. Her pain level of 10/10 (on a pain scale of 1-10) on POD (post-operative day) #1 required adequate analgesia. There were delays with her mobilization. She was reported to be hypertensive. 

Based upon her underlying clinical condition and course, services could not have been provided at a lower level of care.

An inpatient admission is considered medically necessary for this patient.

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 an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Aldactone 50mg. 
The denial is upheld.

The patient is a female patient with androgenetic alopecia. Generic Spironolactone caused terrible headaches, heartburn, and hair loss recurrence. Platelet-Rich Plasma also helped but is painful and expensive. Because of the expense of Aldactone, restarting generic spironolactone was tried but hair loss recurred.
At issue is the medical necessity of Aldactone, 50 milligrams (mg).

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

The requested health service/treatment of Aldactone 50mg is not medically necessary for this patient.
Current literature [1-5] does support the use of spironolactone, either brand name or generic, in the use of female-pattern androgenetic alopecia. The use of spironolactone, with either oral finasteride and either topical or oral minoxidil, demonstrates effective and safe benefit associated with significant hair regrowth. However, no functional, physical, or medical impairment is associated with this condition, and therefore the use of either brand-name Aldactone or generic spironolactone is not medically necessary. Androgenetic alopecia, while socially and psychologically distressing to some (but not all) patients, is one of cosmesis and not a condition associated with pain, limited movement or function, risk of infection, association of cancer, or shortened lifespan. For any form of treatment for any condition to be medically necessary, functional impairment and physical harm to the patient must be demonstrated if that treatment were withheld. Such is not the case with this patient, and with this condition.
Therefore, the requested health service/treatment of Aldactone 50mg is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Developmental Disorder

Treatment: Increase in CDPAS (consumer directed personal assistant services) hours to 37.25 per week

The insurer denied coverage for an increase in CDPAS (consumer directed personal assistant services) hours to 37.25 per week

The denial is upheld 

This is a male who was diagnosed with developmental delay and seizure disorder.  He is currently receiving 25.75 hours/week of CDPAS.  Under review is the requested increase to 37.25 hours/week of CDPAS.

According to the Uniform Assessment System (UAS) report, the patient lives with his parents and extended family (5 members total).  His cognitive ability is described as "severely impaired" and has not significantly changed since the prior assessment. He requires extensive assistance to total dependence for bathing, personal hygiene and dressing.  He requires limited assistance for toilet use. He is infrequently incontinent of bowel and bladder. However, the patient is independent with bed mobility, transfers and ambulation. The clinical records do not support a level of physical impairment, debility or significant functional decline to support the medical necessity of an increase in consumer directed personal assistant service (CDPAS) hours to 37.25 per week.

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).  

From a physical medicine and rehabilitation perspective, the requested increase Consumer Directed Personal Assistant Service (CDPAS) hours to 37.25 per week is not medically necessary.  

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

The insurer's denial of coverage for an increase in CDPAS hours to 37.25 per week is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overdose.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male teen with history of major depressive disorder and ADHD (attention deficit hyperactivity disorder). He was taken to the ED (emergency department) via EMS (emergency medical services) after he took knives and medications and locked himself in his room following an altercation with his family. The medications included fluoxetine, guanfacine, and melatonin.

Upon arrival to the ED (emergency department), the patient had no complaints. Vital signs included temperature 36.8, heart rate 92, respiratory rate 20, and blood pressure 133/81. Examination was significant for moist mucous membranes, pupils equal round and reactive to light, normal heart rate, no focal neurologic deficits, and normal mood. Poison Control was contacted, and due to concerns regarding guanfacine ingestion, recommendations included monitoring (8 hours for IR [immediate release] dosing, > [greater than] 24 hours for ER [extended release] dosing). Symptoms to monitor included respiratory depression, hypotension, bradycardia, and CNS (central nervous system) depression. Admission to the PICU (pediatric intensive care unit) was planned to include toxicology labs and Psychology consultation. Admission orders included 1:1 observation and Psychiatric consultation. He did not voice suicidal ideation. Laboratory evaluation was non-contributory. While in the PICU (pediatric intensive care unit), he remained on continuous cardiorespiratory monitoring. He remained stable and asymptomatic, so was transferred to the Pediatric Ward after about 8 hours. While on the Pediatric Ward, he was evaluated by Psychiatry and eventually discharged.

