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

Diagnosis: Malocclusion
Treatment: Orthodontic care: D8080 braces and D8670 monthly visit x 12
The insurer denied coverage for: Orthodontic care: D8080 braces and D8670 monthly visit x 12
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, Dr. David Schneeweiss identified several clinical findings including overjet; and overbite, ectopic eruption and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 34 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 17 points by internal reviewers. The patient's mother is appealing the decision.

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, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labia-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 34 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 17 points on the HLD index (3 overjet, 5 overbite, 5 anterior crowding, 4 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 D8080 braces and D8670 monthly visit x 12 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 is a teenage female patient. She had abdominal pain and was hospitalized for 3 days. The reason for the prior denial was that the requested inpatient care did not meet criteria. The reason for appeal is that the patient had abdominal pain and possible appendicitis and needed inpatient care.
Brief summary of hospital stay:
Day #1 (Admission note): the patient was seen in emergency department for abdominal pain, initially epigastric and then right lower quadrant. Surgery was consulted and was concerned for possible appendicitis. The recommendation was for admission for observation and serial abdominal exam. The plan was for nothing by mouth (NPO), intravenous fluids, and monitoring. 
Day #2 (Progress note): no additional symptoms since yesterday; no acute events; no fever, nausea, or vomiting. The plan was for ultrasound exam.
Day #3 (Progress note): the patient had a normal ultrasound exam; there were no acute events or symptoms. The patient was discharged home.

The requested health service was not medically necessary.

As documented in the clinical notes, this patient had acute abdominal pain and was suspected to have possible appendicitis after surgery consult. Surgery recommended admission for observation and serial abdominal exam. During the hospital stay the patient received intravenous fluids and oral intakes. The patient's pain was gone after admission, and she tolerated oral (PO) intake. There was no documentation of any acute events. Thus, the acute inpatient care was not medically necessary. During the hospital stay, the patient did not have appendicitis. She had abdominal pain, nausea and chills and symptoms stopped after admission. While there was concern for acute gastritis or gastroenteritis which may require intravenous fluids for dehydration, these can be managed at observational level of care (1-3).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is the case of a patient with a history of ischemic heart disease and prior stent placement to the right coronary and left anterior descending arteries, that presented to the hospital complaining of chest pain radiating to the left arm and back for five days duration.  Past medical history was significant for diabetes mellitus, hypertension, hypercholesterolemia and apical hypertrophic cardiomyopathy.  On arrival to the hospital vital signs were stable: blood pressure (BP) 144/70 and pulse 64. Physical exam revealed no significant abnormality. 12 lead electrocardiogram (ECG) demonstrated sinus rhythm with left ventricular hypertrophy and deep T wave inversions in leads V3-V6.  Serum troponin levels were not elevated (13).  The patient was admitted to the hospital for monitoring and additional testing. Echocardiography demonstrated apical variant hypertrophic cardiomyopathy with blood trapping at the apex. Cardiac catheterization demonstrated nonobstructive coronary artery disease and patent stents in the right coronary artery (RCA) and left anterior descending (LAD) arteries.  The patient was treated with beta blocker and calcium channel blocker therapy and ultimately discharged with plans for future cardiac magnetic resonance imaging (MRI). 

The health plan did not act reasonably, with sound medical judgment and in the best  interest of the patient.  This patient presented with chest pain that worsened with exertion and ECG findings that were markedly abnormal. The patient's pretest probability of coronary artery disease was high (Reference 1).  Utilizing the HEART (History, ECG, Age, Risk Factors, Troponin) score, the patient was considered high risk (8 points) (Reference 2). Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a high risk of major adverse cardiac events (defined as 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 at a higher level of care. Serial troponin measurement, echocardiography and cardiac catheterization were warranted prior to discharge.  In conclusion, admission to the hospital to treat an acute cardiac event was medically necessary.

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 the full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vitamin D deficiency. 
Treatment: Vitamin D Testing. 
The insurer denied Vitamin D testing. 
The health plan's determination is upheld. 

