Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Osteoarthritis (right knee).
Treatment: Pennsaid Solution, Pre-service.
The insurer denied the Pennsaid Solution, Pre-service.
The denial is upheld.

This is a male with right knee pain. He has been indicated for a total knee replacement. His physical examination was significant for tenderness and painful motion. He had taken Meloxicam. A diagnosis of osteoarthritis was reported. He was prescribed Pennsaid.

No, the health plan should not cover the proposed formulary exception for Pennsaid solution.
The records show formulary alternatives were not provided first; the formularies are expected to be as effective as the requested non-formulary drug. The formularies include diclofenac sodium, diclofenac sodium gel 1% [percent] (generic Voltaren Gel), meloxicam tablet, naproxen (except naproxen CR [controlled release] or naproxen suspension).  There was no reported contraindication to use of other agents; the formulary drugs have not been documented as ineffective or as having adverse effects for this patient. The literature does not indicate use of this medication as a first line course of management. There would be no extenuating circumstance to warrant its use.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Constipation
Treatment: Motegrity (prucalopride)

The insurer denied Motegrity (prucalopride). 
The health plan's determination is overturned. 

The patient is a female with constipation. She has failed Miralax, Metamucil, senna/Colace, Dulcolax, Linzess, and Amitiza. Coverage is being requested for Motegrity for the treatment of constipation. The formulary alternatives are lubiprostone (generic Amitiza) and Linzess.

A formulary exception is indicated for this patient. The use of Motegrity is supported in this case. The patient has had chronic constipation symptoms, and failed osmotic and stimulant laxatives, and advanced agents (Amitiza, Linzess). The American Gastroenterological Association Medical Position Statement on Constipation states that newer agents such as Motegrity should be used if non-pharmaceutical laxatives fail. The patient has reportedly failed the formulary agents as well. Motegrity has shown efficacy for the treatment of constipation and associated symptoms including bloating and abdominal pain. For these reasons, Motegrity (prucalopride) is indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid (severe) obesity
Treatment: Panniculectomy
The insurer denied the Panniculectomy. 
The denial is overturned.

This female patient has lost weight following bariatric surgery. She has an abdominal pannus and complains of recurrent rashes in the folds under her pannus. The rashes have persisted despite treatment with topical medications prescribed by her dermatologist. Her surgeon recommends a panniculectomy to treat the rashes.

Yes, the proposed treatment with a panniculectomy is medically necessary.
A panniculectomy (15830) is medically necessary.  According to the American Society of Plastic Surgeons Position Paper "Treatment of Skin Redundancy For Obese and Massive Weight Loss Patients", "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic. Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically these procedures are performed to improve appearance and are therefore cosmetic in nature." 

The records indicate that the patient has failed conservative treatment for her longstanding rashes, including treatment by her primary care physician (PCP) and dermatologist with oral and topical anti-fungal medications. Photos show a female with a pannus that hangs below the pubis. A panniculectomy will eliminate her rashes and is the only remaining treatment that will cure her infections. She has failed all conservative treatments.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The panniculectomy is medically necessary and is in the best interests of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gynecological. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Stay. 
The denial was overturned.  

The patient is a female, gravida 0, who presented to the emergency room (ER) with severe ongoing vaginal bleeding. The patient had started bleeding  and was admitted to another hospital for transfusion. Her bleeding continued, and she presented to this hospital. She was discharged to home, but her bleeding continued at a severe rate.
The patient was admitted after presenting again. She received a transfusion, as well as intravenous (IV) tranexamic acid and oral progesterone to curtail the bleeding. Evaluation showed a large fibroid of 12 centimeter (cm) that was the likely source of the bleeding. She was discharged to home after responding to treatment.
At issue is the medical necessity of the Inpatient Stay.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Inpatient Stay is medically necessary for this patient.
The inpatient stay was medically necessary. This patient had at least 3 weeks of ongoing vaginal bleeding, with numerous presentations over this time for care. She had symptomatic anemia, with a documented drop in hematocrit and heavy bleeding on exam. The fatigue and dizziness the patient reported put her at risk for fall and other maladies outside a monitored setting. The patient required aggressive intervention. IV tranexamic acid is a standard treatment in this scenario and is not an option as an outpatient. A recent Cochrane review validated this approach. [4] This patient fits the category of acute abnormal uterine bleeding and needed aggressive management. American College of Obstetricians and Gynecologists (ACOG) guidelines prescribe assessment and treatment of hypovolemia, and IV medication to stop the bleeding. [1] A large population study via Kaiser likewise recommends a similar approach.[3]
This patient had clearly failed outpatient management, with one prior admission and one prior ER visit with discharge leading up to this admission. The patient's hematocrit of 26 is abnormal, and a marked decrease from her counts the day prior, and the patient was symptomatic with dizziness and fatigue. There is documentation of the patient having heavy bleeding while in the hospital. Her physicians reported witnessing severe bleeding several hours after her presentation. Acute abnormal uterine bleeding, which dictates inpatient management, is defined as bleeding more than one pad per hour. [5] The patient's record shows she was bleeding at least a pad soaked every 10 minutes. Admission was necessary to both address the anemia and administer parenteral medication to stop the bleeding.
Therefore, the Inpatient Stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Hypertension

Treatment: full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld.

