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

Diagnosis: Non-Radiographic Axial Spondylarthritis

Treatment Cimzia 200 milligrams/milliliter (mg/ml) kit

The insurer denied coverage for Cimzia 200 milligrams/milliliter (mg/ml) kit

The denial is overturned

This is a patient with a history of non-radiographic axial spondylarthritis. The patient reported having back pain with rest, joint pain, and stiffness that takes hours to improve. The physician recommended taking 75 milligrams (mg) of Indomethacin twice a day (BID) as needed (PRN) for pain and starting Cimzia. 

UpToDate in "Treatment of axial spondylarthritis (Ankylosing Spondylitis and non-radiographic spondyloarthropathy) in Adults as well as "Safety of rheumatic disease medication use during pregnancy and lactation)" were reviewed.

The following observations can be made:

Enbrel can be used in non-radiographic spondyloarthropathy as well as the other anti-TNF (tumor necrosis factor) medications.

Cosentyx is an alternative to anti-TNF therapy, with or without prior use of anti-TNF therapy.

The potential for pregnancy is an issue. Cosentyx has not been studied much, and is used only to the time of conception

There is more experience with anti-TNF drugs. Cimzia is the only one that is not restricted during the later stages of pregnancy. 

In this case, Cimzia is the most appropriate choice of medication. 

Based on the above, the medical necessity for the Cimzia 200 milligrams/milliliter (mg/ml) kit is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

In brief this was a patient sent from an Urgent Care Clinic to the Emergency Department (ED) via ambulance with a one day history of right sided abdominal pain, associated with nausea and vomiting. Blood work indicated an elevated white blood cell count (29.3). He had an elevated heart rate of 108 beats per minute. Abdominal ultrasound showed acute appendicitis. He received fluids, antibiotics and had an uncomplicated appendectomy.  His pain was well controlled; vital signs were stable. The patient was able to tolerate his diet and had clinically improved and was discharged.   

Ambulatory uneventful/uncomplicated appendicitis even with overnight stay is not considered inpatient level of care. Multiple studies have shown ambulatory appendectomy to be safe and well tolerated in absence of complicating features. 

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

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

Diagnosis: Urinary Retention. 
Treatment: Inpatient Hospital Admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

This is a patient with history of multiple ventral hernias, status post a mesh repair complicated by a fungal infection, who presented to the emergency department with complaint of abdominal pain, nausea and difficulty urinating. The patient had undergone an uncomplicated hernia repair 2 weeks prior but required a foley catheter on discharge for urinary retention. Foley was removed at an office visit but required replacement. The patient did not have foley in the emergency department visit. Computed tomography scan revealed free air in abdominal area. Serum white blood cell count was high; urinalysis (U/A) was abnormal. The patient was started on intravenous antibiotics, and was transferred to a surgical unit in anticipation of possible surgical intervention. Foley was placed with Urology service assistance, 600 milliliters (ml) of urine obtained. Urology/Infectious diseases consulted. The patient's white blood cell count decreased and he remained asymptomatic. Culture returned negative for growth. The patient was cleared for hospital discharge with a foley in place, outpatient follow up care was arranged. 

Per Milliman Care Guidelines (MCG) Abdominal Pain, Undiagnosed - patient fails to meet clinical indications for admission. The patient also fails to meet indications for admission under MCG Urologic Disease "Acute urine retention requiring inpatient care" and MCG Urinary Tract Infection (UTI). 

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient. The inpatient admission was not considered medically necessary for this patient. 

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

Diagnosis: s/p (status post) Laparoscopic cholecystectomy. 
Treatment: Inpatient admission. 

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

The patient is a female. She had a laparoscopic cholecystectomy. 

No, the Inpatient admission was not medically necessary. 

The expected Length of Stay following a laparoscopic cholecystectomy is ambulatory. This patient presented to the ED (emergency department) and was admitted. Surgery was delayed, and this patient was eventually discharged on same day as the surgery. 

In keeping with this expected length of stay, this patient could have been placed at a lower level of care. A review of the medical records documented that all the medical care that this patient did receive including NPO (nothing by mouth), IV (intravenous) fluids, IV (intravenous) antibiotics and pain medications, oral medications, ambulation, and advancing oral diet all could have been provided safely, efficiently, and effectively at a lower level of care, not needing an one day Acute Inpatient Admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overjet greater than 9 mm (millimeter) with incompetent lips or reverse overjet greater that 3.5 mm.

Treatment D8070 braces and D8670 monthly visit (x [times]4).

The insurer denied coverage for D8070 braces and D8670 monthly visit (x4).

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph and tracings, 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 excessive overjet. The orthodontist completed the Handicapping Labio-Lingual Deviation (HLD) index as required asserting the patient exhibits the automatically qualifying condition of overjet greater than 9 mm (millimeter) with incompetent lips or reverse overjet greater that 3.5 mm with reported masticatory/speech difficulties to support orthodontic necessity. 