This is a case review for a male who was ordered a test for serum vitamin D level for the diagnosis of suspected low vitamin D level. Coverage for this test was denied by the health plan. 
There were no letters of medical necessity or office visit notes provided as part of this appeal. 
The patient's bloodwork from the past several years was provided. His vitamin D levels were checked several times before. 

The requested Testing for Vitamin D Level is not medically necessary for this patient.
There is no medical justification provided regarding why the test was medically necessary for the patient. Routine screening for vitamin D levels is not recommended in the absence of symptoms of overt deficiency. No medical records were provided that would suggest overt deficiency.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Elevated triglycerides

Treatment: Vascepa 1 gram (g) Capsule

The insurer denied coverage for Vascepa 1 gram (g) Caps

The denial is upheld
 

Asked to review case for formulary exception of Vascepa therapy for hypertriglyceridemia.  The patient was prescribed Vascepa brand tablets and documentation provided states that the patient had trial and failure of generic icosapent ethyl.  The patient has a history of hypertension, diabetes mellitus, hypertriglyceridemia, atherosclerotic cardiovascular disease and previous percutaneous coronary intervention.  The patient is currently treated with Lipitor 80 milligrams (mg) daily and Vascepa 2 grams (g) twice daily (BID) and has a lipid panel demonstrating a total cholesterol of 181, high-density lipoproteins (HDL) 51, triglycerides (TG) 259 and low-density lipoproteins (LDL) of 78.  Prior to initiating Vascepa, serum triglycerides were 358.  The American Heart Association (AHA) defines moderate elevation of TG levels as those between 200-400(1). The guidelines recommend intensive statin therapy for the treatment of moderate to severe hypertriglyceridemia as well as Omega 3 fatty acid treatment (2).  There have been conflicting trial results demonstrating the efficacy of omega 3 fatty acids in reducing atherosclerotic cardiovascular disease (ASCVD) risk in those with hypertriglyceridemia. However, these findings were largely due to differing patient enrollment and differing doses of omega 3 fatty acids. The REDUCE-IT trial was a prospective double blind placebo controlled trial that enrolled patients with high cardiovascular risk. All patients had statin resistant hypertriglyceridemia. Among patients with elevated triglyceride levels despite the use of statin, the risk of ischemic events and cardiovascular death was significantly lower in the patients treated with Vascepa. (Reference 3) The AHA science advisory noted that the use of Vascepa is an effective and safe option for reducing triglycerides. (Reference 4). The ANCHOR study evaluated reduction in triglyceride levels and compared 2 grams versus 4 grams per day of Vascepa in patients with elevated triglyceride levels (200-500mg/dl).  The study demonstrated a 22% reduction in triglyceride levels with the 4g dose. (Reference 6). In addition, a statistically significant reduction was noted in total and LDL cholesterol. 

The formulary drug, icosapent ethyl is unlikely to cause the patient an adverse reaction. No specific documentation has been submitted to support any adverse reaction or ineffective therapy with icosapent ethyl- generic formulation. 

The formulary drug is likely to be effective and the requested drug is not likely to be more effective than generic formulation.

In conclusion, Vascepa- brand tablets would not be more effective than the formulary medication- generic icosapent ethyl.

The carrier's denial of a request for a Formulary Exception for Vascepa 1gm Capsule to treat hypertriglyceridemia  is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase Personal Care Aide (PCA) Services for a Total Amount of 168 Hours Per Week
The insurer denied Increase Personal Care Aide (PCA) Services for a Total Amount of 168 Hours Per Week.
The denial is overturned.

The patient is an elderly female. Her medical conditions include dementia, diabetes, hypoxia, sleep apnea, and osteoarthritis. Denial of increase personal care aide (PCA) services for a total amount of 168 hours per week is being appealed. The health plan approved 56 hours per week. Uniform Assessment System (UAS) evaluation completed earlier this month shows moderately impaired cognition and functional status: maximal assistance to total dependence with all ADLs (activities of daily living), except eating. She has frequent bowel and bladder incontinence. 
Compared to UAS (Uniform Assessment System) evaluation completed 9 months ago, there has been a decline in functioning.
An Advocacy Report indicates a decline in ability to perform ADLs (activities of daily living) and the patient has unscheduled overnight needs with toileting. She is found soiled in the morning when aides arrive. She has frequent falls.