No, the Inpatient admission was not medically necessary.
This young man threatened ingestion of multiple medications, including guanfacine with potential for cardiorespiratory depression, as well as fluoxetine and melatonin. It is unclear if he actually ingested the medications, although he was seen with putting pills into his mouth. He was asymptomatic in the ED (emergency department) with no suicidal ideation or intent, and this remained the case for the duration of his hospital stay. He was monitored in the PICU (pediatric intensive care unit) for 8 hours per Poison Control recommendations and then transferred to the Pediatric Ward for Psychiatry consultation and determination of best safe disposition. While it was important to monitor for the recommended 8 hours (per Poison Control, appropriate for the IR [immediate release] formulation of guanfacine), he remained hemodynamically stable with no evidence of cardiorespiratory depression and did not require acute inpatient admission. He could have been safely and appropriately managed at a lower level of care such as observation.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

The patient is a male with a past history of febrile seizures who was sick with fever, difficulty breathing and a cough for 3 days. He was seen in urgicare and referred to the Emergency Room (ER) for admission. He had been seen in the ER 10 days before the admission when he had fever to 103. He was found to have a viral illness with isolation of adenovirus and parainfluenza virus from a respiratory nasal viral panel. He was discharged from the ER and continues to have fever for 3 days. There was no fever the next 3 days, but the fever returned to 104 degrees three days prior to the admission. He was seen by his pediatrician and given one dose of intramuscular (IM) antibiotics.
 
In the ER the child was noted to have fever and shallow belly breathing. He had an elevated white blood count of 31.6 with a shift to the left. His sedimentation rate was elevated at 57 and his lactic acid level was elevated at 2.3. A chest x-ray showed a pleural effusion and an infiltrate in the left lung. He was treated with an intravenous (IV) bolus of normal saline and an IV dose of ceftriaxone. Based on the prolonged illness with persistent fever, his increased respiratory effort and the chest x-ray and blood testing he was diagnosed with pneumonia and the decision was made to admit for continuation of IV antibiotics.

The insurer has denied coverage for acute in-patient admission to the hospital.

The patient was treated appropriately in the ER for a diagnosis of pneumonia following a prolonged febrile illness. He had an elevated white blood count with a shift to the left in his polymorphonuclear cells and elevated sedimentation rate and a Lactic acid level. The chest x-ray was also consistent with a left sided pneumonia with the presence of a pleural effusion. The decision to admit to the hospital was consistent with the standard of care for treatment of pneumonia in a child with a pleural effusion.

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 inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spasms during sleep, failure to thrive, and poor oral intake

Treatment: Inpatient hospital admission

The insurer denied coverage for an inpatient hospital admission.

The denial is upheld.

This is the case of a female with a history of intrauterine growth restriction (IUGR) and corpus callosum agenesis, who presented to the emergency room (ER) from a neurology clinic with complaints of spasms during sleep, failure to thrive, and poor oral intake. The patient was admitted for care and underwent assessment utilizing a 24-hour video electroencephalogram (VEEG), started in the ER. The patient had a history of gastrointestinal issues to include projectile vomiting, dietary issues, and constipation. She was discharged after a period of hemodynamic stability. The inpatient care was denied coverage and the provider claims that the patient could not have been safely treated at the observational level. An appeal claimed that the patient presented to the ER with spasms during sleep, had poor oral intake and failure to thrive. She appeared to be sleepy, was admitted for care, and VEEG monitoring was completed. 

According to the Milliman Care Guidelines, clinical indications for admission to inpatient care for issues with failure to thrive include suspected abuse or severe neglect, inpatient level evaluation of psychosocial interaction between child and caregivers is deemed necessary, when there is evidence of severe malnutrition as indicated by one or more of the following to include measurements that are 3 standard deviations below the median for an age and gender standardized population to include weight for height and length, body mass index for age, or mid-upper arm circumference, or if the patient has inadequate weight gain or nutrition intake as indicated by patient age 23 months or younger who is getting less than 25% (percent) of expected body weight. Inpatient admission may also be indicated when there is a need for precise documentation of nutritional intake, serious underlying medical comorbidity necessitating inpatient monitoring or management, ability of caregivers to provide necessary care uncertain, when there is medical instability indicated by one or more of the following to include hypothermia, bradycardia, or hypotension, or minor significant electrolyte abnormality, and if there is insufficient response to outpatient treatment over 2 to 3 months. In the case of this patient, there was no suspicion of abuse or severe neglect, no indication that there is need for psychosocial interaction assessment between the child and caregivers, no indication of severe malnutrition, with the patient medically stable and no record of insufficient response to outpatient treatment. The inpatient admission was not considered emergent, and the assessment and treatment could have been rendered on an outpatient basis or observational basis. 

The health plan acted reasonably, with sound medical judgment, and 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: Low back and Leg pain
Treatment: Spinal Fusion Surgery
The insurer denied Spinal Fusion Surgery.
The determination is upheld. 

The patient has severe chronic low back and leg pain under review for lumbar (L) 4-sacral (S) 1 fusion. Magnetic resonance imaging (MRI) of the lumbar spine shows L4-S1 degeneration without 4 millimeters (mm) of listhesis or instability. Physical therapy (PT) and nonsteroidal anti-inflammatory drugs (NSAIDS) were noted. At issue is the medical necessity of spinal fusion surgery L4-S1.