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 overjet
greater than 9mm with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. This reviewer finds that this automatically qualifying condition is not met and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the findings of the insurer reviewer attaining a score of 13 points on the HLD index (6 overjet, 5 overbite, 2 labiolingual spread).
 
Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies.

Each of the peer reviewed articles concludes that 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.

The clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

The healthcare plan did act reasonably and with sound medical judgement and in the best interest of the patient. 

The insurer's denial of coverage for the D8070 braces and D8670 monthly visit (x4) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spondylosis. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is overturned. 

The patient has a medical history of history of hypercholesterolemia, diabetes, arthritis, anxiety, depression. He was admitted for an elective left L[lumbar]4-5 and L5-S[sacral]1 open laminectomy with medial facetectomy. His diagnosis was spondylosis at L4-5 and L5-S1. [American Society of Anesthesiology] ASA score 2. He had a JP [Jackson-Pratt] drain placed and was ordered neurochecks, pain control, no NSAID [non-steroidal anti inflammatory drugs]. His admission stated that he was transferred from PACU [post anesthesia care unit] with 6/10 pain and dark red blood saturated dressing and JP drain with dark red bloody drainage. His JP drain remained in place. Nurse's note states he remained stable overnight. Pain at incision site and medicated with relief. Dressing changed and neurochecks continue with no acute decline from baseline. Intravenous (IV) antibiotics continue and clear liquids tolerated. He was seen by Physical/Occupational Therapy for impaired mobility, generalized weakness, postop pain, decreased muscle strength, standing dynamic balance and decreased functional mobility. Recommend discharge home. Nurse's note noted dressing dry and intact, ambulatory with steady gait, denies pain at this time. Total output JP drain 140. Neurochecks every four hours. Given oxycodone once. Later, a Nurse's note states effective pain management continues, dressing dry and intact, JP draining serosanguineous fluid, IV antibiotics ongoing. Ambulates with assistance. Total JP drain output 90. Nurse's note notes cleared for discharge by neurosurgery team. He was discharged. 

The patient had a comorbidity of diabetes type II and underwent multilevel laminectomies with the insertion of a JP drain with high output of 140 cc (cubic centimeter). 

Milliman Care Guidelines (MCG) Lumbar Laminectomy state ambulatory is for patients without active comorbidities undergoing minimally invasive or uncomplicated single level elective lumbar laminectomy. Inpatient is for patients who have comorbidities that require prolonged inpatient monitoring, or whose surgery is nonelective or otherwise complex (involving more than one level or includes removal of spinal mass). The patient had a comorbidity of diabetes type II and needed monitoring of his JP drain for multilevel laminectomy per guidelines. (1) 

The inpatient stay for dates in question were medically necessary as he was high risk for complications. His JP drain had output of 140 cc that required ongoing JP drain with monitoring. 

Patients who require multilevel lumbar procedures and/or have a preoperative coagulopathy are at a significantly higher risk for developing a postoperative epidural hematoma. (2) 

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

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute on chronic deep vein thrombosis (DVT), recurrent pulmonary embolus

Treatment: full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld.

The patient has a past medical history of asthma, pulmonary embolism (PE), vasospastic angina, and deep vein thrombosis (DVT) who presented to the Emergency Department (ED) for chest pain, neck pain, headache, and dyspnea on exertion. In the ED, the patient's vital signs were blood pressure 113/70, heart rate 86, respiratory rate 18, and oxygen saturation 98% (percent). Hematology and Cardiology were consulted. Lower extremity doppler found non-occlusive left popliteal DVT. Ventilation perfusion (VQ) scan confirmed a moderately high probability pulmonary embolism. The patient was admitted and treated for DVT and PE. She admitted due to non-compliance with xarelto and was changed back from lovenox to xarelto.  Throughout her hospital stay, the patient remained stable, and her symptoms progressively resolved. The patient was discharged home.

The health care plan act reasonably and with sound medical judgment and in the best interest of the patient.    

The full hospital admission is considered not medically necessary for this patient. This individual did not require full inpatient admission for management of Venous thromboembolism (VTE).  She was hemodynamically stable on admission and was not hypoxic.  No transthoracic echocardiogram (TTE) was performed demonstrating right heart strain/failure.  

As her event was triggered likely by recent coronavirus vaccine and medication non compliance, it would be reasonable to assume that she would be able to quickly recover.  This patient could have been managed in a lower level of care such as observational status on the date of service (DOS) in question. She would have been able to receive Amicar, transfusions and monitoring of her vaginal bleeding in observational status. As this patient was hemodynamically stable and could have been managed in a lower level of care, acute hospitalization was not medically necessary for the DOS in question.

