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

Diagnosis: Duchenne Muscular Dystrophy. 
Treatment: Emflaza (Pre-service). 

The insurer denied the Emflaza (Pre-service). 
The denial is overturned. 

The patient is a boy. He has severe, classical, genetically and clinically confirmed Duchenne muscular dystrophy, epilepsy and global developmental delays. He has previously been treated with steroids, specifically Deflazacort, in Ecuador. He has been treated with this steroid for a couple of years. He has had stabilization of his symptoms while on this steroid. His neurologist is requesting continuing this steroid rather than prednisone, which is more likely to have excessive weight gain and behavioral side effects in a child with well-established developmental delay and immaturity. However, use of Deflazacort was denied by the health plan, since he had not been previously trialed with prednisone/prednisolone. 

Yes, the treatment with Emflaza (Deflazacort) is medically necessary. 

Defazacort use is evidenced superior to that of prednisone in slowing disease progression in Duchenne muscular dystrophy (DMD) in recent multi-center clinical trials.  Patients receiving deflazacort were found to experience significantly slower rates of decline over 48 weeks than those receiving prednisone/prednisolone on multiple measures of ambulatory function. Overall, the associations between steroid group and ambulatory measures were generally consistent in magnitude and direction across the two trials described in this meta-analysis. 

While the health plan did generally act reasonably, the current peer-reviewed, published, authoritative medical literature and best medical judgement strongly suggest that it is in the best interest of the patient to continue Deflazacort therapy in this boy who has had a positive clinical response to this first-in-class steroid and who has been taking this drug. 

The ensemble of the peer-reviewed, published medical literature concerning steroid treatment of Duchenne muscular dystrophy strongly suggests that Deflazacort is more effective than prednisone/prednisolone in slowing disease progression in this severe, early-onset muscular dystrophy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: Braces.
The insurer denied the Braces.
The determination is upheld.

The patient has a Class II Division 2 occlusion and deep overbite. The maxillary and mandibular arches are crowded. He is treatment planned for 24-30 months of orthodontics with elastics to correct his malocclusion. At issue is the medically necessary for braces.

There is no medical reason to correct his malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) This patient presents with none of those conditions. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 2 millimeter (mm) overjet but excessive overjet does not affect oral health related quality of life unless it was greater than 6 mm. (2) If his teeth were aligned it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, the treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overbite.
Treatment: braces.
The insurer denied Comprehensive Orthodontic Treatment of the Adolescent Dentition (Braces). 
The health plan's determination is upheld.

The patient in question is a female with a Class I occlusion with 3 millimeter (mm) overbite and 2 mm overjet. She has minor maxillary and mandibular crowding. She is treatment planned for 20-28 months of orthodontics to correct her malocclusion.

The Comprehensive Orthodontic Treatment of the Adolescent Dentition (Braces) is not medically necessary for this patient.
There is no medical reason to correct her malocclusion with braces. While the patient has minor crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. If her teeth were aligned it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Inpatient hospital

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

The patient is a woman with a history of astrocytoma, hydrocephalus, aqueduct stenosis and refractory migraines who presented to the emergency department with worsening headaches for the past five days. She stated that she received Botox injections seven days earlier for migraines. Since that time, she reported worsening headaches. She went to an outside hospital emergency department and had a head computed tomography (CT) that was negative. She denied changes in her vision, vertigo and fevers. Review of systems was positive for vomiting. Vital signs showed temperature 37.1 Celsius, heart rate 128, and blood pressure 152/120. On physical exam, heart was regular, breath sounds were normal, extraocular movements were intact, she was alert, and cranial nerves were intact. The patient was admitted for headache concerning for shunt obstruction. The plan of care included neurosurgery consult, shunt series x-ray, pain management, and continue other home medications.

The inpatient medical admission was not medically necessary for this patient.
The patient was primarily admitted due to concern for shunt obstruction, but imaging performed shortly after admission ruled this out as a cause of the patient's headache. She appropriately received a cocktail of therapy for her migraine headache which included Depakote, Toradol, magnesium, and anti-nausea agents, but the severity of her symptoms was not consistent with inpatient medical care for migraine. Considering her stability at the time of presentation and the absence of diagnostic data indicating an acute shunt obstruction or other acute anatomic abnormalities, it would have been reasonable to manage the patient at a lower-level care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foot pain (flat feet, hammertoe deformity)
Treatment: Custom Shoe Inserts, Pre-service
The insurer denied the Custom Shoe Inserts, Pre-service.
The denial is upheld.

