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

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

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, posterior unilateral cross bite, and anterior crowding. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index Report, attaining 30 total points. 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. 

Upon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State (NYS) requires the use of an orthodontic index, the HLD Index Report (NYS Medicaid program) modeled after HLD 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 completes the second portion of the index arriving at 30 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support orthodontic care. 

Regarding the validity of the HLD 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. 

Overturn denial as the clinical circumstance as presented does meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval.

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 braces and monthly visits is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dystonia and temporomandibular joint (TMJ) pain
Treatment: Botulinum Toxin
The insurer denied: Botulinum Toxin
The denial is overturned

The patient is an adult female who received botulinum toxin for dystonia and temporomandibular joint (TMJ) pain. This was previously denied as the two conditions were not among the approved conditions for plan criteria for use of botulinum toxin. Clinic notes also note the indication of Botox for chronic migraines.

The botulinum toxin was medically necessary.

The patient has chronic migraines which is one of the covered conditions by plan and this is also supported by the American Academy of Neurology (AAN) guidelines. Furthermore, a review by Calis and colleagues in 2019 notes that botulinum toxin is a viable treatment for temporomandibular joint (TMJ) pain in
those who have not responded to conservative measurements.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, vomiting and diarrhea
Treatment: Inpatient Level of Care
The insurer denied: Inpatient Level of Care
The denial is upheld

This is an adult male with abdominal pain, vomiting, and diarrhea. The patient was hospitalized. The patient had a past medical history of iron deficiency anemia, Barrett's esophagus, hiatal hernia, chronic gastritis, suspected gastroparesis, persistent vomiting, and esophageal colonization of spirochetes with eosinophilic changes treated with four-month course of Flagyl. The patient presented to the emergency room with epigastric pain, vomiting, and diarrhea. The patient had a lipase level of 1696. Other labs showed white blood cell count 10.1 and hemoglobin 15.3. Per the denial letter, "Imaging showed no acute findings. He received intravenous fluids, Zofran, Flagyl, and proton pump inhibitor. Surgery consultant recommended no surgical intervention. He clinically improved, tolerated oral intake, and diarrhea resolved. He remained afebrile and hemodynamically stable and was discharged after an overnight stay."

The proposed treatment is not medically necessary.

The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. An observational level of stay would have been more appropriate for this patient. An observational level of stay would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, and did not have any complications such as intra-abdominal abscess or a surgical abdomen. Therefore, based on review of the submitted medical records, the requested inpatient level of care was not medically necessary for the dates of service in question as it exceeded in scope and intensity the level of care necessary to provide safe, adequate and effective treatment for this patient's condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ventricular tachycardia
Treatment: Outpatient surgery (33262 x 1)
The insurer denied coverage for outpatient surgery (33262 x 1).
The denial is overturned.
 
Asked to review the case of an elderly patient with a history of cardiomyopathy, sustained ventricular tachycardia and Boston Scientific subcutaneous implantable cardiac defibrillator (ICD) system in situ.  The patient was noted to have an appropriate ICD (implantable cardiac defibrillator) shock in the past. The patient was followed with remote monitoring.  A remote transmission submitted for review demonstrated that the device tripped the elective replacement indicator.  The patient was scheduled appropriately for pulse generator replacement surgery.  

This patient had a history of cardiomyopathy and ventricular tachycardia (VT).  He had a class one indication for ICD (implantable cardiac defibrillator) implantation and pulse generator replacement at the time of battery depletion (elective replacement indicator). (Reference 1) Multiple studies have demonstrated the effectiveness of ICD (implantable cardiac defibrillator) therapy in patients at risk for VT (ventricular tachycardia), even after recovery of left ventricular function. (Reference 2). In this case failure to replace the defibrillator would put the patient's life in danger and place them at risk for sudden cardiac death. In conclusion outpatient surgery current procedural terminology (CPT) 33262- Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator- is medically necessary for this patient.

Based on the above, the insurer's denial must be overturned. 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 outpatient surgery (33262 x 1) is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Atopic dermatitis
Treatment: Opzelura 1.5% (percent) Cream
The insurer denied Opzelura 1.5% Cream. The health plan's determination is upheld.

The patient is a male with atopic dermatitis (AD). He has tried and failed triamcinolone and Protopic ointment. The prescriber is a dermatologist. The medication under review is Opzelura 1.5% Cream.

