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

Respiratory System
Diagnostic Testing (other than Radiology)

Diagnosis: Sleep Apnea.
Treatment: Diagnostic Testing - CPAP titration (sleep study).
The insurer denied Diagnostic Testing - CPAP titration (sleep study).
The health plan's determination is upheld.

This is a female patient with a history of snoring and mild obstructive sleep apnea as demonstrated on an in-lab polysomnogram. She had significant difficulty tolerating and setting up correctly a home sleep study and multiple attempts were performed in the past prior to her in-lab diagnostic polysomnogram. Continuous positive airway pressure (CPAP) has been recommended to the patient. The treating otolaryngologist is requesting an in-lab CPAP titration study. The patient/treating otolaryngologist is concerned about her ability to perform titration in the home environment given the current living situation. At issue is the medical necessity of diagnostic testing-CPAP titration (sleep study)
The patient would benefit from CPAP/Autopap therapy to treat her mild obstructive sleep apnea; however, an in-lab CPAP titration study is not medically necessary. Auto-Pap therapy may be initiated given the patient's mild obstructive sleep apnea without significant co-morbidities.
The standard of care is to order in-lab CPAP titration in patients with diagnosed obstructive sleep apnea in addition to having significant cardiovascular/pulmonary comorbidities (for example, heart failure, pulmonary hypertension, significant coronary artery disease). A large meta-analysis found no significant clinical difference in patients who underwent auto-pap therapy versus in the lab CPAP titration study. This reviewer is not aware of any national guidelines detailing absolute requirements for patients who benefit from in-lab CPAP titration versus home titration, but the precision of the study is clinically more important in patients with significant cardiovascular risk factors where untreated or sub-optimally treated obstructive sleep apnea may have a significant health determinant.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient has a history vertigo, hypertension (HTN), polysubstance abuse, asthma, coronary artery disease (CAD) and cerebrovascular accident (CVA). The patient presented to the hospital with complaints of cough and chest pain for 4 days.

At presentation vital signs (V/S): temperature (T) 99.9 F, respiratory rate (RR) 17, blood pressure (BP) 114/71, heart rate (HR) 109, and oxygen saturation (O2 sats) 97% on room air (RA). The patient was in no acute distress (NAD), lungs were clear, cardiovascular systems (CVS) normal, and the abdomen was soft, and non-tender (NT). The patient was alert and oriented x 3.

-	Diagnostic Findings:
-	White blood count (WBC) was 15
-	Hematocrit (Hct) was 34
-	Electrolytes were within normal limits (WNL)
-	Blood urea nitrogen (BUN)/creatinine (Cr) was WNL
-	Influenza was Negative.
-	Chest x-ray (CXR) revealed right (R) basilar consolidation.
-	Electrocardiogram (EKG) showed no acute ST-T Changes
-	Troponin was negative.
-	Echocardiogram (ECHO) was essentially normal. Ejection fraction (EF) was WNL

The patient was admitted to hospital with pneumonia and atypical chest pain (CP) likely from Cocaine. The patient was treated with oral (PO) Levaquin.

This patient did not need acute inpatient hospitalization. She could have been placed in observation status while diagnostic testing and treatment could have been continued.

This patient was afebrile and hemodynamically (HD) stable, was not hypoxic with a CURB score 65 score of Zero. This patient could have been placed in observation while treated with PO Levaquin. This patient remained stable after admission, and was afebrile. Chest Pain was atypical and myocardial infarction (MI) was ruled out. ECHO was WNL. The patient could have been discharged home on oral antibiotics after a period under observation with follow up as an outpatient.

Based on the above, the insurer's denial is 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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia
Treatment:  Personal Care Services: 12 Hours per Day, 7 Days per Week
The insurer denied Personal Care Services: 12 Hours per Day, 7 Days per Week. The health plan's determination is overturned. 