The patient is a female who presented 8 days post a c (cesarean)-section delivery with an elevated blood pressure (150s/90s). She has a history of chronic hypertension. Intravenous (IV) Labetalol and IV Nifedipine were given. Blood pressure remained elevated. The patient was admitted for care. She was given IV magnesium sulfate, Nifedipine, IV Labetalol as needed (PRN), and Acetaminophen PRN. Blood pressures were monitored. The patient's condition improved, and she was discharged. Urine protein was negative.	

This patient presented 8 days after delivery with elevated blood pressure. Delayed postpartum preeclampsia can be defined as signs and symptoms of the disease leading to readmission more than two days but less than six weeks after delivery. The diagnosis of preeclampsia is based on the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman:
Systolic blood pressure greater than or equal to (>=) 140 mmHg or diastolic blood pressure >=90 mmHg (millimetre of mercury), and
1) Proteinuria >=0.3 grams in a 24-hour urine specimen or protein: creatinine ratio >=0.3, or
2) Signs of end-organ dysfunction platelet count less than (<) 100,000/microliter, serum creatinine greater than (>) 1/1 mg/dL (milligrams per deciliter) or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration). 

This patient had elevated blood pressure, no protein in the urine was documented and no elevated liver function test (LFTs) and no end organ dysfunction. 

This patient did not have a diagnosis of preeclampsia. She had significant elevation in her blood pressure.

Ideally this patient would have been observed in the ED (emergency department). Once her blood pressure was controlled, the patient could have been discharged home on home blood pressure monitoring with instructions to return if any worsening of her blood pressure. Admission to the hospital was not medically necessary. 

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

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

Diagnosis: Anterior crossbite with gingival attachment loss.

Treatment D8080 braces and D8670.

The insurer denied coverage for D8080 braces and D8670.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, 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, among other clinical findings. 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. 

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. This index provides six specific conditions that automatically qualify for orthodontic care is utilized.  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. The clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer score on the HLD index attains 8 points (2 overjet, 2 overbite, 4 posterior unilateral crossbite) which is below the required 26 points.

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.  

D8080 braces and D8670 monthly visit is not considered medically necessary for this patient.

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

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

Diagnosis: Central Nervous System/Neuromuscular 
Treatment: Home health Care
The health plan denied the requested increase in personal care assistant hours as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with past medical history significant for arthritis, Alzheimer's dementia, ambulatory dysfunction, hypertension, gastroesophageal reflux disease, glaucoma, and osteoarthritis.

At issue is the medical necessity of the requested increase in personal care assistant (PCA) services to 84 hours per week.

The health plan's determination of medical necessity is upheld, in whole. 

No, the requested health service is not medically necessary for this patient.

The patient has a past medical history significant for arthritis with no loss of motor function noted. It is not medically necessary to increase PCA hours to 84 hours a week. A recent assessment demonstrated no changes with most of her physical functioning since her prior evaluation. There have been no changes with the patient's abilities to perform physical functions such as bed mobility, bathing, personal hygiene, dressing upper and lower body, walking, eating, meal preparation, ordinary housework, and medication management. Her memory is poor. There is reported bladder and bowel incontinence. Based upon this review, the patient was previously reassessed and authorized for more hours. The current personal care hours are adequate to meet the patient's needs. 

An evaluation shows a need for 46.25 hours a week. The health plan approved to 49 hours a week; this was an increase from 42 hours a week. It is my opinion that the services currently provided to the patient are adequate to meet her needs.

Most of the patient's personal care including instrumental activities of daily living (IADLs) and activities of daily living (ADLs) are secondary to her immobility, ambulatory dysfunction, and dementia. She is able to walk in her residence with a walker. There has been a decrease noted in her level of function, which is mainly noted on the amount of time required to help with dressing and some other personal hygiene issues. Her hours are adjusted accordingly. 7 hours per day, 7 days a week of services are sufficient to meet the patient's medical needs.

Additional services for "prevention of falls" for "monitoring" without services being provided are typically not covered under the terms of the plan. In order for services to be considered medically necessary, the assistant must be performing a service such as ADLs or IADLs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: Comprehensive orthodontic treatment

The insurer denied coverage for comprehensive orthodontic treatment.

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 identified several clinical findings including overjet, open bite and has recommended orthodontics. The Orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 18 total points to support orthodontic care. 

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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 18 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining a total of 18 points on the HLD index (5 overjet, 12 open bite, 1 labiolingual spread) which is below the threshold of 26 points to support orthodontic care. Of note in this case, the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval and is aware of this limitation.