The patient is a female who presented with bilateral foot pain.  She had left-sided hammertoe surgery with good result.  She had ongoing degenerative arthritis of her hindfoot due to a progressive pes planus deformity.  She had been managing her hindfoot arthritis with University of California Berkeley (UCBL) type insoles to control her subtalar joint.  She in addition had lost a significant amount of weight.  As she wanted to maintain her activity level she sought several opinions and corticosteroid injections and finally surgical intervention was recommended which would include a subtalar joint fusion.  She opted for continued conservative care with the custom molded University of California Berkeley (UCBL) devices that she had been utilizing for several years with good effect.  She wanted this as an alternative to subtalar fusion.

No, the proposed treatment with Custom Shoe Inserts is not medically necessary.

High-level studies have not shown any benefit of custom versus prefabricated.  Several high-level clinical trials have attempted to demonstrate a difference and there has been none.  There is anecdotal evidence that custom molded inserts have benefit; however, when compared with prefabricated inserts, there has been no quantifiable difference.

High-level clinical studies (1, 2) have shown that there has been no significant difference in custom versus prefabricated inserts.  As such, a prefabricated insert can give the same benefit as a custom molded insert.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class III, vertical growth pattern, maxillary and mandibular crowding, and anterior crossbite with gingival attachment loss (mandibular canines)). 

Treatment: D8080 braces and D8670 monthly visit x 12.

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12.

The denial is upheld. 

This is a female patient who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to skeletal Class III, vertical growth pattern, maxillary and mandibular crowding, and anterior crossbite with gingival attachment loss (mandibular canines).  The orthodontist has completed the Handicapping Labio-Lingual Deviation (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 to support orthodontic necessity.  The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 8 points on review by their internal reviewers. 

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, a Handicapping Labio-Lingual Deviation 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 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 not met as there is no evidence of gingival attachment loss or gingival recession and therefore, does not support comprehensive orthodontic care using this criterion.  In this case, the clinical circumstance does not meet the insurer and the plan criteria to justify orthodontic care.  This reviewer concurs with the HLD index of the insurer attaining 8 points (i.e., 3 overjet, 3 overbite, 2 labiolingual spread).

The coverage for D8080 braces and D8670 monthly visit x 12 is not considered medically necessary for this patient.

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visit x 12 should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: further cardiac risk

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This male patient has a history of hypertension, hypercholesterolemia and coronary artery disease times 4 stents, taking Plavix and aspirin, presented to the Emergency Department (ED) with complaints of chest pain radiating to his throat and neck. It started approximately 1 hour prior to his arrival.  He reported these are symptoms he gets when he has an anxiety attack.  His vital signs were the following: blood pressure of 121/81, heart rate of 74, respiratory rate of 18, and an oxygen saturation rate of 98% in room air. The chest x-ray was clear. An electrocardiogram showed normal sinus rhythm with some T-wave flattening and electrode artifact. Troponin levels were negative times 2.  The patient was admitted for further cardiac risk stratification.  The treatment plan was to continue with aspirin and Plavix, as well as regular telemetry monitoring.  The patient also received Clonazepam for anxiety, as needed. Follow up troponin was negative. An echocardiogram (EKG) was normal. This was most likely non-cardiac since there were 3 negative troponins and that it was possibly an esophageal spasm as the cause of pain. He was discharged with outpatient instructions to follow up.

Using the History, EKG, Age, Risk factors, and Initial troponin (HEART) score risk stratification schema, this patient would have a low 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. Numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care. They found no significant difference in outcome at 30 days between the two groups. Patients presenting with chest pain that were managed in an observation unit had similar 30 day MI rates as those admitted to the hospital. Admission to the hospital to treat an acute cardiac event was not medically necessary.  In conclusion, this patient could have been managed at a lower level of care. 
Inpatient hospital admission was not medically necessary. 

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

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Trauma. 

Treatment: Inpatient facility stay.

The insurer denied coverage for the inpatient facility stay. 

The denial is modified. 

This is a female patient who presented to the Emergency Department (ED) via the Emergency Medical Services (EMS) due to a gunshot wound.  The documentation indicated that the patient was shot while sitting in a car.  Initially, the patient was noted to be alert and oriented.  The patient was able to talk upon arrival to the ED.  The patient had a patent airway.  On day 2 of admission, the patient denied numbness and tingling as well as any voice changes.  The patient did not have any acute bleeding and there was minimal swelling.  The patient continued with treatment which included dressing changes as well as a swallow evaluation.  The patient also underwent additional imaging and continued treatment with analgesics.  The patient continued to improve and was discharged on day 3 of admission.

Regarding the requested inpatient stay, the referenced literature indicates that this patient may be admitted when there is evidence of significant trauma and a lower level of care cannot be provided safely.  This may include the need for frequent monitoring and/or when there is evidence of acute blood loss that may cause abnormalities.  The submitted documentation indicated that this patient presented with a gunshot wound to the cervical spine that resulted in bleeding that was not being controlled upon arrival to the hospital.  While it is noted that the patient had a patent airway, there is a lack of notes detailing the entirety of this stay was appropriate.  This patient would be appropriate for a 1-day inpatient admission to continue monitoring closely given the area of involvement and the possibility of swelling and airway compromise.  This patient did undergo a swallow evaluation and imaging.  There were no abnormalities documented that would warrant continued admission; thus, the request is partially overturned to allow an inpatient admission from day 1 of admission to day 2 of admission.