This is a case review for an elderly female with medical history notable for dementia, difficulty with walking, history of falls, and heart disease. The patient's physician provided a letter of support for this appeal. The letter states that over the last several months the patient's condition has significantly deteriorated. She requires hands-on assistance and prompting to complete all of her activities of daily living. She requires total dependence on assistance for instrumental activities of daily living. 

The requested Personal Care Services: 12 Hours per Day, 7 Days per Week is medically necessary for this patient.
The patient has been steadily deteriorating due to her cardiac condition which has worsened her functional status, which included pre-existing ambulatory dysfunction and dementia. She is reliant on others for all activities of daily living. Specifically, she cannot ambulate, toilet, or transfer without human assistance. Because these needs are expected to arise continuously and on an unscheduled nature throughout the day, the task tool cannot be relied upon to accurately reflect the patient's true needs. It is reasonable to expect that the patient would require personal care assistance throughout all waking hours of the day. Therefore, the request to remain at 12 hours per day, 7 days per week for a total of 84 hours per week of personal care assistance is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is an adolescent female. The request is for orthodontic benefits along with monthly follow up visits. The patient has a Class I malocclusion with moderate upper and lower crowding. The prior denial was due to a score of 19 on the handicapping index scale.

The proposed treatment is medically necessary.

The patient has an anterior crossbite between teeth #10 and #22 with recession and gingival attachment loss. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct the problem and monthly visits are needed to monitor progress. This case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

As per the emergency department (ED) triage note, the patient presented to the ED complaining of intermittent worsening upper abdominal pain and body aches for 1 day. She was afebrile. As per the ED provider note, the patient is without past medical history and presented with 1 day history of epigastric pain associated with nausea. She denied fever or vomiting. Exam revealed the abdomen to be soft with right upper quadrant (RUQ) tenderness without guarding or rebound tenderness.  The note indicated that the plan was computed tomography (CT) and surgery recommendations. Surgery was to take the patient to the operating room. The patient was to be admitted. Lab studies were within normal limits. CT of the abdomen showed the gallbladder to be within normal limits. The plan was for laparoscopic cholecystectomy, as the clinical picture was consistent with acute cholecystitis.

The patient was taken to the operating room and the brief operative note indicated the patient underwent laparoscopic cholecystectomy. Surgery was uneventful.

Based upon the records the acute inpatient admission was not justified, as this patient could have been managed in an ambulatory/observation setting, as she had an uneventful laparoscopic cholecystectomy. She did not have a significantly elevated white blood cells (WBC), and she did not have a fever. She did not have abnormal liver function tests. She presented now with pain and was taken for the laparoscopic cholecystectomy. But this could have been done in an ambulatory/observation setting.

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 Inpatient Admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hyperthyroidism.
Treatment:  Inpatient stay.

The insurer denied an inpatient stay. The health plan's determination is upheld. 

This is a case of a female admitted for diagnosis of hyperthyroidism. The patient presented with one week history of palpitations and bilateral lower extremity swelling left greater than right. She also had been having dyspnea on exertion. Vital signs demonstrated temperature 36.6 (degrees) C (Celsius), pulse 111, blood pressure 126/76, respiratory rate 22 and O2 (oxygen) saturation 100%. Physical exam showed no acute distress or altered mental status. Creatinine was 0.72 with sodium 140. Magnesium was 2.0. The patient was treated with propranolol and endocrinology consult was requested. 

Inpatient Hospital Stay was not medically necessary for this patient.

According to Up-to-date:
"The diagnosis of thyroid storm is based upon the presence of severe and life-threatening symptoms (hyperpyrexia, cardiovascular dysfunction, altered mentation) in a patient with biochemical evidence of hyperthyroidism."