Regarding the validity of the Handicapping Labio-Lingual Deviation 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 referenced below. 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.

In this case the patient's own orthodontist completed HLD index total score of 18 points remains below the threshold of 26 points to justify orthodontic care.

Comprehensive orthodontic treatment 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 comprehensive orthodontic treatment is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System/Pneumonia.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a possible psychiatric disorder, human immunodeficiency virus (HIV), and substance abuse who presented with a headache, malaise, and dry cough.
In the emergency department (ED), his temperature was 98.2F (Fahrenheit), with a blood pressure (BP) of 97/70 millimeters of mercury (mmHg), a respiratory rate (RR) of 17/minute, and an oxygen saturation of 96% (percent) room air (RA). He was in no distress, breathing comfortably with clear lungs, and he was alert and oriented. Lab results included a white blood cell count (WBC) of 5.8, a sodium of 135, a bicarb of 27, a blood urea nitrogen (BUN)/creatinine of 18/0.95, and a creatine kinase (CK) of 503. A chest x-ray (CXR) demonstrated subtle lower lobe opacities. A computed tomography (CT) of the thorax found hazy ground-glass in lingula and the left lower lobe (LLL) and scattered peripheral tree-in-bud changes.
The patient was diagnosed with pneumonia and was started on Ceftriaxone, rhabdomyolysis, for which he was started on intravenous (IV) fluids, and substance abuse, for which he was started on as needed (PRN) Lorazepam, and a possible psychiatric disorder.
The next day, the patient was seen by infectious disease (ID) who recommended checking his CD4 count (T-cell test) and sputum culture, and continuing antibiotics. He still had a cough but was improving; antibiotics were continued.
The following day, the patient was saturating well on room air. He left against medical advice after psychiatry saw the patient and felt he had the capacity to make this decision.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld.

No. An inpatient admission was not medically necessary. The patient presented with dry cough and headache and was diagnosed with pneumonia and rhabdomyolysis. His pneumonia was not severe; he was not severely ill at presentation with no organ dysfunction (encephalopathy, hemodynamic instability, respiratory distress or gas exchange abnormality, or acute kidney injury or marked electrolyte abnormality). By scoring systems, he was unlikely to worsen or need Intensive Care Unit (ICU) care. He improved within an observation care time frame. The main additional diagnosis was rhabdomyolysis which was quite mild (creatine kinase (CK) around 500) making the risk of complications such as acute kidney injury (AKI) extremely low. Given all of these features (low severity at presentation, low risk of worsening, low risk of complications from rhabdomyolysis, rapid improvement), an observation admission would have been reasonable; an inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Tooth decay.
Treatment: D2752 White Glass With Gold Crown, Teeth 3,18,19.
The insurer denied the D2752 White Glass With Gold Crown, Teeth 3,18,19.
The denial is overturned, in part.

The patient is a male. The request is for dental benefits for White Glass with Gold Crown, teeth # 3,18,19. 

The health plan denied the claim because "teeth #3 and 18 did not exhibit significant decay or fracture to warrant a crown"; " tooth #19 had an inadequate root canal fill, and as a result crown placement would not be indicated at this time."

Yes, in part. The requested health service is medically necessary, in part.

Specifically, the requested White Glass with Gold Crown as it relates to teeth # 3 and 19 are medically necessary. The requested White Glass with Gold Crown as it relates to tooth # 18 is not medically necessary.
As supported by the x-ray images, tooth #3 has an existing large amalgam restoration encompassing more than 50% of the clinical crown. The placement of a crown is indicated to protect this tooth from fracturing due to the large existing restoration.

Tooth #19 has been endodontically treated (root canal); standard of care is for crown placement to restore function and prevent fracture post root canal.

Tooth #18 does not exhibit any decay, fracture or has been endodontically treated (root canal) and is not indicated for a crown.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in part.
For Teeth #3 and 19; by not providing full coverage crown on these teeth, they will be more susceptible to significant fracture, which can lead to diminished function and eventual tooth loss.

For Tooth #18, since there was no pathology evident in the documentation submitted; not approving the crown was in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thinning Enamel. 
Treatment: D2751 White Glass With Metal Crown, Tooth 7. 

The insurer denied the D2751 White Glass With Metal Crown, Tooth 7. 
The denial is upheld. 

The patient is a male. Tooth # (number) 7 is evidenced to have had a root canal procedure and also has a small 2 surface composite restoration in it. The reason for the prior denial is that there is not enough tooth structure missing or decayed for a crown to be placed. 

No, the D2751 White Glass With Metal Crown, Tooth 7 is not medically necessary. 

Tooth #7 has had a small access hole created on the back to allow the root canal procedure to be performed. It only needs a small composite filling to close the hole. The tooth has the majority of its bulk (structure) still intact and therefore does not need a crown for strength reasons. 

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