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

Inpatient admission from day 1 of admission to day 2 of admission was medically necessary. Inpatient admission for day 3 of admission is upheld. 

The insurer's denial of coverage for the inpatient facility stay should be modified. The medical necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transjugular intrahepatic portosystemic shunt
(TIPS) procedure
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with alcohol cirrhosis complicated by portal vein (PV) and superior mesenteric vein (SMV) thrombosis who underwent a transjugular intrahepatic portosystemic shunt (TIPS) procedure to address his portal vein thrombosis (PVT) and as a bridge to transplant. The patient is requesting an inpatient hospitalization.

No, the inpatient hospitalization from was not medically necessary.

The patient had a medical history of alcoholic hepatic cirrhosis and portal hypertension with portal vein and superior mesenteric vein thromboses. Transjugular intrahepatic portosystemic shunt (TIPS) procedures are performed to decompress the portal venous system, which ultimately reduces the pressure in the associated retroperitoneal, perigastric and periesophageal varices. By doing so the risk of bleeding, which is often uncontrollable, is reduced. A transjugular intrahepatic portosystemic shunt (TIPS) procedure can be performed as a less than 24 hour hospitalization procedure. Guidelines published by the Society of Interventional Radiology do not list any specific time frame for postprocedural care, but do state that "All patients should be at bed rest and observed in the initial postprocedure period. The length of this period of bed rest will depend on the patient's medical condition." 

This patient underwent an uncomplicated transjugular intrahepatic portosystemic shunt (TIPS) procedure to address his portal vein thrombosis (PVT) and as a bridge to transplant. The patient was stable following the procedure with an unremarkable course, alert and oriented times three, and without complaints. The physical examination was unremarkable and the abdomen was soft and nontender. The patient's total bilirubin was mildly elevated and he was discharged when the total bilirubin trended downwards.

This admission was not appropriate and the mildly elevated total bilirubin could have been followed on an outpatient basis as the patient was stable and without symptoms.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: Braces
The insurer denied the braces.
The denial is overturned. 

The patient is a male requesting dental benefits for orthodontic treatment (braces).
Dental clinical summary -- the patient has a Class I skeletal relationship, severe vertical growth pattern, Class II canine on the right, Class III canine on the left. Mild upper and lower arch crowding. There is a Class III molar on the left; mild upper and lower protrusion.

Yes, the proposed treatment of orthodontic therapy (Braces) is medically necessary.

The patient exhibits a class II canine and individual crossbite of left canine; a Class II canine is when the distal surface of the mandibular canine is mesial to the mesial surface of the maxillary canine.  This speaks to the pronounced misalignment of the canines and overall shifting of the adjacent teeth. The patient also exhibits an individual crossbite of the left upper canine; meaning that tooth sits inside or lingual to the lower canine.  The canines play a very important role in functional guidance--essentially the way the teeth tend to function as we chew and move our teeth from side to side.  These conditions can lead to difficulty with proper speech and chewing.  These are all evident on the x-rays and the photos.

As previously stated, these conditions left untreated can lead to increased difficulty for the patient's ability to chew effectively and can have overall impact on the health of the patient's dentition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cholecystitis

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is overturned. 

This female patient has a history of gallstones and Hashimoto's disease. She presented to the Emergency Room (ER) with complaints of abdominal pain. She was recently admitted to the hospital with cholecystitis. She maintained a low fat diet in an attempt to avoid surgery until after pregnancy. Pain persisted and the patient returned to the ER. An abdominal ultrasound (US) revealed gallbladder thickening in the setting of cholelithiasis. In the ER the patient was given intravenous (IV) fluids, IV Dilaudid, IV Zofran, and IV Acetaminophen. Symptoms persisted and she was admitted with acute cholecystitis. The patient was initially kept on nothing by mouth status. IV fluids were continued and IV Ancef was given every 8 hours. Sequential compression devices were applied and the patient was able to get out of bed as tolerated. She was encouraged to use an incentive spirometer. The patient had a laparoscopic cholecystectomy. The procedure was performed with minimal blood loss and there were no other significant findings. Obstetrics and Gynecology evaluated the patient after surgery. There were no signs of preterm labor and the patient was recovering well. After surgery she had incisional pain. The wound sites were clean and dry. Complete blood count (CBC) was stable. She was placed on Indomethacin to prevent preterm labor and Tylenol as needed for pain. She was instructed to follow up with the Surgeon and Obstetrician following discharge.

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 inpatient hospital admission is overturned.  The medical necessity is substantiated.