The patient in this case was treated for hyperthyroidism but did not have a life-threatening condition with thyroid storm. There was no fever, cardiovascular dysfunction or altered mental status. The patient had shortness of breath and palpitations thought to be related to the hyperthyroidism but did not have a life-threatening condition causing shortness of breath. Testing performed during the hospital stay did not show heart failure on echocardiogram or other abnormality to explain shortness of breath. There was no diagnosis of pulmonary embolism, and the lower extremity ultrasound did not show any deep vein thrombosis. She was simply treated with propranolol and recommended to follow up on an outpatient basis.

Although the patient required services in the hospital setting the monitoring, diagnostics testing and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.
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 overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified Class III malocclusion, and anterior crossbite among other findings. The orthodontist has completed the HLD (Handicapping Labio-Lingual Deviation) 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. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the requirements of the HLD index. The orthodontist is appealing on behalf of the patient.

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant 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 Labio-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 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 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 overturned. 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 D8080 braces and D8670 monthly visit x 12 services is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned


Diagnosis: psoriasis

Treatment: Tacrolimus 0.1% ointment

The insurer denied coverage for Tacrolimus 0.1% ointment

The denial is overturned.

This is a teenager with working diagnosis of psoriasis on the scalp and history of eczema and groin rash. The claim for tacrolimus 0.1% ointment was denied for being off label for psoriasis, which is listed as being on the genitals and prescribed for concern of skin atrophy.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes.

Tacrolimus topical is considered an accepted treatment for psoriasis and especially on areas of thin skin, such as genitals.

"Inverse psoriasis commonly involves skin fold areas including the axillae, perianal skin, intergluteal cleft, inframammary, genital/inguinal, abdominal, and retroauricular folds. Topical calcineurin inhibitors are indicated for the treatment of atopic dermatitis but have also been studied in the treatment of psoriasis... Because these agents do not cause cutaneous atrophy, they have a special role in facial, genital, and intertriginous psoriatic lesions." (Dattola, A. et al. 2018).

"Genital and inverse psoriasis can develop in more than one-third of patients who have psoriasis. Psoriatic plaques in the genital and intertriginous skin are challenging to treat because the skin is thin and often occluded, making it more sensitive to certain therapies. Traditional guidelines indicate topical therapies, such as corticosteroids, topical calcineurin inhibitors (TCI), and vitamin D analogs as first-line recommendation in treating genital and inverse psoriasis." (Hong, et al. 2022).      

The Food and Drug Administration (FDA) has not approved the medication for psoriasis.     

The patient is a good candidate for the drug tacrolimus 0.1% cream.     

The topical treatment with a long-term safe medication is preferred and tacrolimus is a good choice. 

There are likely fewer adverse events with the use of tacrolimus cream.     

The topical treatment of genital psoriasis with tacrolimus cream is more beneficial than equally potent steroid topical use in the same area.                                                    

In summary, the denial of Tacrolimus 0.1% (percent) Ointment and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned



Diagnosis: psoriasis

Treatment: Tacrolimus 0.1% ointment

The insurer denied coverage for Tacrolimus 0.1% ointment

The denial is overturned.

This patient is a teenager diagnosed with genital psoriasis, has been treated with topical tacrolimus for a few years. The treating provider is appealing the recent denial of this medication for continued treatment.

Current literature supports the use of tacrolimus as a safe and effective treatment for genital psoriasis.      

The American Academy of Dermatology and National Psoriasis Foundation have included the use of tacrolimus in the current guidelines for topical therapy for the treatment of psoriasis (Elmets, Craig A. et al. 2021).

"Psoriasis has many cutaneous forms, including vulgaris (plaque), guttate, palmoplantar, inverse, and pustular, which is discussed here as a collective whole.

Psoriasis is an inflammatory, immunologically mediated condition stemming from inappropriate activation of cutaneous T cells and dendritic cells with subsequent release of a variety of cytokines and other soluble mediators. These chemical signals are responsible for keratinocyte hyperproliferation manifesting as characteristic psoriasis morphology. In addition, they contribute to the rampant inflammation underlying a number of systemic disease associations, including arthritis and cardiometabolic diseases, such as dyslipidemia, metabolic syndrome, and heart disease. To combat the local and systemic inflammation inherent to psoriasis, a number of topical and systemic medications have been developed and utilized with varying degrees of success." (Elmets, C. A. et al. 2021).     

