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

Diagnosis: Immunologic Disorders/Arthritis/Rheumatoid Arthritis
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested prescription drug as not medically necessary. 
The health plan's determination is overturned.

The patient is a gentleman with a history of seropositive rheumatoid arthritis, rheumatoid factor reported to be positive, with a presentation of multiple joint pain who previously has failed Methotrexate, Humira, Prednisone, Hydroxychloroquine and Sulfasalazine. The patient also has a history of interstitial lung disease and chronic obstructive pulmonary disease (COPD) with the recent COVID pneumonia and a worsening lung infiltrate. Because of the patient's comorbid conditions, the patient's treating rheumatologist recommended the use of Orencia. The request for Orencia coverage was denied by the insurance company, stating that the treating physician needs to use alternative preferred agents like Enbrel, Rinvoq or Xeljanz. The patient's treating physician appealed the decision stating that because of patient's comorbid conditions and the Black Box warning of serious infection, malignancy and thrombosis associated with JAK (disease modifying anti rheumatoid drugs) inhibitors, the treating physician still believes that Orencia is the safest and best option for the patient and requests reconsideration of the decision.
At issue is the medical necessity of the requested prescription medication, Orencia.

I overturn, in whole, the health plan's determination of medical necessity.

The requested treatment of Orencia Click jet 125 milligrams per milliliter SC (subcutaneous) is medically necessary for this patient considering the patient's comorbid conditions, including COPD and interstitial lung disease.
The patient has interstitial lung disease, COPD and a recent COVID pneumonia. The patient has failed Methotrexate, Humira, Hydroxychloroquine and Sulfasalazine. Because of the patient's comorbid conditions, JAK inhibitors can lead to increased risk of infection. The use of Orencia is a relatively safer option, considering it has been shown to decrease the progression of rheumatoid arthritis-interstitial lung disease (RA-ILD), and it has a numerically less risk of infection than other biologics and small molecules.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Varicose Veins. 
Treatment: Surgical Services. 

The health plan denied the requested procedures as not medically necessary. 
The health plan's determination is overturned. 

The patient is a male who presents with bilateral lower extremity symptomatic varicose veins. His main symptoms include pain, swelling. His symptoms interfere with his activities of daily living including prolonged standing. He has attempted and failed conservative therapy with graded compression stockings without symptomatic relief. Recent magnetic resonance venography (MRV) demonstrated compression of the bilateral common iliac veins. His provider is recommending a venogram with possible intravascular ultrasound, angioplasty and stenting for the treatment of his condition. 

I recommend the complete overturn of the health plan's determination of medical necessity. 

The venogram, intravascular ultrasound, bilateral angioplasty with possible stenting is medically necessary for this patient based on the peer reviewed literature. 
Based on the documentation, the patient has bilateral leg swelling (left worse than right) which may be a result of May-Thurner syndrome. This particular patient is an excellent candidate for intravascular ultrasound (IVUS) and this requested service is strongly supported by the peer reviewed literature. He presents with asymmetric painful left leg swelling and symptoms consistent with possible May-Thurner Syndrome. Intravascular ultrasound is the gold standard for evaluating compression of the vena cava and iliac veins that result from this condition.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Back and leg pain.
Treatment: CPT codes 22857 & 22585 - Removal of Gel Pad Between Back Bones
and New Gel Pad as Replacement, and/or Fusion, Pre-service.

The insurer denied the CPT codes 22857 & 22585 - Removal of Gel Pad Between Back Bones and New Gel Pad as Replacement, and/or Fusion, Pre-service.  The denial is partially overturned. 

The patient is a female with low back and leg pain. The patient failed PT (physical
therapy), pain management and had a previous microdiscectomy at L5-S1 (fifth lumbar spine vertebra - first sacral vertebra). MRI (magnetic resonance image) shows degenerative disc disease at L5-S1 (fifth lumbar spine vertebra - first sacral vertebra) with recurrent disc herniation causing left moderate to severe stenosis. X-ray shows no dynamic instability at L5-S1 (fifth lumbar spine vertebra - first sacral vertebra). The patient was recommended L5-S1 (fifth lumbar spine vertebra - first sacral vertebra) arthroplasty.

No, the proposed lumbar disc arthroplasty is not medically necessary.
The patient has a recurrent disc herniation at L5-S1 (fifth lumbar spine vertebra - first sacral  vertebra) but a lumbar arthroplasty is not considered medically necessary in this patient and would not be standard of care. The patient has evidence of recurrent disc herniation and has failed nonsurgical management but there is no supporting documentation for arthroplasty. Standard of care would indicate fusion. Arthroplasty in this setting would be considered outside standard of care and therefore is not medically necessary or appropriate in this setting.

REASON FOR ADDENDUM:
Please address the medical necessity of fusion for this patient specifically.