There is no medical necessity for the requested surgery as there is no indication for lumbar fusion. There is no clear listhesis of 4 mm or more nor instability at the L4-S1 segments to warrant fusion. Jette et al noted " Positive clinical change was greatest in patients undergoing fusion for spondylolisthesis while complications and the risk of reoperation limited the benefit of fusion for spinal stenosis. The relative safety and efficacy of fusion for chronic low back pain suggests careful patient selection is required (PROSPERO International Prospective Register of Systematic Reviews number, CRD42015020153)." While the magnetic resonance imaging (MRI) of the lumbar spine shows decreased disc space height to 4 mm at L4-5, this does not indicate instability or a severe deformity to warrant a fusion.  This is stating that the disc is degenerative at that segment.  Thus, no instability is noted to warrant fusion.
Therefore, the requested spinal fusion surgery is not medically necessary.

Current smoking was noted in the records submitted for review, with no clear smoking cessation noted 6 weeks prior to fusion surgery. Smoking causes an increased risk of pseudoarthrosis for fusion cases. Nicotine cessation must be documented by negative cotinine test to confirm smoking cessation has in fact occurred. There is a negative Nicotine Metabolite, Serum, and per the state application surgery is scheduled, however, there is no medical necessity for the requested procedure. There is no indication for lumbar fusion as there is no clear listhesis of 4 millimetera (mm) or more nor instability at L4-S1 segments to warrant fusion  My prior opinion remains the same that there is no indication for fusion given a lack of instability. Jette et al noted " Positive clinical change was greatest in patients undergoing fusion for spondylolisthesis while complications and the risk of reoperation limited the benefit of fusion for spinal stenosis. The relative safety and efficacy of fusion for chronic low back pain suggests careful patient selection is required (PROSPERO International Prospective Register of Systematic Reviews number, CRD42015020153)."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back and Leg pain
Treatment: Spinal Fusion Surgery
The insurer denied Spinal Fusion Surgery.
The determination is upheld. 

The patient has severe chronic low back and leg pain under review for lumbar (L) 4-sacral (S) 1 fusion. Magnetic resonance imaging (MRI) of the lumbar spine shows L4-S1 degeneration without 4 millimeters (mm) of listhesis or instability. Physical therapy (PT) and nonsteroidal anti-inflammatory drugs (NSAIDS) were noted. At issue is the medical necessity of spinal fusion surgery L4-S1.

There is no medical necessity for the requested surgery as there is no indication for lumbar fusion. There is no clear listhesis of 4 mm or more nor instability at the L4-S1 segments to warrant fusion. Jette et al noted " Positive clinical change was greatest in patients undergoing fusion for spondylolisthesis while complications and the risk of reoperation limited the benefit of fusion for spinal stenosis. The relative safety and efficacy of fusion for chronic low back pain suggests careful patient selection is required (PROSPERO International Prospective Register of Systematic Reviews number, CRD42015020153)." While the magnetic resonance imaging (MRI) of the lumbar spine shows decreased disc space height to 4 mm at L4-5, this does not indicate instability or a severe deformity to warrant a fusion.  This is stating that the disc is degenerative at that segment.  Thus, no instability is noted to warrant fusion.
Therefore, the requested spinal fusion surgery is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: PMH (past medical history) of HTN (hypertension), HL (hyperlipidemia), CAD (coronary artery disease), DM (diabetes mellitus), arthritis and recurrent falls
Treatment: Personal Care Services (PCS) 9 hours a day, 7 days a week, for a total of 63 hours per week
The insurer denied the Personal Care Services (PCS) 9 hours a day, 7 days a week, for a total of 63 hours per week
The denial is overturned

The patient is a female. She has PMH (past medical history) of HTN (hypertension), HL (hyperlipidemia), CAD (coronary artery disease), DM (diabetes mellitus), arthritis and recurrent falls. She reportedly has weakness, immobility and dementia. She has progressive functional decline. She has dysphagia and is at risk of aspiration and needs close supervision. She is also incontinent of bladder most of the time. The patient lives alone.

Under review is the request for Personal Care Services (PCS) 9 hours a day, 7 days a week, for a total of 63 hours per week.

Yes, the personal care services 63 hours/week are medically necessary.
The patient has multiple co-morbidities. She has recently experienced significant functional decline. The patient continues to deteriorate. The patient has worsening knee pain due to arthritis and has difficulty ambulating. The patient cannot use a walker due to left arm fracture and chronic bilateral shoulder pain. The patient has worsening progressive dementia.

The patient has swallowing difficulty and is at risk of aspiration. She needs constant supervision while eating. She is at risk of aspiration and acute respiratory failure without supervision. She needs help with preparing meals, laundry, shopping, dressing, bathing, toileting and all her ADLs (activities of daily living). The health plan's approved regimen of personal care service 49 hours/week is not adequate to meet this patient's needs.

Therefore, given the above, the requested personal care services 63 hours/week are medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient has limited mobility with significant functional decline. The patient needs more hours.