The requested Increase Personal Care Aide (PCA) Services for a Total Amount of 168 Hours Per Week is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase personal care aide (PCA) services for a total amount of 168 hours per week is being appealed. The health plan approved 56 hours per week. This patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation completed on earlier this month shows the patient requires assistance with all ADLs (activities of daily living), except eating. Her functioning has declined compared to prior UAS (Uniform Assessment System) evaluations. Appeal statement support the need for assistance with all ADLs (activities of daily living) for both day and nighttime assistance with transfers and toileting. The information provided show that this patient has significant limitations in functioning. Her limitations extend through nighttime. The approved PCA (personal care aide) 56 hours per week is insufficient to meet this patient's needs for assistance with ADLs (activities of daily living). The requested increase to 168 hours per week is indicated and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: sepsis
Treatment: inpatient stay
the insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a male with lung cancer status/post (s/p) right upper lobe (RUL) apical segmentectomy and posterior segment wedge resection, diabetes mellitus (DM), hypertension (HTN), HLD (hyperlipidemia), and Asthma who presented to the emergency department (ED) with chest congestion, feeling shortness of breath (SOB), with cough with clear phlegm. He reported a fever to 100.4 the night before and in the morning reported a temperature of 100.7.

The inpatient hospital admission was not medically necessary as of the dates in question. This patient was afebrile and hemodynamically stable throughout admission. He reported low grade fevers at home but was never febrile in hospital. His initial tachycardia resolved quickly, his leukocytosis trended down and his white blood cell count (WBC) was normal. His chest tube was removed on hospital admission day 2. His blood cultures showed no growth, a culture from chest tube site grew out methicillin-susceptible staphylococcus aureus (MSSA). Pleural fluid culture showed no growth.
The patient was clinically much improved, afebrile, hemodynamically stable, with normal WBC. His chest tube was removed. He was continued on antibiotics for a superficial infection at chest tube site. He did not have a deep space infection, he did not have empyema, he did not have a necrotizing fasciitis. As of the date in question, there was no medical reason patient required ongoing inpatient hospitalization. As of the date in question, he could have been safely and appropriately discharged home on oral antibiotics.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Scrotal Wall Abscess
Treatment: inpatient hospital admission
The insurer denied inpatient hospital admission.
The determination is overturned.

The patient is a male child admitted with a diagnosis of a scrotal wall abscess. Management in the hospital included Clindamycin for a potential staphylococcal infection, followed by operative drainage of an ultrasound proven scrotal wall lesion consistent with infected median raphe cyst-given the location. At issue is the medical necessity of inpatient hospital admission.
The inpatient hospital admission was medically necessary to treat the abscess which required drainage and monitoring postoperatively for non-progression. Antibiotic therapy requirements required culture results to preclude a poor outcome. As no intra-scrotal component was identified, simple drainage, culture, and packing was appropriate therapy. Given an afebrile patient with a wound that precluded a resistant organism that could have necessitated intravenous therapy, the patient was appropriately discharged on oral Bactrim and wound care instructions for outpatient monitoring with both medical and surgical teams. The literature supports deliberate diagnosis and management of scrotal wall infections in the pediatric population as they can represent an early sign of a more complex issue from anorectal fistulae (1), or be associated with potentially resistant organisms (2). The hospital admission was appropriate for decisive care of the patient and assurance of ongoing management that prevents a return to emergency room (ER) and potentially poor patient outcome.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: breast abscess
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

This case involves a woman with polysubstance abuse who was admitted to the hospital due to left breast pain with erythema caused by a breast abscess. The abscess started as a pimple two weeks before this presentation and progressively worsened. She developed ulcerations to the left breast. She also had right medial thigh ulcerations with a hard lump underneath. At the time of the admission, there was no drainage from the ulceration. The patient has a history of methicillin-resistant staphylococcus aureus (MRSA) based on nasal swabs. Medical history includes seizure disorder, treated with phenobarbital, with unclear compliance. The emergency department (ED) requested the medical admission and surgery consultation, with plans for incision and drainage.