The patient has been on this medication for several years.  As the treating provider has indicated, use of topical steroids would cause potential damage to the skin in the patient's affected area. He has done well on this medication, and therefore, is an excellent candidate for tacrolimus.     

The patient has been stabilized on this medication and to change would cause potential destabilization. 

Per Amiri, D et al (2023), "Topical calcineurin inhibitors appear to have an important role in the treatment of facial and genital psoriasis."     

The patient has not demonstrated any adverse reactions since starting treatment a few years ago as per submitted documents.     

The patient has been stable on tacrolimus, a standard treatment for genital psoriasis.  Due to increased risk of skin atrophy with other standard topical treatments (steroids), use of tacrolimus remains to be the more beneficial treatment.                                                    

In summary, the denial of Tacrolimus 0.1% Ointment and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned


Diagnosis: psoriasis

Treatment: Tacrolimus 0.1% ointment

The insurer denied coverage for Tacrolimus 0.1% ointment

The denial is overturned.


The patient is a teenager with a diagnosis of psoriasis affecting the groin area.  The patient has been treated with tacrolimus 0.1% ointment to the groin previously.  The request is for continuation of tacrolimus ointment to treat the groin psoriasis.  

Based on the submitted documentation, the use of tacrolimus 0.1% ointment is the most beneficial treatment available.  

Treating intertriginous areas, such as the groin requires non-steroidal options.  Tacrolimus ointment is a non-steroidal anti-inflammatory ointment which is commonly used for atopic dermatitis as well as other inflammatory dermatoses-including psoriasis.  The patient is using betamethasone and hydrocortisone 2.5% in other areas as needed based on the medical chart.  

The patient is a good candidate for therapy with tacrolimus ointment as the area treated is the groin and requires a non-steroidal option for long term care.  

The continued use of tacrolimus ointment to treat the psoriasis of the groin would likely be more beneficial with less potential adverse side effects than alternative therapies.  The decision is reversed based on the standard of care.  

In summary, the denial of Tacrolimus 0.1% Ointment and coverage for the requested medication should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip fracture. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The health plan's determination is upheld. 

The patient is a female with asthma/chronic obstructive pulmonary disease (COPD), PVD (peripheral vascular disease), anxiety, and prior seizure who had a mechanical fall and fractured her left hip. 
In the emergency department (ED), temperature was 36.4 degrees C (Celsius), blood pressure (BP) 110/81, heart rate (HR) 81, respiratory rate (RR) 18, and spo2 (oxygen saturation) 96% room air (RA). She was uncomfortable but not in distress, heart was regular, breathing comfortably, lungs clear, and alert and oriented. White blood cell count (WBC) 18.7, Na (sodium)134, bicarbonate 29, and blood urea nitrogen (BUN) /Cr (creatinine)11/0.82. Chest x-ray (CXR) was clear. Pelvic films showed non-displaced sub-capital left femoral neck fracture.

An inpatient admission was not medically necessary. The patient had a hip fracture, but it was non-displaced, and there were no other active medical issues. She was able to proceed to surgery the next day, and the surgery was uncomplicated. She had post-operative pain, but by post-operative day 1, the pain was manageable with oral pain medications, and she was able to be discharged on oral pain meds. She did not have a complication of the surgery, compartment syndrome, complicated fracture or multiple fractures, complication of the fracture (significant blood loss, compartment syndrome, fat embolism, etc.), severe or uncontrollable pain (as above, while she did have pain, on post-operative day 1, this was managed with oral medications alone and responded well, allowing for discharge that same day), limb-threatening injury, major injury, etc. A lower level of care would have been reasonable. She did not meet criteria for inpatient admission.