REVIEWER'S RESPONSE:
As mentioned, the patient has evidence of recurrent disc herniations, which is a sign of
microinstability causing disc herniations to recur. The use of fusion in this setting has been well demonstrated and supported by the literature. Patients who fail one to two microdiscectomies are indicated for fusion, as they have microinstability that is causing the disc to continue to recur. In this setting, such as the patient in this clinical scenario, fusion is appropriate and medically necessary as a means of treating the instability.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Constipation. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a female who presented with abdominal pain and constipation. She was well until 6 days prior to admission when she developed diffuse abdominal pain. She was constipated and also had decreased urine output. She had tried an enema at home but did not produce a bowel movement. She was seen by her primary doctor and was given lactulose and dicyclomine, but still had no result. Her abdominal pain continued and she also had suprapubic pain. She continued to have decreased urine output as well as a feeling of being unable to empty her bladder. 

She was seen in the emergency department and was found to have tenderness throughout her abdomen. Laboratory values were obtained. An abdominal x-ray showed a large stool burden in the ascending colon. She received Maalox for the abdominal pain. She was given Fleet and mineral oil enemas but still had no bowel movement. She also received a bolus of normal saline. They subsequently initiated a GoLYTELY bowel cleanout. 

The inpatient hospital admission was medically necessary. The patient presented with severe constipation and abdominal pain. She attempted treatment as an outpatient but was unsuccessful. She was also given appropriate treatment in the emergency department setting, but still did not have a bowel movement and her x-ray showed a large stool burden in the ascending colon. Her pain was up to 10 out of 10 in intensity. She required prompt treatment in an inpatient setting with close monitoring and ongoing evaluation for effect. 

The decision-making at the time of admission for this patient was consistent with her young age, the presence of severe constipation and significant pain that did not respond to outpatient or emergency department therapy, and the need for intensive treatment with close monitoring to ensure adequate effect. Disimpaction is necessary for patients with severe constipation and pain and requires inpatient care for a clean out when outpatient therapy is unsuccessful.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class II retruded mandible, maxillary and mandibular crowding, deep bite, and severely excessive overjet). 
Treatment: Orthodontic treatment.

The insurer denied coverage for orthodontic treatment.  The denial is upheld. 

This patient is a female child who presented for evaluation for orthodontic care. The Orthodontist recommended comprehensive orthodontics due to skeletal Class II retruded mandible, maxillary and mandibular crowding, deep bite, and severely excessive overjet. The Orthodontist has not submitted the Handicapping Labio-Lingual Deviation (HLD) Index as required as it is not in the submitted documentation. 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 13 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, 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 does not submit an HLD index but presumably
claims an automatic qualifying condition of excessive overjet. This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care. This reviewer concurs with the findings of the insurer of attaining 13 points on the HLD index (6 points overjet, 5 points overbite, 2 points 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 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.

Uphold denial as the clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient.
 
The insurer's denial of coverage for orthodontic treatment is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous system/neuromuscular Disorder-Other-benign paroxysmal postural vertigo 
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient has a past medical history of hypertension (HTN) and hyperlipidemia (HLPD) who was admitted with complaints of (c/o) five-day history of dizziness associated with imbalance. Vital signs were unremarkable. Physical exam was notable for right eye nystagmus, right tongue deviation, and left eyebrow deviation. Lab work was unremarkable. Imaging studies: chest x-ray (CXR) showed bibasilar scarring, computed tomography (CT) scan of the head showed no acute intracranial pathology, magnetic resonance imaging (MRI) of the brain showed no acute pathology. The patient was diagnosed with acute vertigo and treated with serial troponins, biochemical work-up, neurological checks, and neurology consultation. Neurology evaluated the patient, diagnosed with benign paroxysmal postural vertigo (BPPV), and started the patient on anti-platelets therapy for risk reduction. The patient was discharged in stable condition. 