A formulary exception is not indicated in this case.
The formulary drug would be as effective as the non-formulary drug. The formulary drug would not have adverse effects. According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the preferred medications covered by the patient's insurance plan, such as crisaborole (Eucrisa), are effective treatments for the management of atopic dermatitis.
According to Paller et al "Crisaborole demonstrated a favorable safety profile and improvement in all measures of efficacy, including overall disease severity, pruritus, and other signs of AD."
It is noted that the patient has tried and failed topical tacrolimus. However, the patient has no true contraindications to the other preferred, formulary medications which have been shown to be effective for the treatment of atopic dermatitis. The evidence-based literature is consistent and in line with the plan formulary. The preferred agents, such as crisaborole, are appropriate agents for the treatment of the patient's atopic dermatitis. The formulary medications should be tried and failed prior to initiating Opzelura 1.5% Cream.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration, abdominal pain, diarrhea.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is a pre-school male child with unremarkable medical history that presented to the emergency department with two-week history of intermittent diffuse abdominal pain, vomiting, and diarrhea. He had one episode of fever to 101, with decreased appetite and activity. After one episode of vomiting, he fell off the bed hitting his head, with no loss of consciousness. The patient's vital signs included temperature 36.7, heart rate 113, and respiratory rate 20. Examination was significant for tired but non-toxic appearance, moist mucous membranes, diffuse abdominal tenderness, no rebound or guarding, and non-focal neurologic exam. Bedside glucose was 53. Labs were significant for white blood cell (WBC) count 9.51 thousand (K), platelets 348 thousand, sodium 134, potassium 4.9, carbon dioxide (CO2) 15, chloride 96, aspartate aminotransferase (AST) 42, and alanine amino transferase (ALT) 9. Urinalysis was unremarkable except for large ketones and large blood. COVID and respiratory syncytial virus (RSV) rapid testing was negative. The patient was treated with an intravenous fluid bolus and admitted for ongoing intravenous hydration. Overnight, the patient remained afebrile, with improved appetite, increased activity, and good oral intake. He was deemed stable for discharge the next day to follow-up with his pediatrician in two to three days.

The proposed inpatient hospital admission was not medically necessary.

Acute inpatient hospitalization was not medically necessary in this case. Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of five years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health 
Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications. Hospitalization may be necessary for 
those that do not respond to oral hydration and anti-emetic treatment, as well as those with severe dehydration.
This young male child presented with two-week history of intermittent diarrhea, some fever, and an episode of vomiting. He was dehydrated, not able to take sufficient fluids by mouth in the 
emergency department. While it was reasonable to monitor the patient in the hospital for improving intake and ability to keep up with fluid losses, he was overall hemodynamically stable with no evidence of impending hypovolemic shock and no significant metabolic abnormalities. He did not require acute inpatient admission and could have been safely managed at a lower 
level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This patient has a history of asthma. He presented to the emergency department (ED) with complaints of shortness of breath (SOB), chest tightness and wheezing of 1 week duration. The patient reported coming to the ED the previous day also for similar complaints. The patient reported increased use of the rescue inhaler but not much relief. He denied fever or chills. Peak expiratory flow (PEF) was 380.

Vital signs at presentation: Temperature 97.8 degrees F (Fahrenheit), Pulse 117, Respirations 16, Blood Pressure 124/83, oxygen saturation on room air was 94% (percent). He was in no acute distress. Lung exam revealed bilateral wheezing. He was able to speak full sentences. No use of accessory muscles documented. The patient was alert and oriented x 3 and the neurological exam was unremarkable.

The patient was treated with Albuterol and Ipratropium nebulizer, Fluticasone, Dexamethasone intravenous (IV), IV fluids and magnesium. Lab studies were within normal limits. His white blood cell count was 10.6. D Dimer was negative. Chest x-ray revealed no infiltrates, effusion or pneumothorax.

The patient reported improvement after treatment in the ED but still had some chest tightness and was continued on steroids and bronchodilators. He remained stable after admission and was subsequently discharged home.

This patient did not need acute inpatient hospitalization. He could have been placed in observation level for diagnostic testing and treatment. Observation could be for up to 48 hrs. The patient had improved after initial treatment in the ED. He was ambulatory, tolerating food and fluids and the chest x-ray showed no positive findings. He was not hypoxic and there was low clinical probability for pulmonary embolism.

This patient could have been placed under observation while diagnostic testing and treatment were initiated. The patient could have been managed on observation status and subsequently discharged home on oral medications and nebulizers.

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: Overturned

Diagnosis: Crohn's disease
Treatment: Stelara 90 mg every 4 weeks
The insurer denied Stelara 90 mg every 4 weeks.
The determination is overturned.

This is a female patient with moderate to severe Crohn's disease, primary sclerosing cholangitis, and iron-deficiency anemia. She failed mesalamine, Humira and Cimzia with 6-mercaptopurine. She started Stelara and has been on Stelara with 6-mercaptopurine. A colonoscopy showed mild to moderate Crohn's ileocolitis (with ileal ulceration and colonic erythema, congestion, and inflammatory polyps); Stelara was increased to 90 milligrams (mg) every 4 weeks. She is now in clinical remission. The medical necessity of Stelara 90 milligrams (mg) every 4 weeks for the treatment of Crohn's disease is under review.