The inpatient hospital admission was medically necessary.
Based on the provided documentation, the patient has a large breast abscess, likely due to methicillin-resistant staphylococcus aureus (MRSA), that required incision and drainage in the operating room. Admission vital signs showed evidence of systemic inflammatory response syndrome (SIRS), with tachycardia and low-grade fever. Bedside incision and drainage (I&D) was not feasible given the abscess size, therefore exceeding the observation level of care. Additionally, the initial blood cultures showed bacterial growth, which was quite concerning. Simple cellulitis with a small abscess can be managed typically under an observation level of care, with bedside I&D, packing, and discharge with an oral antibiotic regimen. However, this patient appears to have a history of drug use, history of MRSA, and seizure disorder, limiting the choice of antibiotics use. In addition, there is evidence of multi-antibiotic resistance from the operative culture. There is also a secondary wound/abscess in the right thigh, which qualifies this as a complex infection. The patient was at risk for developing severe sepsis and septic shock, and the determination to admit under an inpatient level of care appears appropriate based on nationally accepted medical guidelines and criteria. Based on these facts, inpatient admission was indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Temporomandibular disorder
Treatment: D8080 Braces, D8670 Monthly Visit
The insurer denied: D8080 Braces, D8670 Monthly Visit
The denial is overturned.

The patient is a teenage female. The request is for orthodontic benefits with monthly visits. The patient has a Class III malocclusion with severe TMD (temporomandibular disorder). There is also facial asymmetry and a maxillary cant to the occlusion. The treatment plan is to have orthodontic treatment and orthognathic surgery. The health plan's prior denial of coverage was due to patient scoring 6 points on the handicapping index scale. The denial is being appealed.

The requested D8080 Braces, D8670 Monthly Visit are medically necessary.

The patient has two permanent anterior teeth in crossbite. These are automatic qualifiers for orthodontic benefits according to the handicapping index scale. Orthodontic treatment is needed to correct the patient's malocclusion. Monthly visits are needed to make sure the treatment is progressing properly. This case has medical necessity.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Constipation

Treatment: Ibsrela 50 mg (milligram) tablet to treat constipation

The insurer denied coverage for Ibsrela 50 mg (milligram) tablet to treat constipation

The denial is overturned.

The patient has a history of constipation. An office visit note has been submitted for review. The patient was having abdominal pain and rectal bleeding. The patient was on Miralax but was continuing to have symptoms. At the time of the visit, the patient was on lbsrela. The physician has attached an addendum stating that the patient has previously tried and failed Linzess, Trulance, and Amitiza. 

UpToDate has an article titled "Treatment of Irritable Bowel Syndrome in Adults." The article discusses treatment of irritable bowel syndrome with constipation (IBS-C). The recommendation is that if patients fail soluble fiber such as psyllium, polyethylene glycol  (PEG) should be given. If there is persistent constipation after treatment with a PEG preparation, the patient should be treated with lubiprostone, linaclotide, or plecanatide. Tenapanor is given for patients who have failed the other constipation treatments. 

The insurance company has denied the lbsrela based on the lack of documentation of the failure of the formulary alternatives which are Linzess and Lubiprostone. The physician has put into the medical record that these medications have previously been tried and failed. Since the physician has documented that there was a failure of Lubiprostone and Linzess, then giving lbsrela is appropriate treatment. 

The formulary alternatives are not likely to cause an adverse reaction. However, the physician has written in the medical record that the formulary alternatives were ineffective. It is the advice of UpToDate to give lbsrela when Linzess and Amitiza are ineffective. The denial is reversed.

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is expected to be ineffective.

The non formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Ibsrela 50 milligram (mg) tablet is reversed.