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department with five-day history of dizziness associated with imbalance. The patient received a thorough evaluation from neurology and was ultimately diagnosed with BPPV. In addition, the radiological work-up did not demonstrate any acute findings, the admission blood pressure (BP) was less than (<) 220/140, there was no eclampsia, cardiac enzymes indicative of infarction or acute coronary syndrome (ACS), hypertensive emergency, hemodynamic instability, or evidence of acute end-organ injury, such as intracranial hemorrhage, acute renal failure, focal neurologic abnormalities, or aortic dissection. The patient is documented to have a grossly non-focal neurological examination and was awake, alert, and oriented to person, place, and time (AAOx3). Overall, this patient was treated with meclizine, anti-hypertensives, radiological work-up, and neurology consultation, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of asthma, gastritis and polysubstance abuse and was admitted with complaints of (c/o) chest and abdominal pain associated with nausea and vomiting. Her vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD), abdomen with epigastric tenderness, no rebound/guarding. Lab work was notable for a white blood cell count (WBC) of 16.1, lactate 2.6, positive (+) urine drug screen (UDS) for cannabinoids. A chest x-ray (CXR) showed no acute abnormality, a computed tomography (CT) scan of the abdomen/pelvis showed no acute pathology. An electrocardiogram(EKG) showed new T wave inversions in V1 and V2. The patient was diagnosed with nausea/vomiting and was treated with intravenous (IV) fluids and anti-emetics. The patient was documented to be improved with emergency department (ED) intravenous (IV) pain medication. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with c/o chest and abdominal pain associated with nausea and vomiting. The patient did not have associated high-risk features, such as renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability. In addition, while the patient had abdominal pain and nausea/vomiting, she responded to pain medications, and did not have a bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable, the pain responded to medications, and she did not have an acute kidney injury, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. The patient presented with gastritis versus peptic ulcer disease (PUD), was treated and responded to intravenous fluids (IVF), anti-emetics, antacids, gastroenterology (GI) consultation, and pain control, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genitourinary/Kidney Disorder-Chronic Kidney Failure/ESRD.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient admission as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient has a history of end stage renal disease (ESRD) on dialysis, diabetes mellitus, heart failure with preserved ejection fraction (EF), and hypertension who presented to the emergency department (ED) on with shortness of breath and leg swelling. He stated that he no longer had a dialysis center and had missed his previous dialysis session. In the ED, his blood pressure was critically high at 200/99. He was afebrile with heart rate of 98 beats per minute (bpm) and was saturating well on room air. 2+(plus) pitting edema was noted on physical examination. His creatinine was elevated to 12.2 with potassium up to 5.6. Chest x-ray showed evidence of pulmonary vascular congestion. Nephrology was consulted for hemodialysis. The patient was taken to dialysis  and then admitted to the hospital for pulmonary edema and hypertensive emergency. His blood pressure (BP) remained elevated at 188/87 and 172/97 on rechecks. He was started on Procardia extended release (XL). His BP had improved to 136/80. He was taken for a second dialysis session. His lower extremity edema was noted to be improved. He was continued on dialysis on a Tuesday, Thursday, Friday schedule and kept in hospital while Social Work struggled to find him an outpatient dialysis center. Finally an outpatient dialysis center was arranged for the patient, and he was discharged home at that time. 

Inpatient stay was medically necessary. This patient had hypertensive emergency with systolic blood pressure critically high at 200. As pulmonary edema was found on his chest x-ray, he met Milliman Care Guidelines (MCG) criteria for admission for hypertension (systolic BP greater than(>) 180 with end organ damage). The hypertension persisted despite ED treatment with BP still elevated at 188/87 and 172/97 on rechecks. It was prudent to admit this patient to continue with efforts to lower blood pressure via both repeat dialysis sessions (the second session was done the day following the first session) and medications, and to monitor for blood pressure stability. This high risk patient especially required close monitoring at the inpatient level of care due to his multiple co-morbidities, including heart failure and diabetes in addition to end-stage renal disease. Uncontrolled hypertension to this degree put him at high risk of stroke, decompensated heart failure and acute coronary syndrome, among other possible complications. Although he clinically improved with dialysis, he did not have an outpatient dialysis center arranged and it would have been unsafe to discharge him home until this was arranged for him. Unfortunately, although the patient was clinically improved it took additional time for an outpatient dialysis center to be secured and the patient was discharged home on that date.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a woman with a history of cyclic vomiting syndrome on methadone and recent bacteremia who was admitted to the hospital. She presented with non-bloody vomiting for the past one day. She reported being unable to tolerate an oral diet. She had been recently admitted for similar reasons and left against medical advice. She denied headache, chest pain and palpitations. In the emergency department, vital signs showed blood pressure 129/80, heart rate 89, and oxygen saturation 98%. Labs were notable for white blood cell (WBC) 10 and potassium 5.5. On physical examination, she had multiple crusted herpetic lesions orally and heart was regular, breath sounds were normal and the abdomen was soft. The patient was admitted for intractable vomiting. 

The inpatient stay was medically necessary. The reason is the patient had severe and persistent vomiting, electrolyte abnormalities, and inability to maintain adequate nutritional intake. The severity of her symptoms is usually treated at the inpatient level of care. In addition, the patient developed a line-associated DVT which increased her complexity due to her recent history of incompletely treated bacteremia. The infectious disease service was consulted and the vascular surgery service was also consulted. Although she did leave against medical advice during a prior recent hospitalization, she needed further care during this hospitalization and it was appropriate to provide it at the inpatient level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Over retained deciduous molar tooth.
Treatment: D8080 Braces and D8670 Monthly Visit x4, Pre-service.

The insurer denied the D8080 Braces and D8670 Monthly Visit x4, Pre-service.  The denial is upheld.

The patient is a female requesting dental benefits for orthodontic treatment (braces) and four monthly visits.  The patient presents with an over retained deciduous molar tooth on the lower right side.  A treatment plan was created to extract this tooth and use orthodontic treatment (braces) to close the space.  Three-dimensional (3D) imaging, photos and panoramic x-ray have been taken.

No, the proposed treatment of orthodontic therapy (braces) and four monthly visits are not medically necessary.
Orthodontic treatment is an invasive treatment that is used to straighten and correct teeth that are misaligned.  The patient does not exhibit any misaligned teeth, excessive overjet, overbite, crossbite to warrant orthodontic therapy. The documentation submitted does not show that any of these condition are present.

The need for orthodontic treatment is not supported by any of the records presented.