Current medical literature supports the continuation of Stelara 90 mg every 4 weeks as medically necessary for the treatment of Crohn's disease in this case.
A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohn's disease that was resistant to anti-tumor necrosis factor (TNF) therapy (Sandborn, et al). Another study showed a 73 percent (%) response in patients with anti-TNF-resistant Crohn's disease, and 80% of responders maintained remission for 1 year (Kopylov, et al). The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor medications, which the patient has failed (Tuskey, et al). A study showed dosing at 90 mg every 4 weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every 4 weeks (Kopylov, et al). Multiple studies have shown that a majority of patients in whom Stelara dosing every 8 weeks failed to control symptoms responded to dosing every 4 weeks (Wils, et al; Battat, et al; Khorrami, et al; Ollech, et al; Fumery, et al; Haider, et al). In this case, the patient had a colonoscopy showing inflammation while taking Stelara every 8 weeks. The American College of Gastroenterology guidelines for the treatment of Crohn's disease state that medication dose should be "adjusted in order to attempt to optimize therapy" (Battat, et al; Lichtenstein, et al). Decrease of the current Stelara dose (every 4 weeks) or discontinuation of Stelara (even if an alternative is attempted immediately) may result in loss of disease control, with complications such as stricture, fistula, bowel obstruction, flare, hospitalization, need for surgery, or other complications. For these reasons, the request to continue Stelara 90 mg every 4 weeks is supported as medically necessary for the treatment of this patient's Crohn's disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tremor, Falls, Down Syndrome
Treatment: Consumer directed personal care assistance services, a total of 56 hours/week
The insurer denied consumer directed personal care assistance services, a total of 56 hours/week.
The determination is overturned.

This is a male patient with a medical history notable for Down syndrome and falls. The patient is approved for 35 hours/week of consumer directed personal care assistance services. The patient and his care team requested an increase to 56 hours/week, and this request was denied by the health plan.

The patient's physician provided a letter of support for this appeal. The letter states that the patient has had a significant physical decline. His hearing and tremors have worsened. He is not able to direct his own care. He has to avoid prolonged standing and walking. He requires assistance with showering, feeding, and changing pull-ups.

A Mini-Mental State Exam (MMSE) was completed and the score was 10/30. This score is consistent with moderate to severe dementia.

A Uniform Assessment System (UAS) was completed and was available for review. The review was conducted via teleconference with the patient's sister present. Cognition was moderately impaired. For his instrumental activities of daily living (IADLs), he requires total dependence for finances. He requires maximal assistance for meal preparation, housework, medications, phone use, and shopping. For his activities of daily living (ADLs), he requires extensive assistance for bathing, hygiene, dressing, and toilet use. He requires limited assistance for walking, locomotion, toilet transfer, and eating. He is independent with bed mobility. Of note, the patient had a fall and has chronic back pain and tremor which contribute to challenges with ADLs. He ambulates with a cane with hands-on assistance. He "exhibits need for additional assistance and supervision with all tasks of daily living." He is frequently incontinent of urine and uses pull-ups at night for incontinence care. A task tool associated with the assessment recommended 35 hours/week to address his personal care needs. At issue is the medical necessity of consumer directed personal care assistance services, a total of 56 hours/week.

The requested health service of consumer directed personal care assistance services, a total of 56 hours/week is medically necessary for this patient.

The patient has had a functional decline and now requires hands-on assistance with nearly all ADLs. He has cognitive impairment and is not self-directing. He will need assistance with locomotion and with toileting, including changing soiled pull-ups. The task tool cannot be relied on to accurately reflect his true need given the continuous and unscheduled nature of his personal care needs. The UAS states that he "exhibits need for additional assistance and supervision with all tasks of daily living." Therefore, it is medically necessary to increase his personal care hours to address his needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Computed tomography (CT) scan (procedure code 74177)
The insurer denied coverage for the CT scan (procedure code 74177).
The denial is upheld.

The patient was complaining of bloating, left sided abdominal discomfort which was mostly epigastric, arm pain, shortness of breath (SOB), and coughing. Her vital signs were stable and the oxygen saturation was 99 percent (%) on room air. Her physician ordered a computed tomography (CT) scan of the chest, abdomen, and pelvis. There was a family history of metastatic breast cancer and pancreatitis. The CT scan was read as having no specific findings to account for the patient's symptoms.

Milliman Care Guidelines (MCG) guideline A-0013 lists clinical indications for an abdominal/pelvic CT scan. These indications include having an aortic aneurysm, abdominal abscess, evaluation of a known cancer, jaundice, evaluation of severe liver disease, abdominal mass, and abdominal pain if there are other indications. These indications include having unexplained pain after a plain X-ray or ultrasound imaging, intestinal obstruction, suspected diverticulitis, suspected splenic infarction, suspected appendicitis, and persistent right upper quadrant (RUQ) pain after obtaining an ultrasound. The patient did not have these conditions. She also did not have acute pancreatitis, complicated pyelonephritis, or abdominal trauma.

This patient had some abdominal discomfort and bloating. She did not have a known cancer or abdominal mass. MCG guidelines advise obtaining ultrasound imaging for unexplained abdominal pain prior to obtaining a CT scan. Since there is no prior ultrasound, mass, or known malignancy, the abdominal and pelvic CT scan did not meet MCG guidelines. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for CT scan (procedure code 74177) is not substantiated.