As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate.

Multiple studies have demonstrated the feasibility and safety of outpatient management of VTE in the hemodynamically stable patient.  

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

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

Diagnosis: Cellulitis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient has a past medical history significant for asthma, osteoarthritis, obesity, sickle cell trait, and status post left knee meniscectomy weeks prior presented to the emergency department with complaints of left knee pain, erythema and drainage.  
Vitals on presentation included: Temperature 36.7 Celsius, Blood Pressure 153/90, Pulse 100, Respiratory Rate 15, oxygen (O2) saturation 97% (percent).

The patient was empirically started on intravenous antibiotics (Ancef) for possible left knee cellulitis versus superficial abscess. Ultrasound of the knee demonstrated no drainable fluid collection. Infectious Diseases consulted for antibiotic management. Patient remained afebrile, hemodynamically stable, and was discharged to continue outpatient management on oral antibiotics.

According to documentation, the patient was admitted to hospital for worsening knee pain and swelling. Otherwise, she was afebrile, hemodynamically stable with normal O2 saturation. No hard copies of laboratory results were available for review, however, admission notes state that labs done at her surgeon's office showed a normal WBC (white blood cells) (10.2), and knee fluid cultures were negative. The patient had no evidence for a disseminated infection and no further surgical intervention was deemed necessary. Based on above findings, patient met criteria for observation level of management. She did not meet criteria for acute hospitalization.

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

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

Diagnosis: Tooth decay
Treatment: White glass with metal crown for tooth #10
The insurer denied the White glass with metal crown for tooth #10
The denial is overturned

The patient is a female. Tooth #10 had severe decay present, necessitating a root canal procedure and crown.

Yes, the requested white glass with metal crown for tooth #10 is medically necessary.
Tooth #10 had severe decay present, necessitating a root canal procedure and crown. The tooth needs a crown to properly restore it after the root canal procedure.

The x-rays provided show some diffuseness at the end of the root making it difficult to see the final length of the root canal filling. However, determination of what is considered a short root canal filling is at the discretion of the treating provider.

Tooth #10 needs a crown because it had a large cavity and a root canal filling. If the root filling is too short, root canal treatment may have to be redone first, but the crown is still needed regardless.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior Crossbite with Gingival Attachment Loss

Treatment D8080 braces and D8670 monthly visit

The insurer denied coverage for D8080 braces and D8670 monthly visit

The denial is overturned

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 anterior crossbite with gingival attachment loss, in addition to other clinical findings.  The orthodontist has completed the Handicapping Labiolingual Deviation Index (HLD)  index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. 

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, a Handicapping Labiolingual Deviation Index (HLD) 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 crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual lndex, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies.  The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the D8080 braces and D8670 monthly visit is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease.
Treatment: PCW services of 10 hours per day, 7 days per week for a total of 70 hours per week.
The insurer is denied coverage for PCW services of 10 hours per day, 7 days per week for a total of 70 hours per week.
The denial is overturned. 

This male patient has a history of Alzheimer's disease, Parkinson's disease, prostate cancer, hearing loss, macular degeneration and Fuchs' corneal dystrophy, leg edema and osteoporosis.

The UAS(Uniform Assessment Systerm) indicates the patient has two informal helpers, the wife and a child. The patient's wife receives PCW(Personal care worker) services due to her own health issues and functional impairment. It appears unlikely that she can provide physical assistance with ADLs(activities of daily living) for her husband. The advocate's letter indicates the patient has 3 children. One daughter has extensive time commitments for her work and is unable to provide care on a daily basis. The other children have additional family responsibilities and are unable to provide care to the patient on a regular basis. As per NYS(New York State) regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide assistance with ADLs and IADLs when needed. 
The family is requesting PCW services 10 hours per day for the patient. The insurer's final adverse determination notice indicated the patient's wife was receiving PCW 5 hours per day. 

The determination from this review for PCW hours for the patient cannot be based on PCW services for his wife, as this is a variable that can change based on his wife's health and functional status. The wife may still have PCW 5 hours per day, or she may have more or less than 5 hours per day. Approval of the requested 10 PCW hours per day for the patient will at least maintain the services he has been receiving (10 hours per day), even if his wife's hours are decreased or discontinued. If the wife continues to have PCW services, her hours will extend the total PCW hours per day (mutual services between patient and wife) and can provide the patient with assistance earlier in the morning (it was reported that he gets up 2-3 hours before the aide arrives, which probably includes toilet use) and extend the evening hours to provide more time for dinner and all evening ADLs before going to bed.

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

The carrier's denial of coverage for the PCW services of 10 hours per day, 7 days per week for a total of 70 hours per week is overturned.  The medical necessity is substantiated.